Express Lane Eligibility, Medicaid Coverage, and Acute Care Use among Children with Depression in Two Southern States

Objective:

Medicaid is the largest insurer of youth in the U.S. Depression is one of the most prevalent and disabling disorders treated among Medicaid-insured children. Continuous Medicaid coverage facilitates access to primary care, medication, and other routine outpatient services, which are critical interventions to manage depression and other chronic conditions. Therefore, disruptions in Medicaid coverage can potentially exacerbate outcomes among depressed youth, leading to subsequent use of acute services. During the past decade, various policies aimed at improving coverage continuity have been implemented in state Medicaid programs. However, there is little empirical evidence on whether these policies actually improve Medicaid continuity and how they affect healthcare utilization among depressed youth.

One policy, Express Lane Eligibility (ELE), enables states to simplify Medicaid eligibility recertification processes for youth and potentially reduce their coverage disruptions. ELE allows Medicaid to use other agencies’ data to certify and renew children’s eligibility, even if the agencies use different methodologies to determine income or other criteria. This study estimates the impact of ELE on Medicaid coverage continuity and its downstream effect on acute care utilization among children with depression.

Methods:

We identified 97,730 Medicaid-insured youth beneficiaries (<18 years old) with a depression diagnosis using 2008-2011 Medicaid Analytic eXtract File data from seven states. We measured the following outcomes during the year after index depression diagnoses: (1) any coverage disruption, defined as an enrollment gap of more than one month; (2) length of coverage disruptions; (3) number of emergency department (ED) visits; (4) number of inpatient episodes; and (5) total inpatient days. We employed a quasi-experimental difference-in-difference method, combined with propensity score weighting, to separately compare outcomes among youth living in Louisiana and Alabama (which implemented ELE) versus among those residing in Missouri, Virginia, Texas, Georgia, and North Carolina (which did not adopt ELE) before versus after ELE implementations.

Results:

In Alabama, ELE implementation led to a 56% reduction in the likelihood of Medicaid coverage disruptions and a 53% reduction in the length of coverage disruptions [p<0.001] over the 9-month treatment period after depression diagnosis. ELE implementation in Alabama also led to a 19% reduction in total mental health related emergency department (ED) visits [p<0.05] during the treatment period. In Louisiana, the ELE processes had a counterintuitive positive effect on the disenrollment rate and the use of MH-related ED services [p<0.01], and had no effect on other outcomes.

Conclusions:

We observed heterogeneous effects of ELE implementation on coverage continuity and acute services utilization among youth with depression in Alabama and Louisiana. Alabama’s ELE implementation had a significant effect on reducing Medicaid coverage discontinuities for depressed youth, contributing to a downstream effect on the decreased use of acute services for mental disorders. As states continue their efforts to streamline enrollment and promote retention, strategies similar to Alabama’s ELE processes merit consideration. The counterintuitive ELE effects in Louisiana suggest that variation in how states operate ELE may result in disparate impacts on youth. More research is needed to investigate the heterogeneity in the long-term effect of ELE on vulnerable populations.