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Abstract

To examine whether previous Affordable Care Act (ACA) Medicaid expansions had an added effect on the mental health of low-income adults during the COVID-19 pandemic in 2020 and 2021. We use the 2017-2021 Behavioral Risk Factor Surveillance System (BRFSS) data. We use an event study difference-in-differences model to compare the number of days in poor mental health in the past 30 days and the likelihood of frequent mental distress among 18 to 64 year old individuals with household incomes below 100% of the federal poverty level who participated in BRFSS in one of the surveys from 2017 to 2021 and who resided in states that expanded Medicaid by 2016 or states that had not expanded by 2021. We also examine the heterogeneity of the expansion effects across subpopulation groups. We find some evidence that the Medicaid expansion was associated with better mental health during the pandemic for adults younger than 45, females, and non-Hispanic Black and other non-Hispanic non-White individuals. There is some evidence of an added benefit to mental health from Medicaid expansion status during the pandemic for some subgroups among low-income adults, suggesting potential health benefits from Medicaid eligibility during public health and economic crises.

Keywords

Affordable Care Act Medicaid expansion mental health frequent mental distress COVID-19

What do we already know about this topic?

The COVID-19 pandemic brought unprecedented economic, social, and health challenges. Previous Medicaid expansions have been associated with increased access to coverage and health services among low-income population.

How does your research contribute to the field?

This study examines if prior Medicaid expansions affected the mental health of adults below 100% of the federal poverty level in the COVID-19 pandemic-era and finds some evidence that the expansion is associated with better mental health, especially among adults younger than 45 years, females, and non-Hispanic Black and other non-Hispanic non-White individuals.

What are your research’s implications toward theory, practice, or policy?

The findings add some evidence to the potential health benefits of Medicaid eligibility for low-income adults, especially benefits to mental health during public health and economic crises.

Introduction

The novel coronavirus disease 2019 (COVID-19) pandemic and some of the policies implemented to slow down its spread brought unprecedented economic, social, and health challenges that likely had major impacts on mental health. Millions of Americans reported loss of work and income, or reduced work hours because of the pandemic.¹ Low-income individuals, women, and racial and ethnic minorities were particularly impacted as they experienced greater job loss.^2,3 Unemployment can increase stress and financial insecurity and reduce self-esteem, which could worsen mental health.⁴ Compounding and exacerbating the pandemic impacts on mental health were the fears and worries surrounding COVID-19 risk of infection and related restrictions of social distancing, business and school closures, quarantines, and isolation, all of which have had profound social and mental health effects.^5-7

Mental health disorders affect over 20% of adults and are disproportionally more prevalent among low-income individuals.⁸ Prior to the implementation of the Affordable Care Act (ACA) and its related Medicaid expansions, the uninsured rate was markedly higher among individuals with mental health disorders (20%) compared with the general population (15%), and less than 50% of people with mental health disorders received treatment.^9-11 Health insurance coverage is critical to accessing mental health services, particularly among low-income populations. The ACA Medicaid expansions beginning in 2014 and continuing with additional states expanding in subsequent years have increased coverage among adults with household income below 138% of the federal poverty level (FPL). Evidence on effects of the ACA Medicaid expansions before the pandemic suggests improved access and utilization of mental and other health care services,^12,13 and improved mental health^14-22 particularly in the early years of the expansions as take-up of Medicaid coverage significantly increased.²³ However, whether there was an added benefit from the prior expansions to mental health during the pandemic is not well understood. With added shocks to mental health during the pandemic and disruptions to insurance coverage and access to essential mental health care services, one hypothesis is that Medicaid coverage for low-income individuals in expansion states may have buffered against some of the adverse impacts on mental health by providing greater access to needed mental health services (such as access to prescription drugs or mental health care providers providing psychotherapy via telehealth) compared to similar income individuals without Medicaid coverage in non-expansion states. Furthermore, Medicaid coverage during the pandemic may have conferred additional financial security in the event of losing a job or employer-sponsored coverage^24,25 or illness, which has been associated with higher rates of anxiety, depression, and substance abuse.²⁶ Therefore, in this study, we examine whether the prior ACA Medicaid expansions provided an added benefit to the mental health of low-income individuals compared to non-expansion states during the pandemic.

Studies report an increase in adverse mental health conditions during the pandemic.^27,28 These conditions worsened among younger adults due to school closures, employment loss, and increased feelings of social isolation.^29,30 Furthermore, women were more likely than men to reduce work hours, leave their jobs to homeschool or take care of other family activities.^31,32 Studies report a greater increase in depression and anxiety rates among women compared to men as their burden of responsibilities disproportionately increased during the pandemic.³³ Hispanic and non-Hispanic Black populations had a greater increase in self-reported depression and anxiety rates.^34,35 In addition to disproportionally experiencing economic hardship from the pandemic, Black populations also had higher COVID-19 hospitalizations and mortality.^36,37

As mentioned above, the ACA Medicaid expansions before the pandemic may have an incremental effect on mental health of low-income individuals during the pandemic in two main ways. The first possible mechanism is through access to mental health services for individuals who needed them, which may include care for newly onset or worsening prior mental health conditions during the pandemic. Without coverage, low-income individuals would have little access to such needed services. The second plausible mechanism is by providing additional financial security from Medicaid coverage^38-41 after (potential) loss of employer-sponsored coverage as a result of the pandemic-related unemployment or underemployment, which might reduce stress and improve mental wellbeing.⁴² This second pathway might be especially important during a global pandemic when most people become keenly attentive to their own and their family’s health. The reduction in stress with insurance coverage and financial protection from illness might be more salient during such time.

