Relationship Between the Types of Insurance Coverage and Outpatient Mental Health Treatment Use Among Older Adults

Abstract

Using the public use data files of the 2008 to 2012 National Survey on Drug Use and Health, this study examined (a) the payment sources for mental health treatment among those aged 50 to 64 years and those aged 65+ years and (b) the relationship between outpatient mental health treatment use and different types of insurance coverage among members of these two age groups. The results show that 16% of the 50 to 64 age group and 10% of the 65+ age group used inpatient or outpatient mental health treatment in the preceding year. Logistic regression analyses showed that mental health problem severity and public insurance programs (Medicare, Medicaid, and Department of Veterans Affairs [VA]/military insurance) significantly increased the odds of receiving outpatient treatment. Private insurance was not a significant factor for either age group. Older adults with mental health problems must be encouraged to seek treatment and need to be informed about mental health coverage included in their insurance(s).

Keywords

mental health treatment insurance coverage public mental health programs symptom severity

Community-residing older adults are less likely to perceive a need for and use professional mental health services than younger adults (Choi, DiNitto, & Marti, 2014). The Collaborative Psychiatric Epidemiologic Surveys (CPES) conducted from 2001 to 2003 found that less than 30% of those aged 55 years or older with mood and/or anxiety disorders had used any mental health services in the preceding year (Byers, Arean, & Yaffe, 2012; Garrido, Kane, Kaas, & Kane, 2011; Mackenzie, Pagura, & Sareen, 2010). A study of older Medicare fee-for-service beneficiaries (aged 65+ years) between 2003 and 2005 also found that less than a quarter of those with a depression diagnosis received any depression treatment (Akincigil et al., 2011). Data from the 2004-2007 National Survey of Drug Use and Health (NSDUH) showed that 38% of those aged 65 years or older with past-year serious psychological distress (SPD) received mental health services in the preceding year (Han, Gfroerer, Colpe, Barker, & Colliver, 2011). Research also showed that treatment for the majority of older adults who used any mental health service consisted of prescription medication from primary care physicians, whereas only a small minority received psychotherapy from specialty mental health care providers. For example, Akincigil et al. (2011) found that among Medicare beneficiaries with a depression diagnosis, the proportion receiving antidepressants increased from 53.7% to 67.1% between 1992 and 2005, whereas the proportion receiving psychotherapy declined from 26.1% to 14.8% during the same period.

Limited mental health service use, especially lack of specialty treatment, among older adults stems from attitudinal barriers such as sense of stigma, lack of perceived need, and desire to handle problems alone (e.g., self-sufficiency beliefs) as well as system-level barriers such as shortages of mental health providers and geriatric mental health programs and inadequate or discriminatory financing of mental health care (Bartels, 2003; Ell, 2006; Mackenzie et al., 2010). Older adults also mentioned treatment costs as a deterrent to mental health care (Sirey, Franklin, McKenzie, Ghosh, & Raue, 2014; Weinberger, Mateo, & Sirey, 2009). Choi et al. (2014) also found that more than onethird of adults aged 50 years or older who perceived the need for mental health treatment but had not used it reported costs and lack of insurance as a reason for not accessing it. However, little research has examined whether older adults’ mental health treatment use is associated with their insurance coverage. Although more than 95% of older adults aged 65 years or older have Medicare coverage, it is not clear if other types of insurance coverage may facilitate treatment access. The purposes of this study were to examine (a) the payment sources for mental health treatment among those aged 50 to 64 years and those aged 65+ years as reported by those who received mental health treatment during the preceding 12 months and (b) the relationship between outpatient mental health treatment use and different types of insurance coverage in these two age groups.

Background, Conceptual Framework, and Hypotheses

Mental Health Treatment Payment Sources

Mental health care spending has remained at less than 7% of all health care spending in the United States for more than two decades, and most mental health treatment care is covered by public sources (Levit et al., 2008; Substance Abuse and Mental Health Services Administration [SAMHSA], 2013a, 2013b). For example, public payers, including Medicare, Medicaid, Department of Veterans Affairs (VA), Department of Defense, SAMHSA-administered block grants, the Indian Health Service, and state/local mental health agency programs, paid for 60% of all mental health treatment (compared with 49% of all health care treatment) in 2009 (SAMHSA, 2013b). Private payers, including consumer out-of-pocket expenses, private insurance, and spending from philanthropic and other nonpatient revenue sources, paid for the remaining 40%. Of the US$147 billion spent on mental health care in 2009, Medicare paid 13%, Medicaid 27%, other federal programs 5%, other state/local programs 15%, out-of-pocket expenses 11%, private insurance 26%, and other private sources 3% (SAMHSA, 2013b). Thus, among private payment sources, private health insurance was the largest payer, followed by out-of-pocket expenses. Between 1986 and 2005, office-based specialty providers of mental health and substance abuse treatment services continued to largely depend on private insurance and out-of-pocket payments, whereas hospitals’ share of funding from private insurance decreased (Levit et al., 2013).

