National Estimates of Interruptions in Health Insurance Coverage Associated with Mental Health

Background

Health insurance is a key determinant of access to mental health care. Recent efforts to achieve equity in access have focused in part on increasing insurance coverage for groups that have been disproportionately less likely to be insured in the past. But consistency of coverage among those with mental illness (MI) is an important dimension of access that has received relatively little attention. Disruptions in coverage are likely to expose individuals to financial risk and diminish access to treatment. This is especially important for individuals with MI, as unmet health care need in that population continues to be high. In this study, we compared insurance coverage interruption rates between adults with and without MI.

Methods

We analyzed pooled cross-sectional data from the 2014-2015 National Survey on Drug Use and Health (NSDUH), an annual survey of the civilian, noninstitutionalized US population aged 12 and older. Our analytic sample included respondents aged 18-64 who had insurance when surveyed (N = 65,045). The primary outcome measure was whether respondents had had any past-year interruptions in coverage. We compared outcomes between respondents who met criteria for any past-year MI and those who did not with sub-analyses by severity of MI (mild, moderate, or serious). Mental illness was identified and measured in severity using NSDUH’s probabilistic algorithm based on the K6 and WHODAS scales. Unadjusted and adjusted differences were estimated using logistic regression models. Covariates included age, sex, race/ethnicity, marital status, overall self-reported health, education, employment, and family income. We used weighting procedures to account for the complex survey design and to make estimates nationally representative.

Results

NSDUH respondents were equally likely to have health insurance regardless of MI (any: 85.5%, none: 86.3%; P = 0.077). Among those who were insured, those with any MI were younger and more likely to be male, non-Hispanic white, unmarried, in worse overall health, and of lower socioeconomic status compared to those with no MI. In unadjusted comparisons, those with any MI were about 46.5% more likely than those with no MI to have experienced a past-year interruption in insurance coverage (any: 12.6%, none: 8.6%; P < 0.001). The difference was largest for those with serious MI, who were about 65.0% more likely to have had a coverage interruption than those with no MI (P < 0.001). In adjusted comparisons, those with any MI remained about 25.8% more likely to have an interruption (P < 0.001), and those with serious MI remained about 37.4% more likely (P < 0.001).

Discussion

This study reveals that interruptions in health insurance coverage are significantly more common among those with MI than those without MI. Overall, we found that approximately 4.1 million individuals with MI experienced past-year coverage interruptions as recently as 2015. Future insurance-oriented efforts aimed at improving access to care should focus not just on increasing overall coverage rates but also on eliminating interruptions in coverage. These interruptions disproportionately affect individuals with MI, exposing them to additional financial risk and barriers to receiving care when it is needed.