In addition, in March 2020, Congress passed the Families First Coronavirus Response Act (FFCRA), providing states with an additional 6.2 percentage-point increase in federal matching assistance percentage (FMAP) to provide continuous coverage for Medicaid.^43-45 This provision may have increased coverage, reduced churning in Medicaid and interruption in access to health care services among covered individuals that may occur over time and further enhanced the expansion effect on financial security and access to mental health services. The Centers for Medicare & Medicaid Services (CMS) report an increase of 25% nationally in the population covered by Medicaid between February 2020 and January 2022.⁴⁶ Therefore, we also examine whether there was an added effect of the ACA Medicaid expansion on coverage in 2020-2021.

There is emerging evidence of the effects of the previous ACA Medicaid expansions on the mental health of low-income individuals during the COVID-19 pandemic. Two studies report that Medicaid expansion nullified the negative effect of loss of work on mental health.^25,42 Another study reported no statistically significant difference in changes in days not in good mental health in the past 30 days during 2020 between expansion and non-expansion states overall, although the study found a statistically significant decline in this outcome for non-Hispanic Black individuals.⁴⁷ That study, however, included individuals up to 138% of the FPL and did not examine the effect separately for individuals below 100% of the FPL. In non-expansion states, individuals within 100-138% of the FPL are eligible for insurance marketplace subsidies, so including them in the sample may attenuate the effect of the Medicaid expansion. Furthermore, that study did not evaluate the effect on frequent mental distress characterized as experiencing 14 or more days of poor mental health in the past month, an indicator of diagnosable depressive and anxiety disorder.⁴⁸ Employing nationally representative data, we focus on individuals below 100% FPL who are expected to benefit most from the Medicaid expansions (consider the eligibility of those at 100%-138% FPL for subsidized marketplace insurance coverage). We also evaluate potential heterogeneity across age, sex, race/ethnicity, and whether children lived in the household.

Study Data and Methods

Data and Sample

We use data from the Behavioral Risk Factor Surveillance System (BRFSS), a nationally representative cross-sectional telephone survey conducted annually by the Centers for Disease Control and Prevention and state governments. The survey is conducted in all states and the District of Columbia, and it is designed to represent the non-institutionalized adult population in the United States. For this study, we include BRFSS data from 2017 to 2021, from states that expanded Medicaid by 2016 and states that had not expanded by 2021 to compare them on changes in mental health over time, including from 2019 to 2021. We exclude states that expanded Medicaid after 2016 (Idaho, Maine, Missouri, Nebraska, Oklahoma, Utah, and Virginia). Medicaid expansions by 2016 (including 4 states and the District of Columbia that had full or near full expansions before 2014 but also adopted the ACA expansion in 2014) comprise the treated group. We restrict the sample to low-income adults aged 18 to 64 with household incomes below 100% of the FPL; as a reference, for a single individual in 2021, this income was below $12 880.⁴⁹ As income is reported in ranges in the BRFSS, we use the midpoints of the income ranges and then assign to each individual income as a percentage of the FPL considering household structure.^50,51 We exclude from the sample respondents whose income is between 100% and 138% FPL since, as noted above, they receive subsidies in non-expansion states to obtain insurance through the health insurance marketplace. The analytical sample consisted of 128 074 adults surveyed between 2017 and 2021, with household incomes less than 100% FPL. There were 92 061 adults in Medicaid expansion states and 36 013 adults in non-expansion states.

Outcomes

BRFSS asks respondents about the number of days in the past 30 during which their mental health was not good, including experiencing stress, depression, and emotional problems. We use this measure of mental health as the main outcome. In addition, we construct a binary indicator for frequent mental distress equal to 1 if the respondent had 14 or more days in poor mental health and 0 otherwise.⁵²

We also examine whether coverage changed differentially in 2020 and 2021 (compared to 2019) between previously expanded states and non-expansion states as a potential mechanism affecting mental health. As noted above, an added (incremental) effect from the earlier Medicaid expansions on mental health during the pandemic may develop without a greater increase in new enrollment in expansion states. However, if expansion states had greater enrollment during the pandemic, this may also contribute to an incremental effect on mental health among the population of income-eligible adults. BRFSS asks whether respondents have any form of health care coverage but does not ask about insurance type in all years. Therefore, in addition to the BRFSS data, we use data from the American Community Survey (ACS),⁵³ and Medicaid enrollment data reported by states through the Medicaid Budget and Expenditures System (MBES).⁵⁴

Research Design and Statistical Analysis

To investigate the incremental effect of Medicaid expansion, we estimate difference-in-differences models that compare changes in the outcomes in the Medicaid expansion states to changes in outcomes in the non-expansion states. Because we are interested in how the effect varied over time from 2017 to 2021, we estimate event study models. The event study allows us to examine the effects of the expansions relative to the base year of 2019, and to also test the parallel trends assumption of similar trends in outcomes between expansion and non-expansion states before the pandemic. The event study DD model is:

\begin{array}{l} Y_{i s m t} = β_{0} + \sum_{t = 1}^{T} β_{t} (M e d i c a i d E x p a n s i o n_{s} * Y_{t}) + δ X_{i s t} \\ + γ Z_{m s} + α_{m s} + θ_{t} + ε_{i s t} \end{array}

