Substance Use Disorder Treatment and Youth Access to Public Health Insurance

This study explores the effects of state-level public health insurance expansions on substance use disorder (SUD) treatment utilization among youth aged 12 to 18. Low-income youth have historically had little access to public health insurance, even relative to younger low-income children, and this coverage has not always included SUD treatment. We leverage expansions in public insurance eligibility – and SUD treatment access – generated by U.S. states’ decisions to expand coverage through Medicaid and the State Children’s Health Insurance Program (SCHIP) during 2000-2010.

Adolescence is a key developmental period in setting lifelong health and human capital trajectories. Many SUDs emerge during this period, and treatment at this time can have important lifecourse benefits. In fact, early treatment can have a high ratio of benefits to costs given the high long-term costs –private and public – of persistent SUDs as an adult. Effective treatments are increasingly available on the market, but unmet need for treatment remains high, with cost and lack of insurance coverage for SUD treatment acting as critical barriers to treatment receipt.

Beginning in the 1980s, the federal government and various state governments began to expand access to public health insurance coverage . However, these expansions were highly targeted; mandates for coverage of pregnant women and infants did not apply to older children. In the early 1990s, both federal mandates and voluntary state expansions began to create a more generous eligibility environment for older children (aged 6-18). In 1997, states obtained a new opportunity for federal assistance in funding health insurance for children via SCHIP. States could expand health insurance for youth either through direct Medicaid expansions or supplemental SCHIP programs for children ineligible for Medicaid (with eligibility thresholds above those of their states’ Medicaid programs). While Medicaid programs typically had meaningful coverage of SUDs, SCHIP programs varied more in their coverage. Typical states in 2010 had income eligibility thresholds between 100% and 200% of the federal poverty level (FPL) for older children.

In this paper, we use differences-in-differences models applied to administrative data drawn from the Treatment Episodes Data Set (TEDS) 2000-2010. We take advantage of variation in Medicaid and SCHIP income thresholds to identify the effects of more generous state coverage on SUD treatment utilization while controlling for a wide range of time-varying factors. We have also separately gathered state-by-year policy data indicating whether each state’s Medicaid and/or SCHIP programs cover the full range of SUD services, and our analysis will check the robustness of our findings across states with different levels of SUD coverage.

Our findings suggest that public health insurance expansions lead to increases in SUD treatment utilization (overall admissions as well as admissions by treatment setting), with the effects driven primarily by girls. We also find evidence of compositional shifts among patients receiving treatment: e.g., increases in the share of girls and patients with previous treatment history receiving treatment, and fewer admissions from the criminal justice system. We find no spillover effects to older adult SUD patients.

See more of: Effect of Public Insurance Expansion on Childhood Outcomes
See more of: Health Systems, Health Reform and Health Care Financing

<< Previous Abstract | Next Abstract