Data on payment sources and distributions by age group are not available; however, public spending is estimated to be an even greater proportion of all mental health care spending for the 65+ age group as almost all older adults are covered by Medicare and more than half of older men in this age group are veterans and may be eligible for VA health care (Federal Interagency Forum on Aging-Related Statistics, 2012). In 2011, of all Medicare fee-for-service beneficiaries, 2.4 million or 8.4% of those aged 65+ years and 2.0 million or 25% of those aged below 65 years had Medicare mental health claims (SAMHSA, 2013a). In terms of treatment providers and/or modality, 1.4% of all Medicare fee-for-service beneficiaries with a mental health claim received mental health care from a home health agency, hospice, or skilled nursing facility, 5.7% received inpatient treatment, and 93% received outpatient/noninstitutional services, including services rendered in outpatient facilities such as hospital outpatient departments, rural health clinics, renal dialysis facilities, outpatient rehabilitation facilities, and community mental health centers, or services provided by noninstitutional providers, such as physicians, physician assistants, psychologists, clinical social workers, and nurse practitioners (SAMHSA, 2013a).

These data show that (a) only a small percentage of older adults receive mental health treatment, (b) the vast majority of those who do receive care get outpatient treatment, (c) this outpatient care largely consists of primary care physician visits where prescription medications are the most common treatment modality, and (d) only a small portion get psychotherapy (Akincigil et al., 2011; Bogner, de Vries, Maulik, & Unützer, 2009). Prior to implementation of Medicare outpatient mental health parity in 2014, the co-payment rate for outpatient mental health treatment was 50%, in contrast to a 20% co-payment for medical and surgical treatment. The substantial cost for psychotherapy visits posed a significant barrier to accessing mental health services unless one had supplemental Medicare (“medigap”) insurance approved by the Centers for Medicare and Medicaid Services or other private health insurance such as employer-provided coverage that covered the 50% co-payment (Bartels, 2003). Thus, private health insurance may also be an important part of older adults’ mental health care spending. For Medicare and Medicaid dual eligibles, Medicaid may pay for the co-payment for outpatient visits; thus, Medicaid may be another resource positively associated with mental health treatment use.

Conceptual Framework and Hypotheses

The conceptual framework for this study is Andersen’s (1995) behavioral model of health service use. According to Andersen’s model, health service access and utilization is a function of (a) predisposition to service use, (b) personal and system-level factors that enable or impede use, and (c) individuals’ perceived treatment need. Predisposing factors include individuals’ demographic characteristics and attitudes, values, and knowledge about health and health services that might affect their perceptions of need and health service use. For example, racial/ethnic minority older adults are significantly less likely than non-Hispanic Whites to perceive a need for and use mental health care due to a higher level of stigma associated with mental health problems, cultural values and beliefs that emphasize the importance of self-sufficiency and religious coping rather than professional treatment use, more negative attitudes toward professional mental health treatment use, and a lack of insight into psychological problems (Conner, Copeland, Grote, Koeske, et al., 2010; Conner, Copeland, Grote, Rosen, et al., 2010; Jimenez, Bartels, Cardenas, & Alegría, 2013; Jimenez, Bartels, Cardenas, Dhaliwal, & Alegría, 2012). Older men are also less likely to use mental health services than older women (Garrido et al., 2011; Mackenzie, Scott, Mather, & Sareen, 2008). Factors that enable or impede service use include social support, income, insurance coverage, availability and accessibility of services, transportation to treatment, and waiting times. Based on data from the Baltimore Epidemiologic Catchment Area Cohort, Maulik, Eaton, and Bradshaw (2011) found that in general, higher levels of social support from spouse/partner, relatives, and friends in time of a life event were associated with reduced specialty psychiatric service use. Likewise, employed individuals may be less likely to use mental health services because they are more likely to be more socially connected. However, Choi et al. (2014) found that among middle-aged and older adults, college education and higher income were positively associated with mental health treatment use.