where Y_ismt represents the outcome for individual i living in state s interviewed in month m in year t. Medicaid Expansion_s represents treatment states and equal 1 if the individual lives in a state that expanded Medicaid and equal 0 if the individual lives in a state that did not expand Medicaid. Y_t is an indicator for whether year t is 2017, 2018, 2020, and 2021 with 2019 as the reference year. X_ist is a vector of individual-and state-level control variables that includes education, sex, race/ethnicity, age, marital status, if respondent has children, employment status, if respondent owns or rents their home, cell-phone sample indicator, unemployment rate, state per capita income, and an indicator for whether the state offers earned income tax credits (EITC). Z_ms is a vector of COVID-related policies⁵⁵ that may also impact mental health: stay-at-home/shelter-in-place orders, state of emergency declaration, and closures and reopening of restaurant. For these variables we include indicators for each month the policies were in effect during the pandemic. α_ms is a vector of month-by-state fixed effects, and θ_t is a vector of year fixed effects. Standard errors are clustered by state. Because all treated states have expanded before 2017, there is no switching in expansion status in this model. β_t represents the differences between the changes in outcomes in expansion versus non-expansion states over time, including the change from 2019 to 2021. All regressions are weighted by the BRFSS sampling weights. We also stratify the model by race/ethnicity, age groups, sex, and whether children lived in the household to check for any heterogeneity across subgroups. To assess the robustness of our findings, we estimate an alternate model that excludes respondents that were interviewed in January and February of 2020 before the World Health Organization (WHO) declared a pandemic and the US declared a national emergency.⁵⁶ The descriptive statistics for the model analyses is presented in Supplemental Appendix Table 1. We also present the estimates without sampling weights.

Medicaid Expansion Effects on Coverage

To investigate the effect of Medicaid expansion on coverage, we estimate a similar model using data on coverage separately from the BRFSS, ACS, and the Medicaid enrollment data. The ACS collects individual level data on insurance status along with other important demographic and socioeconomic characteristics. Using the ACS, we include a sample similar to the BRFSS sample from 2017 through 2021 to examine changes in insurance type. We also use monthly reports of Centers for Medicare & Medicaid Services (CMS) Medicaid enrollment data reported by states through the Medicaid Budget and Expenditures System (MBES) to compare Medicaid enrollment per population 18 to 64-year-old (calculated as the ratio of total Medicaid enrollment and population 18-64-year-old) between expansion and non-expansion states from 2017 through 2021. Data are adjusted using BRFSS weights, ACS weights, and population weights are used for the Medicaid enrollment data.

Results

Medicaid Expansion Effects in Total Sample

Figure 1 shows the descriptive trends in the number of days not in good mental health in the past 30 and the cutoff of 14 days or more for frequent mental distress (without any adjustment for covariates) in Medicaid expansion and non-expansion states from 2017 to 2021. Between 2017 and 2019, there is an increase in the number of days in poor mental health in both expansion and non-expansion states. In contrast, there is a relatively small decline in this outcome in 2020 (slightly more in expansion states) but a sharp increase in 2021 in both expansion and non-expansion states. However, there is less such increase in 2021 in expansion states. The trends for frequent mental distress largely follow those of the days count measure especially during the pandemic.

Figure 1.

Trends in the number of days in poor mental health and frequent mental distress, Medicaid expansion versus non-expansion states, BRFSS 2017-2021.

Figure 2 presents the event study difference-in-differences graphs for the differences in mental health outcomes—number of days not in good mental health and frequent mental distress between Medicaid expansion states and non-expansion states over the years, with 2019 as the reference period. The detailed estimates are in Supplemental Appendix Tables 2 and 3. There is a decline in both mental health outcomes in 2020 and 2021 relative to 2019 associated with the Medicaid expansion. However, the estimate is not statistically significant for the number of days not in good mental health and marginally significant (P < .1) for frequent mental distress in 2021. For the latter outcome, Medicaid expansion is associated with a 3.5 percentage-point decline in the likelihood of frequent mental distress in 2021 compared to 2019; however, the difference in the 2017-2019 pre-trend between expansion and non-expansion states is marginally significant, although in the opposite direction to the effects in 2020 and 2021. The estimates are similar when excluding observations pre-pandemic in January and February in 2020 (Supplemental Appendix Tables 4 and 5). The unweighted estimates of the Medicaid expansion effect (Supplemental Appendix Tables 6 and 7) are noticeably smaller (in absolute value) and the estimate the day count measure is near null and in the opposite direction. This difference between the weighted and unweighted suggests potential heterogeneity in the effects across states, in which case the unweighted estimate of the average effect may be less generalizable. As noted above, differences between expansion and non-expansion states before 2019 are in the opposite direction in the weighted model and overall not statistically significant.

Figure 2.

Event study estimates of the Medicaid expansion effects on the number of days in poor mental health in the past 30 days and frequent mental distress, BRFSS 2017-2021.

Medicaid Expansion Effects Among Demographic Subgroups

Figures 3 to 6 report the event study difference-in-differences estimates for the number of days not in good mental health and frequent mental distress among demographic subgroups by age, race/ethnicity, gender, and having children in the household or not. Supplemental Appendix Tables 2 and 3 show the detailed estimates.

Figure 3.

Event study estimates of the Medicaid expansion effects on the number of days in poor mental health in the past 30 days and frequent mental distress by age groups, BRFSS 2017-2021

Figure 4.

Event study estimates of the Medicaid expansion effects on the number of days in poor mental health in the past 30 days and frequent mental distress by gender, BRFSS 2017-2021.

Figure 5.

Event study estimates of the medicaid expansion effects on the number of days in poor mental health in the past 30 days and frequent mental distress by race/ethnicity, BRFSS 2017-2021.

Figure 6.

Event study estimates of the Medicaid expansion effects on the number of days in poor mental health in the past 30 days and frequent mental distress by parental status, BRFSS 2017-2021.

Comparing by age (Figure 3), we find that for 25 to 34-year-old, the ACA Medicaid expansion is associated with a 1.8 fewer days not in good mental health (P < .05) and 5.8 percentage point (P < .1) lower likelihood of frequent mental distress in 2021. The pre-trend differences between expansion and non-expansion states are statistically significant for this group, but they are in the opposite direction, suggesting that the Medicaid expansion effect is unlikely to be biased in direction. For 35 to 44-year-old individuals, the expansion is associated with 1.9 (P < .01) and 1.4 (P < .1) fewer days not in good mental health in 2020 and 2021 respectively. During the same period, there is an 8 percentage-point (P < .01) and 7 percentage-point (P < .05) lower likelihood of frequent mental distress in those years, respectively. There are no statistically significant pre-trend differences for this age group. Estimates are smaller and statistically non-significant for the other age groups.

