At the Intersection of Health, Health Care and Policy Cite this article as: Tami L. Mark, Katharine R. Levit, Tracy Yee and Clifton M. Chow Spending On Mental And Substance Use Disorders Projected To Grow More Slowly Than All Health Spending Through 2020 Health Affairs, 33, no.8 (2014):1407-1415 doi: 10.1377/hlthaff.2014.0163
The online version of this article, along with updated information and services, is available at: http://content.healthaffairs.org/content/33/8/1407.full.html
For Reprints, Links & Permissions: http://healthaffairs.org/1340_reprints.php E-mail Alerts : http://content.healthaffairs.org/subscriptions/etoc.dtl To Subscribe: http://content.healthaffairs.org/subscriptions/online.shtml
Health Affairs is published monthly by Project HOPE at 7500 Old Georgetown Road, Suite 600, Bethesda, MD 20814-6133. Copyright © 2014 by Project HOPE - The People-to-People Health Foundation. As provided by United States copyright law (Title 17, U.S. Code), no part of Health Affairs may be reproduced, displayed, or transmitted in any form or by any means, electronic or mechanical, including photocopying or by information storage or retrieval systems, without prior written permission from the Publisher. All rights reserved.
Not for commercial use or unauthorized distribution Downloaded from content.healthaffairs.org by Health Affairs on July 26, 2015 at FLORIDA INTL UNIV
Spending Trends By Tami L. Mark, Katharine R. Levit, Tracy Yee, and Clifton M. Chow 10.1377/hlthaff.2014.0163 HEALTH AFFAIRS 33, NO. 8 (2014): 1407–1415 ©2014 Project HOPE— The People-to-People Health Foundation, Inc.
doi:
Spending On Mental And Substance Use Disorders Projected To Grow More Slowly Than All Health Spending Through 2020
Tami L. Mark is a vice president at Truven Health Analytics in Bethesda, Maryland.
Spending on mental and substance use disorders will likely grow more slowly than all health spending through 2020. We project that spending on mental and substance use disorders, as a share of all health spending, will fall from 7.4 percent in 2009 ($172 billion out of $2.3 trillion) to 6.5 percent in 2020 ($281 billion out of $4.3 trillion). This trend is the projected result of reduced spending on mental health drugs because of patent expirations, the low likelihood of innovative drugs entering the market, and a slowdown in spending growth for hospital treatment. By 2020 the expansion of coverage to previously uninsured Americans under the Affordable Care Act (ACA), combined with the projected slowdown in Medicare provider payment rates under the ACA and the Budget Control Act of 2011, are expected to add 2.7 percent to behavioral health spending, compared to spending without these changes. ABSTRACT
S
ince 1998 the Substance Abuse and Mental Health Services Administration (SAMHSA) has published historical estimates of spending for the treatment of mental and substance use disorders. Through this work SAMHSA has measured levels of spending and trends over time by payers and providers, using a framework analogous to the one used by the Centers for Medicare and Medicaid Services (CMS) to create estimates of all health spending. The historical spending estimates for mental and substance use disorders have revealed important trends in the financing and delivery of behavioral health treatment in the United States, such as the growth in spending for prescription medications to treat these conditions and the important role played by Medicaid in financing treatment.1,2 In this article we present spending projections through 2020 that are designed to anticipate how past trends based on data since 1986 may evolve or change in the future. These projections of spending for mental and substance use disor-
Katharine R. Levit (katharine [email protected]) is a director at Truven Health Analytics. Tracy Yee is a research leader at Truven Health Analytics. Clifton M. Chow is a research leader at Truven Health Analytics.
der treatment incorporate trends in spending for provider services and its payer sources as well as the expected impacts of the Affordable Care Act (ACA), both overall and by payer and provider.