As for need factors, studies have found that severe symptom severity, psychiatric diagnoses, suicidal behaviors, bereavement, and past mental health service use were strong predictors of treatment use and/or perceived treatment need (Bogner et al., 2009; Byers et al., 2012; Mackenzie et al., 2010). Lack of perceived treatment need in itself was found to be a barrier to mental health service use among adults with mental disorders with or without comorbid substance dependence (Chen et al., 2013). A study based on two epidemiologic data sets (the 2006 NSDUH and the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions) also found that, after controlling for mental disorders, those with drug and/or alcohol abuse/dependence were more likely than those without substance use disorders (SUD) to use mental health services (Edlund, Booth, & Han, 2012). A CPES-based study also found that any alcohol abuse and dependence symptoms increased the odds of mental health treatment use among the 65+ age group (Garrido et al., 2011). The significant association between SUD and mental health treatment use may be because (a) mental health treatment is more common than SUD treatment, (b) individuals with SUD may believe they can get adequate treatment for their SUD from mental health service providers, and (c) they believe their psychiatric issues may be more a mental health problem than a SUD problem (Edlund et al., 2012). In the present study, we also included self-rated health as a need factor given its significant association with psychosocial aspects of health and long-term prognostic power for depression (Ambresin, Chondros, Dowrick, Herrman, & Gunn, 2014; Mavaddat et al., 2011).

Based on an examination of mental health care spending data and Andersen’s health services use model, we posited the following hypotheses:

Hypothesis 1 (H1): Controlling for predisposing factors (i.e., race/ethnicity and gender), other enabling factors (i.e., marital status, employment status, education, and income), and need factors (i.e., poorer self-rated health, major depressive episode, SPD, serious suicidal ideation, perceived unmet need for mental health treatment, and SUD), Medicare, Medicaid, and private health insurance will be positively associated with outpatient mental health treatment use for the 50 to 64 age group.

Hypothesis 2 (H2): Medicaid, VA coverage, and private insurance will be positively associated with outpatient mental health service use among the 65+ age group.

Given the near-universal Medicare coverage of older adults, Medicare was not included in the model for the 65+ age group. We also posited that

Hypothesis 3 (H3): Controlling for predisposing and enabling factors, all need factors will be associated with outpatient mental health treatment use among both the 50 to 64 and 65+ age groups.

Method

Data and Sample

Data for this study came from the public use files of the 2008 to 2012 NSDUH. The annual NSDUH series measures the prevalence of substance use among the civilian, noninstitutionalized, U.S. population aged 12 years or older (Inter-University Consortium for Political and Social Research [ICPSR], 2012). Questions about mental disorders and mental health and substance abuse treatment are also asked of respondents aged 18 years and older. Survey respondents were interviewed in private at their place of residence using a combination of methods (audio computer-assisted self-interview [ACASI], computer-assisted personal interview, and computer-assisted self-interview). ACASI is used to provide respondents with a highly private and confidential means of responding to questions and to increase the level of honest reporting of illicit drug use and other sensitive behaviors (ICPSR, 2012).

To increase the study’s power to detect low frequency events (e.g., illicit drug use disorders among older adults), we combined 5 years of data. The survey sampling and data collection methods for the variables examined in this study were the same for all 5 survey years. The total number of respondents who completed the survey was 55,739 in 2008, 55,772 in 2009, 57,873 in 2010, 58,397 in 2011, and 55,268 in 2012. The present study focused on the 29,634 respondents aged 50+ years from 2008 to 2012; 18,443 were 50 to 64 years of age and 11,191 were 65+ years of age. (The NSDUH public use data sets do not provide chronological age to protect respondent anonymity and the privacy of responses.) NSDUH’s multistage area probability sampling design made it unlikely that any duplication of survey respondents occurred in the pooled 5 years of survey data.