When stratifying by gender (Figure 4), we find that among females the expansion is associated with 0.8 (P < .05) and 0.9 (P < .05) fewer days not in good mental health in 2020 and 2021, and with lower likelihood of frequent mental distress reduced by 3.5 (P < .05) and 3.9 (P < .01) percentage-points, respectively, without statistically significant pre-trend differences. Estimates for males are smaller and statistically non-significant and are of the opposite direction in 2020.

Comparing across race/ethnicity (Figure 5), we find that for non-Hispanic Black individuals, the expansion is associated with 1.8 fewer days not in good mental health (P < .1) in 2020 and with 6.9 percentage-point lower likelihood of frequent mental distress (P < .1) in 2021. Among other non-Hispanic, non-White individuals, there are 2.1 fewer days not in good mental health (P < .05) and 9.3 percentage-point lower likelihood of frequent mental distress (P < .05) in 2021. In this group, there is marginally significant difference in the 2017-2019 pre-trend between expansion and non-expansion states although of the opposite direction to the 2021 effect estimate. The Medicaid expansion effect estimates are smaller for the other groups and statistically non-significant. Finally, the Medicaid expansion is associated with a 3.5 percentage-point lower likelihood of frequent mental distress in households without children in 2021 (P < .1), though the 2017-2019 pre-trend difference is marginally significant and of the opposite direction. This estimate is close although not statistically significant for households with children. (Figure 6). The subgroup estimates are similar excluding observations interviewed in January and February in 2020 (Supplemental Appendix Tables 4 and 5).

The unweighted estimates by the demographic subgroups are reported in Supplemental Appendix Tables 6 and 7. These estimates suggest improvement in mental health for 25 to 34 year-old, non-Hispanic Black, and other non-Hispanic, non-White individuals. However, the unweighted estimates are smaller (in absolute value) for females and are not statistically significant, suggested effect heterogeneity across states.

Medicaid Expansion Effects on Coverage

Supplemental Appendix Table 8 to 13 presents the estimates for the expansion effects on coverage on the full sample and subgroups using the BRFSS, ACS, and CMS Medicaid enrollment data. The results indicate no incremental effects on coverage during the pandemic using the BRFSS and Medicaid enrollment data (Supplemental Appendix Tables 8 and 9). Using the ACS data, there is a 1.4 percentage-point increase in Medicaid coverage in 2020 (Supplemental Appendix Table 8). Across subgroups, there is suggestive evidence of an effect from the expansions on coverage in 2020 or 2021 among individuals aged 25 to 34-year-old, Male, non-Hispanic White and other, and childless adults (Supplemental Appendix Tables 10–13). However, the results using the ACS data should be interpreted cautiously given the concern about non-response bias in the ACS in 2020 associated with the pandemic.^57,58

Discussion

This study evaluates whether previous Medicaid expansions had an added effect on mental health during the COVID-19 pandemic in 2020-2021-era. Specifically, the study compares the mental health of low-income adults during those years of the pandemic compared to before between states that had expanded Medicaid by 2016 and those that had not expanded Medicaid by 2021 using an event study difference-in-differences design and data from BRFSS. We find some evidence that the Medicaid expansion is associated with better mental health, particularly among adults younger than 45 years, females, and non-Hispanic Black and other non-Hispanic, non-White individuals. The pandemic and pandemic-related economic hardship had widespread effects on the population, particularly among low-income, Black, women, and young adult populations. The findings suggest that access to Medicaid coverage during an economic and public health crisis may partially offset some of the negative financial and health impacts of the pandemic, in this case, effects on mental health.

The suggested benefit to mental health from higher Medicaid eligibility might result from greater access to needed mental health treatments among those experiencing mental health problems. Before the pandemic, the ACA Medicaid expansions had been associated with an increase in mental health care utilization,^13,59 access to care for people with mental distress,^60,61 and availability of mental health treatments.^12,21 The pandemic created barriers to and disrupted the delivery of mental health care. Overall, outpatient services declined 60% in the early months of the pandemic in 2020 as providers made practice adjustments and deferred non-emergency services. Similarly, studies report a decline in initiation of mental health medications during the pandemic.^62,63 However, low-income individuals with Medicaid coverage in expansion states may have had greater access to mental health services during the pandemic than individuals with similar income in non-expansion states, including via telehealth care which some state Medicaid programs expanded during the pandemic.⁶⁴ Studies show that the utilization of telehealth for mental health conditions increased during the pandemic,⁶³ specifically among young adults,⁶⁵ females,⁶⁶ and individuals with serious mental illness.⁶⁷ In addition to greater access to services, there is also the possibility of an added effect on financial security during the pandemic as noted above. Before the pandemic, Medicaid expansion has been associated with a reduction in financial distress,⁶⁸ specifically among non-Hispanic Black individuals.²⁴ Because coverage protects against the financial shocks of unexpected catastrophic medical events, it may confer “feelings of security” that may improve mental health among individuals that are more likely to be impacted.^18,22 However, BRFSS does not provide data to investigate these potential mechanisms, which we leave for future research.

