Health Care for Common Mental Illnesses: The Impact of National Insurance Reforms on Utilization and Spending and A Study of Services Provided in General Medical Settings

Depression and anxiety affect more Americans than any other mental illness. Although effective treatments are available, treatment is often inadequate, delayed, or absent altogether. Individuals with depression or anxiety and groups at risk of developing these problems face a range of barriers to appropriate treatment, including difficulties obtaining health insurance, limitations in coverage for mental health services, and challenges accessing specialized care relative to general medical care. Recent policies aimed to improve access to mental health care by expanding insurance coverage, improving fairness in insurance benefits, and strengthening services in general medical settings. The objectives of this dissertation were to examine: 1) the impact of insurance expansion on mental health care among individuals with depression and anxiety, including changes that may signal adverse selection; 2) the association between insurance benefits reform and mental health care among individuals with depression and anxiety; and 3) the correlates of depression care and the role of screening in diagnosis and treatment among outpatient primary care visits. The first study estimated changes in the probability and quantity of mental health service use and total and out-of-pocket spending among young adults and a separate sample of new enrollees after the dependent coverage provision (DCP) of the Affordable Care Act was implemented. The DCP was associated with increased service use and spending without higher intensity service use by new enrollees, suggesting those who gained coverage needed treatment but not at higher levels. The second study estimated changes in the probability and quantity of mental health service use and total and out-of-pocket spending among young adults after the Mental Health Parity and Addiction Equity Act (MHPAEA) was implemented. The MHPAEA was associated with small shifts in service use without increased financial protection, suggesting modest changes in this population that were attributable to the policy. The third study assessed the correlates of depression screening, diagnosis, and treatment in representative primary care settings and estimated the relationship between screening rates and the probability of diagnosis and treatment. Patterns of depression care suggested that physicians focused on high-risk patients. Additionally, higher screening rates were associated with higher rates of depression identification and treatment