Measures

Mental health treatment use was measured with questions about staying overnight or longer in a hospital or other facility to receive treatment or counseling, and/or receiving any outpatient treatment or counseling for “any problem with emotions, nerves, or mental health (not including treatment for alcohol or drug use)” during the past 12 months (yes = 1, no = 0). Inpatient treatment settings included a private/public psychiatric hospital, a psychiatric unit of a general hospital, a medical unit of a hospital, other types of hospitals, and other inpatient/residential facilities. Outpatient treatment/counseling venues included an outpatient mental health clinic or center; the office of a private therapist, psychologist, psychiatrist, social worker, or counselor that was not part of a clinic; a doctor’s office that was not part of a clinic; an outpatient medical clinic; a partial day hospital or day treatment program; military/VA facility; work/parents’ work/employee assistance program (EAP)/job training/career counseling program; school/university setting/clinic/center; social services/human services; telephone counseling, hotline/crisis unspecified; and another place (ICPSR, 2012). In the NSDUH, prescription medication use was assessed with the question, “During the past 12 months, did you take any prescription medication that was prescribed for you to treat a mental or emotional condition?” Respondents were also asked if they received “treatment, counseling, or support” from the following alternative sources: acupuncturists or acupressurists; chiropractors; herbalists; in-person support group or self-help group; Internet support group or chat room; spiritual or religious advisors, such as a pastor, priest, rabbi; telephone hotlines; and massage therapists. In the present study, mental health treatment use refers to treatment (including prescription medications) received from inpatient or outpatient settings listed above (referred to as “professional care” hereafter). Treatment received solely from alternative sources was excluded as insurance does not cover some of them (e.g., support groups, religious advisors, and massage therapists).

Sociodemographic variables (predisposing factors) were race/ethnicity (Black, Hispanic, Asian/other, and non-Hispanic White [reference category]) and gender (male vs. female).

Enabling factors other than insurance coverage were marital status (married vs. not married), educational level (college graduate vs. less than college education), income (income >200% vs. <200% of the federal poverty line [FPL]), and employment status (employed full- or part-time vs. not employed).

Insurance coverage types were Medicare, Medicaid, VA/military insurance (i.e., VA health care, Tricare, Champus, ChampVA, or other military health care), and private health insurance (“any type of health insurance other than Medicare, Medicaid and coverage provided to military personnel and their dependents; it includes coverage by a health maintenance organization [HMO], fee for service plans, and single service plans; obtained through the respondent’s or family member’s work, such as through an employer, union, or professional association”).

Each respondent was asked if he or she was covered by each of these insurances (yes = 1, no = 0 for each) at the time of the survey. Only 2.3% of all respondents aged 50+ years (and 2.4% [3.1% of the 50-64 age group and 0.7% of the 65+ age group] of those who received mental health treatment) reported any time in the preceding 12 months when they did not have health insurance. Thus, almost 98% of the study sample had no lapse in insurance coverage during the preceding year.

Self-rated health was measured on a 5-point scale (1 = excellent to 5 = poor).

Mental health problems included (a) major depressive episode (MDE) that met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV; American Psychiatric Association, 1994) diagnostic criteria during the worst/most severe period of time, lasting 2 weeks or longer, in the past 12 months (yes = 1, no = 0); (b) SPD (yes = 1, no = 0) measured with the six-item Kessler Psychological Distress Scale (K6; SPD = 1 if K6 ≥ 13 or 0 if K6 < 13; Kessler et al., 2003), experienced in the worst month in the past year (Cronbach’s α for the K6 among the study sample was .91); and (c) self-reported serious suicidal ideation (“At any time in the past 12 months . . . including today, did you seriously think about trying to kill yourself?” The question did not elaborate on the meaning of “seriously”; yes = 1 vs. no = 0).

Perceived unmet need for mental health treatment (perceived treatment need hereafter) was measured with the question, “During the past 12 months, was there any time you needed mental health treatment or counseling for yourself but didn’t get it?” (yes = 1 vs. no = 0).

Alcohol and/or illicit drug use disorder was measured with DSM-IV criteria for alcohol and illicit drug abuse and dependence. In the NSDUH, alcohol and marijuana abuse and dependence were assessed only if respondents reported use of the respective substance on more than 5 days in the preceding year, whereas all other illicit drug abuse and dependence were determined if any use was reported in the preceding year.

Analysis

All analyses were conducted with Stata/MP 13’s svy function to account for NSDUH’s multistage, stratified sampling design. Stata’s subpop command was used for all analyses of subsamples to ensure that variance estimates incorporate the full sampling design. For the 5-year pooled data set for this study, adjusted person-level analysis weights were created by dividing the final person-level analysis weights by the number of years of combined data (five in the current study) following NSDUH guidelines for combining sampling weights across multiple survey years. All estimates presented in this study are weighted except sample sizes. Descriptive statistics (χ² tests and t tests) were used to compare characteristics of mental health treatment users versus nonusers, and for treatment users, the types of treatment and treatment providers and payment sources for outpatient treatment in each age group. Then, multivariate binary logistic regression analyses were used to test the study hypotheses focusing on outpatient treatment use in each age group. The proportions of the sample that received inpatient treatment were small in both age groups (see the Results section below). Furthermore, inpatient treatment is less likely to be voluntary (of the user’s choice) than is outpatient treatment.