A related question is whether there was an incremental effect on Medicaid enrollment in expansion states that would lead to an added benefit on mental health among the income eligible population. Using multiple data sources-BRFSS, ACS, and the Centers for Medicare & Medicaid Services (CMS) Medicaid enrollment data from 2017 to 2021, we find some evidence of an incremental effect on coverage and across some subpopulation groups using the ACS data indicating that some of the added benefit to mental health during the pandemic may have resulted from gains in access to Medicaid coverage in expansion states. However, this result should be interpreted with caution due to concerns about survey quality issues in 2020.⁵⁷ CMS reports an increase in Medicaid enrollment nationally during the pandemic, although this appears to be largely driven by the FFCRA maintenance of eligibility and continuous enrollment rather than new applicants.^69,70 Also, our study excludes states that expanded after 2016 including those that expanded during the pandemic which may have experienced different effects on coverage.

The temporary FMAP with the continuous eligibility and enrollment provisions are scheduled to end in 2023. Continuous eligibility and enrollment are scheduled to expire on the 31st of March and the temporary FMAP will gradually phase out by December 2023.⁷¹ Reversing these provisions may lead to breaks in or loss of coverage if individuals encounter barriers related to providing required documentation for Medicaid redetermination.⁷⁰ Such coverage interruptions may reduce access to needed mental health services. Reforms to facilitate enrollment and limit coverage interruptions for eligible adults are needed not only during the pandemic but also after that, especially if the pandemic has long-term effects on mental health.

This study has limitations. The measures for poor mental health in the BRFSS are self-reported, leaving the possibility for measurement error. However, measurement errors are unlikely to be associated with Medicaid expansion or to bias the estimates. The pandemic may have disrupted data collection processes among states. However, we do not expect that these changes will bias the results unless changes in data collection during this period systematically differed between expansion and non-expansion states. Another caveat is that even though studies using other data report declining mental health conditions in the general population and among subpopulation groups during the pandemic,^6,27,35,72 mental health trends before and after the pandemic using the BRFSS data seem to suggest less of an effect from the pandemic on mental health in 2020 than other surveys. Depending on the data source and timing of the survey, estimates of the pandemic’s effects on mental health may differ in magnitude.⁷³ One study reported an increase in anxiety and depression in 2020 using the Household Pulse Survey (HPS) and the National Health Interview Survey (NHIS) but reported an opposite trend using BRFSS data (consistent with the trends in descriptive Figure 1).⁷⁴ However, any potential bias in mental health trends during the pandemic in a given survey would only influence the Medicaid expansion effects if this bias differed between expansion and non-expansion states. Furthermore, there is a sharp increase in days not in good mental health in 2021 in the BRFSS as noted above. In any case, it would be important to replicate this study using other national datasets, including the NHIS (which would require access to the restricted data since state geocodes are not publicly available in that dataset). Since the HPS started during the pandemic, it would not be possible to evaluate pre-trends between expansion and non-expansion states in that dataset; therefore, its value for understanding the Medicaid expansion effects in this particular case is limited.

Conclusion

We find that previous ACA Medicaid expansions are associated with an added benefit to the mental health of individuals below 100% FPL in 2020-2021 during the COVID-19 pandemic. This association does not appear to result from a larger increase in new enrollment in expansion states in that year compared to non-expansion states but rather from prior and continuing coverage. This finding adds to the evidence of the health benefits from the Medicaid expansions to income-eligible individuals, including during public health and economic crises.

Supplemental Material

sj-docx-1-inq-10.1177_00469580231166738 – Supplemental material for Effects of the Affordable Care Act Medicaid Expansions on Mental Health During the COVID-19 Pandemic in 2020-2021

Supplemental material, sj-docx-1-inq-10.1177_00469580231166738 for Effects of the Affordable Care Act Medicaid Expansions on Mental Health During the COVID-19 Pandemic in 2020-2021 by Onyinye Oyeka and George L. Wehby in INQUIRY: The Journal of Health Care Organization, Provision, and Financing

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Presence of Declarations,and Ethics and Consent statements

Our study does not require an ethical board approval because we use publicly available and deidentified data.

ORCID iD

Onyinye Oyeka

Supplemental Material

Supplemental material for this article is available online.

References

U. S. Bureau of Labor Statistics. Supplemental Data Measuring the Effects of the Coronavirus (COVID-19) Pandemic on the Labor Market. U. S. Bureau of Labor Statistics; 2020. Accessed December 14, 2021. https://www.bls.gov/cps/effects-of-the-coronavirus-covid-19-pandemic.htm#highlights

Fronstin

Woodbury

. How Many Americans Have Lost Jobs with Employer Health Coverage During the Pandemic? The Commonwealth Fund; 2020. Accessed December 14, 2021. https://www.commonwealthfund.org/publications/issue-briefs/2020/oct/how-many-lost-jobs-employer-coverage-pandemic

Kochhar

. Unemployment Rate is Higher Than Officially Recorded, More so for Women and Certain Other Groups. Pew Research Center; 2020. Accessed December 14, 2021. https://www.pewresearch.org/fact-tank/2020/06/30/unemployment-rate-is-higher-than-officially-recorded-more-so-for-women-and-certain-other-groups/

Guerin

Barile

Thompson

McKnight-Eily

Okun

AH.

Investigating the impact of job loss and decreased work hours on physical and mental health outcomes among US adults during the COVID-19 pandemic. J Occup Environ Med. 2021;63(9):e571-e579.

Brülhart

Klotzbücher

Lalive

Reich

SK.

Mental health concerns during the COVID-19 pandemic as revealed by helpline calls. Nature. 2021;600(7887):121-126. doi:10.1038/s41586-021-04099-6

Sojli

Tham

Bryant

McAleer

COVID-19 restrictions and age-specific mental health-U.S. probability-based panel evidence. Transl Psychiatry. 2021;11(1):418. doi:10.1038/s41398-021-01537-x

Leigh-Hunt

Bagguley

Bash

, et al. An overview of systematic reviews on the public health consequences of social isolation and loneliness. Public Health. 2017;152:157-171. doi:10.1016/j.puhe.2017.07.035

National Institute of Mental Health. Mental Illness. National Institute of Mental Health. https://www.nimh.nih.gov/health/statistics/mental-illness

Substance Abuse and Mental Health Services Administration. Substance Use and Mental Health Estimates from the 2013 National Survey on Drug Use and Health. Substance Abuse and Mental Health Services Administration; 2014. Accessed August 18, 2022. https://www.samhsa.gov/data/sites/default/files/NSDUH-SR200-RecoveryMonth-2014/NSDUH-SR200-RecoveryMonth-2014.htm

10.

Walker

Cummings

Hockenberry

Druss

BG.

Insurance status, use of mental health services, and unmet need for mental health care in the United States. Psychiatr Serv. 2015;66(6):578-584. doi:10.1176/appi.ps.201400248

11.

Garfield

Lave

Donohue

JM.

Health reform and the scope of benefits for mental health and substance use disorder services. Psychiatr Serv. 2010;61(11):1081-1086. doi:10.1176/ps.2010.61.11.1081

12.

Blunt

Maclean

Popovici

Marcus

SC.

Public insurance expansions and mental health care availability. Health Serv Res. 2020;55(4):615-625. doi:10.1111/1475-6773.13311

13.

Breslau

Han

Lai

Impact of the Affordable Care Act Medicaid expansion on utilization of mental health care. Med Care. 2020;58(9):757-762. doi:10.1097/MLR.0000000000001373

14.

Simon

Soni

Cawley

The impact of health insurance on preventive care and health behaviors: evidence from the first two years of the ACA Medicaid expansions. J Policy Anal Manag. 2017;36(2):390-417. doi:10.1002/pam.21972

15.

Winkelman

TNA

Chang

VW.

Medicaid expansion, mental health, and access to care among childless adults with and without chronic conditions. J Gen Intern Med. 2018;33(3):376-383. doi:10.1007/s11606-017-4217-5

16.

Griffith

Bor

JH.

Changes in health care access, behaviors, and self-reported health among low-income US adults through the fourth year of the Affordable Care Act. Med Care. 2020;58(6):574-578. doi:10.1097/MLR.0000000000001321

17.

Cawley

Soni

Simon

. Third year of survey data shows continuing benefits of Medicaid expansions for Low-Income childless adults in the U.S. J Gen Intern Med. 2018;33(9):1495-1497. doi:10.1007/s11606-018-4537-0

18.

McMorrow

Gates

Long

Kenney

GM.

Medicaid expansion increased coverage, improved affordability, and reduced psychological distress for low-income parents. Health Aff. 2017;36(5):808-818. doi:10.1377/hlthaff.2016.1650

19.

Winkelman

TNA

Segel

Davis

. Medicaid enrollment among previously uninsured Americans and associated outcomes by race/ethnicity-United States, 2008-2014. Health Serv Res. 2019;54:297-306. doi:10.1111/1475-6773.13085

20.

Courtemanche

Zapata

. Does Universal Coverage Improve Health? The Massachusetts Experience. National Bureau of Economic Research; 2012.

21.

Baicker

Allen

Wright

Taubman

Finkelstein

AN.

The effect of Medicaid on management of depression: evidence from the Oregon Health Insurance experiment. Milbank Q. 2018;96(1):29-56. doi:10.1111/1468-0009.12311

22.

Finkelstein

Taubman

Wright

, et al. The Oregon Health Insurance Experiment: evidence from the first year. Q J Econ. 2012;127(3):1057-1106. doi:10.1093/qje/qjs020

23.

Wehby

Lyu

The impact of the ACA Medicaid expansions on health insurance coverage through 2015 and coverage disparities by age, race/ethnicity, and gender. Health Serv Res. 2018;53(2):1248-1271.

24.

Shadowen

Alexander

Guerra

, et al. Virginia Medicaid expansion: new members report reduced financial concerns during the COVID-19 pandemic. Health Aff. 2022;41:1078-1087. doi:10.1377/hlthaff.2021.01910

25.

Sances

Campbell

AL.

State policy and mental health outcomes under COVID-19. J Health Polit Policy Law. 2021;46(5):811-830. doi:10.1215/03616878-9155991

26.

Forbes

Krueger

RF.

The Great Recession and mental health in the United States. Clin Psychol Sci. 2019;7(5):900-913. doi:10.1177/2167702619859337

27.

Lee

Singh

GK.

Monthly trends in self-reported health status and depression by race/ethnicity and socioeconomic status during the COVID-19 pandemic, United States, April 2020 – May 2021. Ann Epidemiol. 2021;63:52-62. doi:10.1016/j.annepidem.2021.07.014

28.

Jia

Guerin

Barile

, et al. National and state trends in anxiety and depression severity scores among adults during the COVID-19 pandemic - United States, 2020-2021. MMWR Morb Mortal Wkly Rep. 2021;70:1427-1432.

29.

Weissbourd

Batanova

Lovison

Torres

. Loneliness in America: How the Pandemic Has Deepened an Epidemic of Loneliness and What We Can Do About It. Making Caring Common Project. Harvard Graduate School of Education; 2021. https://static1.squarespace.com/static/5b7c56e255b02c683659fe43/t/6021776bdd04957c4557c212/1612805995893/Loneliness+in+America+2021_02_08_FINAL.pdf

30.

Perlis

Green

Guo

, et al. The Covid States Project: A 50-State Covid-19 Survey Report #84: Covid-19 Deaths and Depression. The COVID State Project; 2022. Accessed December 14, 2022. https://www.covidstates.org/reports/covid-19-deaths-and-depression

31.

Augustine

Prickett

Gender disparities in increased parenting time during the COVID-19 pandemic: a research note. Demography. 2022;59(4):1233-1247. doi:10.1215/00703370-10113125

32.