Results

Sample Characteristics by Mental Health Treatment Use

Table 1 shows that 16% of the 50 to 64 age group and 10% of the 65+ age group reported that they used inpatient or outpatient mental health treatment in the preceding year. For both age groups, treatment users were more likely to be non-Hispanic White and less likely to be male, employed, or to have served in the military than nonusers. For the 50 to 64 age group, treatment users were also less likely to be married and to have income >200% of FPL than nonusers. For the 65+ age group, treatment users were more likely to be college graduates than nonusers.

Table 1.

Sample Characteristics by Age Group.

	Age 50 to 64 (n = 18,443)				Age 65+ (n = 11,191)
Percent or M (SE)	All 100%	No MH treatment 83.90%	MH treatment 16.10%	p	All 100%	No MH treatment 90.05%	MH treatment 9.95%	p
Percent or M (SE)	All 100%	No MH treatment 83.90%	MH treatment 16.10%	p	All 100%	No MH treatment 90.05%	MH treatment 9.95%	p	Male	48.5	51.13	34.78	<.001	43.62	44.79	33.00	<.001
Race/ethnicity				<.001				<.001
Non-Hispanic White	73.64	71.71	83.69		79.75	78.72	87.33
Black	10.82	11.60	6.73		8.46	8.81	5.30
Hispanic	3.80	4.26	1.41		3.11	3.38	0.64
Asian	9.64	10.41	5.66		6.98	7.18	5.16
Other	2.11	2.03	2.50		1.70	1.71	1.57
Married	66.54	68.39	56.92	<.001	57.34	57.66	54.38	.126
Employed	68.79	71.45	54.97	<.001	21.20	21.62	17.36	.009
College graduate	31.96	31.79	32.89	.409	25.11	24.68	29.00	.039
Income ≥ 200% of FPL	75.48	76.67	69.28	<.001	69.86	69.78	70.62	.665
Military service	13.82	14.21	11.81	.002	25.96	26.47	21.33	.006
Insurance coverage
Medicare	8.18	6.41	17.37	<.001	94.58	94.53	95.02	.601
Medicaid	6.61	5.41	12.89	<.001	8.10	7.84	10.44	.024
VA/military insurance^a	5.83	5.46	7.76	<.001	11.04	10.78	13.38	.050
Private health insurance^b	73.84	75.34	66.06	<.001	66.39	66.66	63.91	<.001
Any health insurance	87.74	87.09	91.14	<.001	99.33	99.30	99.63	.006
Health status
Self-rated health^c	2.52 ± 0.02	2.46 ± 0.02	2.85 ± 0.03	<.001	2.75 ± 0.03	2.73 ± 0.03	3.01 ± 0.04	<.001
Fair or poor health	17.70	15.39	29.75	<.001	23.69	22.80	31.74	<.001
Past-year mental health problems, perceived mental health treatment need, and substance use disorders
Major depressive episode	7.11	3.07	28.16	<.001	2.40	1.29	12.49	<.001
Serious psychological distress	7.94	3.91	28.93	<.001	3.95	2.62	15.92	<.001
Serious suicidal thoughts	3.03	1.48	11.13	<.001	1.66	1.14	6.37	<.001
Perceived treatment need	3.48	1.70	12.74	<.001	1.13	0.41	7.60	<.001
Alcohol/drug abuse or dependence	4.90	4.10	9.04	<.001	1.78	1.45	4.82	<.001

Note. The p values denote differences between treatment users and nonusers. MH = mental health; FPL = Federal poverty line; VA = Department of Veterans Affairs.

Tricare, Champus, ChampVA, VA/military.

Including plans offered through employer, union, or professional association.

Higher ratings denote worse health.

With respect to insurance coverage at the time of survey, treatment users in both age groups had a higher rate of any insurance coverage than nonusers. Treatment users in the 50 to 64 age group were more likely than nonusers to have had Medicare, Medicaid, and VA/military insurance, but they were less likely to have had private health insurance. For the 65+ age group, users did not differ from nonusers in Medicare coverage, but users were more likely to have had Medicaid and VA/military insurance and less likely to have had private health insurance.

Treatment users in both age groups also had poorer self-ratings of health than nonusers. As expected, treatment users also had significantly higher rates of MDE, SPD, serious suicidal ideation, perceived treatment need, and alcohol and/or illicit drug use disorders. Further analyses (not displayed in Table 1) showed that 54% of the 50 to 64 age group and 39% of the 65+ age group with any past-year mental disorder (MDE, SPD, and serious suicidal thoughts) received mental health treatment while 7% of the 50 to 64 age group and 5% of the 65+ age group without any of these mental health problems received mental health treatment.

Provider and Type of Treatment and Payment Sources

Table 2 shows that of mental health treatment users, slightly less than 5% of the 50 to 64 age group and 7% of the 65+ age group received inpatient treatment; 46% of the younger group and 35% of the older group received outpatient treatment; and 88% of the younger group and 86% of the older group received pharmacotherapy. Further analysis found that 77% of the 50 to 64 age group and 73% of the 65+ age group who received outpatient treatment also received pharmacotherapy. Among treatment users, 24% of the 50 to 64 age group and 17% of the 65+ age group used alternative treatment along with professional treatment.

Table 2.

Provider and Type of Mental Health Treatment and Outpatient Treatment Payment Sources.

	Age 50 to 64	Age 65+	p
Treatment type	(n = 3,087)	(n = 1,079)
Inpatient treatment	4.67	6.62	.066
Outpatient treatment	46.00	35.32	<.001
Prescription medication	88.33	86.32	.226
Treatment provider	(n = 3,087)	(n = 1,079)
Professional only	76.14	83.17	<.001
Both professional and alternative	23.86	16.83	<.001
Outpatient treatment payment sources	(n = 1,433)	(n = 370)
Self and/or family member	33.54	21.45	<.001
Medicare	14.51	58.84	<.001
Medicaid	8.48	4.99	.054
VA/military insurance	6.66	13.16	<.001
Employer	8.22	1.27	<.001
Private health insurance	43.43	33.57	.008
Rehabilitation program	0.50	0.45	.908
Other public program	2.34	1.08	.429
Other private program	1.54	1.01	.395
Free treatment	2.71	1.75	.306
Medicare payment for outpatient treatment	(n = 1,433)	(n = 370)
Medicare only	7.46	30.20	<.001
Medicare + Medicaid	2.90	2.90	.994
Medicare + private insurance	2.02	18.81	<.001
Medicare + self/family	2.10	6.69	.001

Note. The p values denote differences between the 50-64 age group and the 65+ age group.

For the 50 to 64 age group, private insurance was the most frequent payer for those who received outpatient treatment (43%), followed by payment made by treatment users or their family members (34%), and Medicare (15%). For the 65+ age group, Medicare (alone or in combination with private insurance, patient/family out-of-pocket payment, and Medicaid) paid for outpatient treatment for the largest percentage of treatment users (59%), followed by private insurance (34%), payment by treatment users or their family members (21%), and VA/military insurance (13%).

Association Between Treatment Use and Symptom Severity and Insurance: Multivariate Analysis

Table 3 shows that of predisposing factors, being male and racial/ethnic minority status significantly decreased the odds of having received treatment in both age groups. Of enabling factors other than insurance coverage, being married and being employed decreased the odds of treatment in the 50 to 64 age group only, but college graduates had significantly higher odds of treatment receipt in both age groups. Income was not a significant factor for either age group.

Table 3.

Mental Health and Health Conditions and Insurance Coverage as Correlates of Outpatient Treatment Use Versus Nonuse: Odds Ratios (ORs) and 95% Confidence Intervals (CIs) From Logistic Regression Analysis.