Pabilonia

Vernon

Who is doing the chores and childcare in dual-earner couples during the COVID-19 era of working from home?

Rev Econ Househ. Published online January 9, 2023. doi:10.1007/s11150-022-09642-6

33.

Ranji

Frederiksen

Salganicoff

Long

. Women, Work, and Family During COVID-19: Findings from the KFF Women's Health Survey. Kaiser Family Foundation; 2021. https://www.kff.org/womens-health-policy/issue-brief/women-work-and-family-during-covid-19-findings-from-the-kff-womens-health-survey/

34.

Thomeer

Moody

Yahirun

Racial and ethnic disparities in mental health and mental health care during the COVID-19 pandemic. J Racial Ethn Health Disparities. 2023;10:961-976. doi:10.1007/s40615-022-01284-9

35.

Czeisler

MÉ

Lane

Petrosky

, et al. Mental Health, substance use, and suicidal ideation during the COVID-19 pandemic - United States, June 24-30, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(32):1049-1057. doi:10.15585/mmwr.mm6932a1

36.

Price-Haywood

Burton

Fort

Seoane

Hospitalization and mortality among black patients and white patients with Covid-19. New Engl J Med. 2020;382(26):2534-2543. doi:10.1056/NEJMsa2011686

37.

Khanijahani

Tomassoni

Socioeconomic and racial segregation and COVID-19: concentrated disadvantage and Black Concentration in association with COVID-19 deaths in the USA. J Racial Ethn Health Disparities. 2022;9:367-375. doi:10.1007/s40615-021-00965-1

38.

Kaestner

Mazumder

Miller

Wong

The effect of the affordable care act Medicaid expansions on financial wellbeing. J Public Econ. 2018;163:99-112. doi:10.1016/j.jpubeco.2018.04.009

39.

Miller

Kaestner

Mazumder

Wong

The ACA Medicaid expansion in Michigan and Financial Health. J Policy Anal Manag. 2021;40(2):348-375. doi:10.1002/pam.22266

40.

Zewde

Eliason

Allen

Gross

The effects of the ACA Medicaid expansion on nationwide home evictions and eviction-court initiations: United States, 2000-2016. Am J Public Health. 2019;109(10):1379-1383. doi:10.2105/ajph.2019.305230

41.

Himmelstein

Effect of the Affordable Care Act’s Medicaid expansions on food security, 2010-2016. Am J Public Health. 2019;109(9):1243-1248. doi:10.2105/ajph.2019.305168

42.

Mukhopadhyay

The Effects of Medicaid Expansion on Job Loss Induced Mental Distress During the COVID-19 Pandemic in the US. Institute for the Study of Labor IZA; 2022:15150 doi:10.2139/ssrn.4114709

43.

Khorrami

Sommers

BD.

Changes in US Medicaid enrollment during the COVID-19 pandemic. JAMA Netw Open. 2021;4(5):e219463. doi:10.1001/jamanetworkopen.2021.9463

44.

Tolbert

Orgera

Damico

. What Does the CPS Tell Us About Health Insurance Coverage in 2020? Kaiser Family Foundation; 2020. Accessed December 14, 2021. https://www.kff.org/uninsured/issue-brief/what-does-the-cps-tell-us-about-health-insurance-coverage-in-2020/

45.

Ruhter

Conmy

Chu

Peter

De Lew

Sommers

. Tracking Health Insurance Coverage in 2020-2021 (Issue Brief No. HP-2021-24). Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services. Accessed December 14, 2021. https://aspe.hhs.gov/sites/default/files/documents/2fb03bb1527d26e3f270c65e2bfffc3a/tracking-insurance-coverage-2020-2021.pdf

46.

Centers for Medicare & Medicaid Services. December 2021 and January 2022 Medicaid and CHIP Enrollment Trends Snapshot. Centers for Medicare & Medicaid Services; 2022. Accessed December 14, 2022. https://www.medicaid.gov/medicaid/national-medicaid-chip-program-information/downloads/dec-2021-jan-2022-medicaid-chip-enrollment-trend-snapshot.pdf

47.

Rakus

Soni

Association between state Medicaid expansion status and health outcomes during the COVID-19 pandemic. Health Serv Res. 2022;57:1332-1341. doi:10.1111/1475-6773.14044

48.

Centers for Disease Control and Prevention. Measuring Healthy Days. Centers for Disease Control and Prevention; 2000. Accessed February 26, 2023. https://www.cdc.gov/hrqol/pdfs/mhd.pdf.

49.

Assistant Secretary for Planning and Evaluation. Poverty Guidelines. Office of the Assistant Secretary for Planning and Evaluation; 2021. Accessed December 14, 2022. https://aspe.hhs.gov/topics/poverty-economic-mobility/poverty-guidelines

50.

Semprini

Lyu

Shane

Wehby

GL.

The effects of ACA Medicaid expansions on health after 5 years. Med Care Res Rev. 2022;79:28-35. doi:10.1177/1077558720972592

51.

Lyu

Wehby

GL.

Heterogeneous effects of Affordable Care Act Medicaid expansions among women with dependent children by state-level pre-expansion eligibility. J Womens Health. 2021;30(9):1278-1287. doi:10.1089/jwh.2020.8776

52.

Centers for Disease Control and Prevention (CDC). Self-reported frequent mental distress among adults–United States, 1993-1996. MMWR Morb Mortal Wkly Rep. 1998;47(16):326-331.

53.

Ruggles

Flood

Goeken

Schouweiler

Sobek

. IPUMS USA: Version 12.0 [2017-2021]. IPUMS; 2022. Accessed January 25, 2023. https://www.ipums.org

54.