	Age 50 to 64 (n = 18,443)		Age 65+ (n = 11,191)
	OR	95% CI	OR	95% CI
Male (female)	0.50***	[0.44, 0.57]	0.55***	[0.45, 0.67]
Black	0.40***	[0.33, 0.48]	0.51**	[0.34, 0.77]
Hispanic	0.41***	[0.33, 0.52]	0.53**	[0.34, 0.82]
Asian/other	0.46***	[0.32, 0.64]	0.40**	[0.21, 0.75]
(Non-Hispanic White)	0.46***	[0.32, 0.64]	0.40**	[0.21, 0.75]
Married	0.79**	[0.68, 0.91]	1.05	[0.85, 1.29]
(Not married)	0.79**	[0.68, 0.91]	1.05	[0.85, 1.29]
Employed	0.79**	[0.69, 0.90]	0.85	[0.69, 1.05]
(Not employed)	0.79**	[0.69, 0.90]	0.85	[0.69, 1.05]
College graduate	1.36***	[1.20, 1.55]	1.41**	[1.16, 1.72]
(No college degree)	1.36***	[1.20, 1.55]	1.41**	[1.16, 1.72]
Income > 200% of FPL	1.05	[0.89, 1.25]	1.14	[0.93, 1.39]
(Income < 200% of FPL)	1.05	[0.89, 1.25]	1.14	[0.93, 1.39]
Medicare	2.18***	[1.79, 2.65]
(No Medicare)	2.18***	[1.79, 2.65]
Medicaid	1.65***	[1.30, 2.10]	1.53*	[1.06, 2.20]
(No Medicaid)	1.65***	[1.30, 2.10]	1.53*	[1.06, 2.20]
VA/military insurance^a	1.60***	[1.26, 2.04]	1.44**	[1.10, 1.88]
(No VA/military insurance)	1.60***	[1.26, 2.04]	1.44**	[1.10, 1.88]
Private health insurance^b	1.14	[0.95, 1.36]	0.96	[0.79, 1.16]
(No private insurance)	1.14	[0.95, 1.36]	0.96	[0.79, 1.16]
Self-rated health^c	1.02*	[1.00, 1.04]	1.03*	[1.00, 1.05]
Major depressive disorder (MDE)	4.42***	[3.66, 5.33]	4.30***	[2.77, 6.68]
(No MDE)	4.42***	[3.66, 5.33]	4.30***	[2.77, 6.68]
Serious psychological distress (SPD)	3.45***	[2.89, 4.13]	3.60***	[2.52, 5.12]
(No SPD)	3.45***	[2.89, 4.13]	3.60***	[2.52, 5.12]
Serious suicidal thoughts	2.17***	[1.56, 3.01]	2.78***	[1.88, 4.10]
(No suicidal thoughts)	2.17***	[1.56, 3.01]	2.78***	[1.88, 4.10]
Perceived treatment need	2.22***	[1.68, 2.92]	9.40***	[5.31, 16.66]
(No perceived need)	2.22***	[1.68, 2.92]	9.40***	[5.31, 16.66]
Alcohol/drug abuse or dependence	1.89***	[1.39, 2.57]	3.07**	[1.65, 5.72]
(No abuse or dependence)	1.89***	[1.39, 2.57]	3.07**	[1.65, 5.72]

Note. F(18,43) = 64.82, design df = 60, p < .001 for the 50 to 64 age group; and F(17, 44) = 19.60, design df = 60, p < .001 for the 65+ age group. FPL = Federal poverty line; VA = Department of Veterans Affairs. Reference category is given within parenthesis.

Tricare, Champus, ChampVA, VA, military.

Including plans offered through employer, union, or professional association.

Higher ratings denote worse health.

***

p < .001; **p < .01; *p < .05

H1 and H2 were partially supported because public but not private insurance increased the odds of outpatient treatment for both age groups (Medicaid, and VA/military insurance were significant for both groups and Medicare was also significant for the 50 to 64 age group). H3 was fully supported because all need factors (MDE, SPD, serious suicidal thoughts, perceived treatment need, SUD, and poorer self-rated health) significantly increased the odds of having received outpatient treatment in both age groups.

Discussion

To fill a gap in research on older adults’ mental health treatment, this study examined the relationship between their outpatient mental health treatment use and different types of insurance coverage. As expected, Medicare (alone or in combination with private insurance) is the most common payer for the 65+ age group. Private insurance was a payment source for one third of treatment users in the 65+ age group and the largest group (more than 40%) of treatment users in the 50 to 64 age group. However, the study’s key finding is that for both age groups, public insurance programs, but not private insurance, were significant correlates of mental health treatment use, controlling for individuals’ predisposing, other enabling, and need factors.

Medicaid and VA/military insurance coverage were significant predictors of mental health treatment use for the 50 to 64 and the 65+ age groups. Medicare was also a significant predictor for the 50 to 64 age group (Medicare was not entered in the model for the 65+ age group because of near-universal coverage for this age group). Though mental health claims remain a small fraction of Medicare spending (3.0% in 1998, rising to 3.9% in 2009; SAMHSA, 2013a), the finding that Medicare is a significant correlate for the 50 to 64 age group is especially notable as it shows that Medicare facilitates access to both health and mental health care for disabled individuals in this age group. Medicaid, as a significant correlate of mental health treatment in both age groups, also shows that it facilitates access to treatment among those who may not have other sources of payment or need help with co-payments (e.g., low-income Medicare beneficiaries). The findings also demonstrate that mental health problem severity and perceived treatment need are the most important correlates of treatment use in both age groups. Higher rates of mental health problems among treatment users may have also resulted in significantly higher rates of perceived unmet treatment need. It appears that perception of treatment need (odds ratio [OR] = 9.40, 95% confidence interval [CI] = [5.31, 16.66]) is an especially important factor for treatment use in the 65+ age group. The significant association between SUD and mental health treatment use in the current study corroborates previous studies’ findings (Edlund et al., 2012; Garrido et al., 2011).