Centers for Medicare & Medicaid Services. Medicaid Enrollment Data Collected Through MBES. Centers for Medicare & Medicaid Services. https://www.medicaid.gov/medicaid/national-medicaid-chip-program-information/medicaid-chip-enrollment-data/medicaid-enrollment-data-collected-through-mbes/index.html

55.

Raifman

Nocka

Jones

, et al. COVID-19 US State Policy Database. Boston University School of Public Health; 2020. Accessed February 8, 2022. https://statepolicies.com/

56.

Declaring a National Emergency Concerning the Novel Coronavirus Disease (COVID-19) Outbreak. Federal Register 2020:15337-15338.

57.

Census Bureau. Census Bureau Announces Changes for 2020 American Community Survey 1-Year Estimates. United States Census Bureau; 2021. https://www.census.gov/newsroom/press-releases/2021/changes-2020-acs-1-year.html

58.

United States Census Bureau. An Assessment of the COVID-19 Pandemic’s Impact on the 2020 ACS 1-Year Data. United States Census Bureau; 2021. https://www.census.gov/library/working-papers/2021/acs/2021_CensusBureau_01.html

59.

Harju

Neufeld

The impact of the Medicaid expansion on telemental health utilization in four Midwestern states. Telemed E Health. 2021;27(11):1260-1267. doi:10.1089/tmj.2020.0476

60.

Novak

Anderson

Chen

Changes in health insurance coverage and barriers to health care access among individuals with serious psychological distress following the Affordable Care Act. Adm Policy Ment Health. 2018;45(6):924-932. doi:10.1007/s10488-018-0875-9

61.

Fry

Sommers

BD.

Effect of Medicaid expansion on health insurance coverage and access to care among adults with depression. Psychiatr Serv. 2018;69(11):1146-1152. doi:10.1176/appi.ps.201800181

62.

Nason

Stein

Frank

Stein

MB.

Decline in new starts of psychotropic medications during the COVID-19 pandemic. Health Aff. 2021;40(6):904-909. doi:10.1377/hlthaff.2021.00028

63.

Mehrotra

Chernew

Linetsky

Hatch

Cutler

Schneider

EC.

The Impact of COVID-19 on Outpatient Visits in 2020: Visits Remained Stable, Despite a Late Surge in Cases. The Commonwealth Fund; 2021. https://www.commonwealthfund.org/publications/2021/feb/impact-covid-19-outpatient-visits-2020-visits-stable-despite-late-surge

64.

Rae

Amin

Cox

Panchal

Miller

BF.

Telehealth Has Played an Outsized Role Meeting Mental Health Needs During the COVID-19 Pandemic. Kaiser Family Foundation; 2022. https://www.kff.org/coronavirus-covid-19/issue-brief/telehealth-has-played-an-outsized-role-meeting-mental-health-needs-during-the-covid-19-pandemic/#:~:text=Telehealth%20has%20played%20a%20particularly,for%20these%20services%20via%20telehealth

65.

Cantor

McBain

Pera

Bravata

Whaley

CM.

Who is (and is not) receiving telemedicine care during the COVID-19 pandemic. Am J Prev Med. 2021;61(3):434-438. doi:10.1016/j.amepre.2021.01.030

66.

Mansour

Tajanlangit

Heyward

Mojtabai

Alexander

GC.

Telemedicine and office-based care for behavioral and psychiatric conditions during the COVID-19 pandemic in the United States. Ann Intern Med. 2021;174(3):428-430. doi:10.7326/m20-6243

67.

Zhu

Myers

McConnell

Levander

Lin

SC.

Trends in outpatient mental health services use before and during the COVID-19 pandemic. Health Aff. 2022;41(4):573-580. doi:10.1377/hlthaff.2021.01297

68.

Gotanda

Jha

Kominski

Tsugawa

Out-of-pocket spending and financial burden among low income adults after Medicaid expansions in the United States: quasi-experimental difference-in-difference study. BMJ. 2020;368:m40. doi:10.1136/bmj.m40

69.

Sugar

Peters

De Lew

Sommers

. Medicaid Churning and Continuity of Care: Evidence and Policy Considerations Before and After the COVID-19 Pandemic. Assistant Secretary for Planning and Evaluation Office of Health Policy; 2021.https://aspe.hhs.gov/sites/default/files/private/pdf/265366/medicaid-churning-ib.pdf

70.

Corallo

Garfield

Tolbert

Rudowitz

Medicaid Enrollment Churn and Implications for Continuous Coverage Policies. Kaiser Family Foundation; 2021. https://www.kff.org/medicaid/issue-brief/medicaid-enrollment-churn-and-implications-for-continuous-coverage-policies/

71.

Centers for Medicare & Medicaid Services. Key Dates Related to the Medicaid Continuous Enrollment Condition Provisions in the Consolidated Appropriations Act, 2023. Centers for Medicare & Medicaid Services; 2023. https://www.medicaid.gov/sites/default/files/2023-01/cib010523_1.pdf

72.

Twenge

Joiner

TE.

U.S. Census Bureau-assessed prevalence of anxiety and depressive symptoms in 2019 and during the 2020 COVID-19 pandemic. Depress Anxiety. 2020;37(10):954-956. doi:10.1002/da.23077

73.

Kessler

Chiu

Hwang

, et al. Changes in prevalence of mental illness among US adults during compared with before the COVID-19 pandemic. Psychiatr Clin North Am. 2022;45(1):1-28. doi:10.1016/j.psc.2021.11.013

74.

Dobson

Graham

Hua

Pinto

Despair and Resilience in the U.S.: Did the COVID Pandemic Worsen Mental Health Outcomes? Global Economy and Development program at Brookings; 2022. https://www.brookings.edu/wp-content/uploads/2022/03/Despair-and-Resilience.pdf

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