In sum, insurance coverage, especially public insurance programs, is an important contributor to older adults’ mental health treatment use. However, insurance coverage is a necessary, but not a sufficient, condition for treatment use. As Andersen’s behavioral model of health service use posits, predisposing and other enabling factors are also important contributors leading to treatment use. Even with insurance coverage, a lack of help-seeking behavior due to stigma, culture beliefs, lack of readiness to seek treatment, lack of insight into psychiatric problems, and lack of perceived treatment need pose barriers to older adults’ access to mental health treatment. Our findings corroborate previous studies that older men and racial/ethnic minorities are less likely to use mental health treatment. In addition, other structural problems, such as a lack of easily accessible outpatient specialty mental health programs and of mental health providers, especially those that focus on treating older adults, are likely to be significant barriers.

The present study has a few limitations that stem from data constraints. First, the study’s focus was on treatment access, not treatment retention or completion, because the NSDUH data did not indicate if treatment users received a full course of treatment. Previous studies indicate that treatment dropout is not uncommon among older adults (Lippens & Mackenzie, 2011). Second, as predisposing factors such as personal attitudes, values, and beliefs regarding mental health treatment were not available in the data set, gender and race/ethnicity were used as proxies. Third, system-level treatment access barriers (e.g., lack of availability or accessibility of treatment programs, including culturally and linguistically relevant programs that might appeal to members of racial/ethnic minority groups) were also not available in the data set; therefore, they could not be controlled in the multivariate analysis. Fourth, as the NSDUH measures respondents’ health insurance status at the time of the survey interview, health insurance coverage may differ from coverage at the time of mental health treatment. However, given that 98% had no coverage lapse in the preceding year, the probability of this was small. Despite these limitations, the study, based on a nationally representative sample, provides strong support that public insurance facilitates treatment access for those with late-life mental disorders.

Older adults with mental disorders tend to use health care more frequently than their peers without such problems. One study found that medically ill fee-for-service Medicare participants with depression incurred twice the health care costs as their counterparts without depression, with higher costs observed in every cost category except specialty mental health care, after adjusting for demographic and other clinical differences (Unützer et al., 2009). Treatment of depression and other mental disorders in late life should be regarded as an investment to reduce other health care costs, and more importantly, to reduce disease burden from both mental health and health problems and improve older adults’ quality of life.

The study’s policy, practice, and research implications are as follows: (a) Older adults, especially men and racial/ethnic minorities, need to be educated about the mental health coverage included in their insurance plan(s), and those with mental health problems must be encouraged to seek treatment. (b) Given that a significant proportion of older adult treatment users paid for treatment out-of-pocket, subsidy programs for co-payment and deductibles would help reduce low-income older adults’ financial burden for treatment. (c) Health care providers should pay increased attention to late-life mental disorders, as older adults with mental health problems tend to be under-identified and under-treated (Calleo et al., 2009). Clinician-diagnosed mental disorders are likely to help increase older adults’ perceived need for treatment. Health care providers’ identification of SUD is also likely to facilitate mental health treatment use among older adults. (d) Integrated behavioral health care programs in primary health care settings and treatment programs for comorbid mental and SUD may also be more effective for older adults as a single entry system is likely to reduce system barriers to accessing treatments for these problems separately. (e) Future research needs to examine if different types of insurance coverage may be associated with older adults’ retention and completion of mental health treatment. Future research should also examine if expanded private health insurance coverage and requirements for more insurance policies to provide parity for treatment of mental and SUD under the Patient Protection and Affordable Care Act of 2010, as well as expanded parity under Medicare, facilitates increased treatment use among those with mental and SUD, including older adults.

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.

Author Biographies

Namkee G. Choi, PhD, is a professor in the School of Social Work, University of Texas at Austin.

Diana M. DiNitto, PhD, is a professor in the School of Social Work, University of Texas at Austin.

C. Nathan Marti, PhD, is a lecturer and biostatistician in the School of Social Work, University of Texas at Austin.

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