Study Data And Methods Definitions Treatment services for mental and substance use disorders were defined by a subset of “mental disorders” codes—290 through 319— in the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9CM). We used principal diagnosis only to determine whether or not to include a treatment. We excluded dementias, tobacco use disorder, developmental delays, and intellectual disabilities.3 Our projections excluded costs not directly related to treatment, such as those stemming from lower productivity, missed workdays, or drug-related crimes. They also excluded expenditures for treating medical conditions that are caused by mental and substance use disorders, such as liver cirrhosis. We did not include serAugust 2014
33:8
Downloaded from content.healthaffairs.org by Health Affairs on July 26, 2015 at FLORIDA INTL UNIV
Health A ffairs
1407
Spending Trends vices through self-help groups such as Alcoholics Anonymous because these programs are free to participants. We included drugs that were administered for the treatment of mental and substance use disorders if their major indication was for the treatment of these conditions, regardless of the associated diagnosis. Baseline Methods We prepared the forecasts in two steps that were similar to those used to produce the national health spending projections.4 First, we calculated baseline projections using historical trends from 1986 through 2009 and selected additional information for 2010 through 2012. Second, we separately modeled the impacts of the ACA, which were added to the baseline projections. To create the baseline projections of spending on mental and substance use disorder treatment for each provider, we used five-factor and production models. The five-factor model allocates spending growth to changes in population, utilization, general inflation, net price increases specific to the service (net of general inflation), and residual changes in remaining influences. The production model was employed when suitable utilization and service-specific price measures required for the five-factor model were not available. This model develops projections from estimates of the costs of inputs used to produce services. For both types of models, each factor’s growth was projected using regression or actuarial techniques. Next, the growth rates were multiplied together in each year to forecast annual spending growth for that year. These annual growth rates were then applied to the previous year’s spending to produce the forecast. Forecasted spending was partitioned for each payer, and for mental health and substance use disorders separately, for 2010–20, based on relationships or trends found in historical estimates.5 Projections of prescription drug spending were developed separately by evaluating price per prescription, price inflation, population growth, and the timing of patent expirations and their impact on prices.6 Effects Of The Affordable Care Act Following the lead of CMS, we modeled the effects of the ACA separately and added those impacts to our baseline projections. We used two methods. First, we estimated the effects of the major insurance enrollment expansion on Medicaid, private insurance, and out-of-pocket spending as additional people become insured. Second, we estimated the legislative impacts that affected other payers, which included reductions in Medicare payment updates to certain providers and Medicare payment reductions from the Budget Con1408
H e a lt h A f fai r s
A ugus t 201 4
trol Act of 2011. In the first method we simulated the health care costs associated with people becoming newly insured under Medicaid or through the health insurance exchanges (Marketplaces) in 2014 and beyond. We used information from the Congressional Budget Office from May 2013 and data from the 2011 American Community Survey to estimate the number of people eligible for Medicaid and the Marketplaces.7,8 We estimated the number of eligible people expected to enroll based primarily on information from the Congressional Budget Office and a CMS actuarial report and memo.7,9,10 Data from the National Survey on Drug Use and Health11 provided statistics on the percentage of enrollees by income and insurance status who are current users of mental and substance use disorder treatment. For uninsured people gaining coverage under the ACA, we assumed an increase in spending of 25 percent, which reflects additional service use if the cost of treatment is partially paid by a third party.12 This increase is based on a similar assumption used by CMS. We estimated insurance treatment spending per user for mental and substance use disorders for Medicaid recipients based on 2008 Medicaid Analytic eXtract claims and for private insurance enrollees using the 2011 Truven Health MarketScan Research Databases. These point-in-time estimates of spending per user were escalated through 2020 using our baseline projections of Medicaid and private insurance spending for mental and substance use disorders and enrollment projections from the Congressional Budget Office. Out-of-pocket cost sharing for employer-sponsored insurance plans was based on information included in MarketScan claims; for Marketplace plans, it was based on information from the Massachusetts health reform efforts.13 To project the effects of the ACA on Medicare, other federal payers, and other private payers, we used trends exhibited in all health spending.4 More detailed information on our methods is available in a report we prepared under contract for SAMHSA.5 Limitations Projections always involve some level of uncertainty. Uncertainty increases when the projection period includes a new law, such as the ACA, that has not been fully implemented. Implementation usually reveals consequences that were not anticipated and may require a course correction to achieve the desired effect, which could change the trajectory of the projections. Assumptions regarding enrollment will be influenced by outreach efforts, ease of enrollment, and other factors that may alter spending
33 : 8
Downloaded from content.healthaffairs.org by Health Affairs on July 26, 2015 at FLORIDA INTL UNIV
trends. Although the prevalence of behavioral health conditions among uninsured adults is expected to be disproportionately high, this population’s ability to navigate the enrollment process may dampen the rate of enrollment for people with mental and substance use disorders. Also, treatment use rates for mental and substance use disorders may vary from expectations, and states that have declined to expand Medicaid may change that decision in the future. We have not attempted to estimate the effect of workforce shortages on the price of treatment. Nevertheless, these projections provide a reasonable scenario of treatment spending trends for mental and substance use disorders that can help policy makers anticipate and plan for the future.
Study Results Spending Projections Annual growth in treatment spending for mental and substance use disorders is expected to slow in relation to all health spending from 2009 through 2020 (Exhibit 1). From 1986 through 1998, spending on the treatment of mental and substance use disorders grew at an average annual rate that was 2 percentage points slower than spending on all health (6.0 percent and 8.1 percent, respectively). From 1998 through 2009, average annual growth rates in spending were similar for mental and substance use disorders (6.7 percent) and
for all health (6.8 percent).2 Between 2009 and 2020 we expect to see a return to slower spending growth for the treatment of mental and substance use disorders (4.6 percent annual average increase) than existed in the previous eleven years (6.7 percent) and growth that is slower than the average annual growth in all health spending (5.8 percent). Thus, the downward trend in the share of all health spending for treatment of these conditions—from 7.4 percent in 2009 to 6.5 percent in 2020—is expected to resume. This growth pattern is heavily influenced by the introduction and use of new medications to treat mental health conditions in the late 1990s, followed by the expiration of patents on important prescription drugs during 2010–20. Purchases of newly introduced medications boosted spending growth between 1998 and 2002 to rates 2.9 percentage points higher than they would have been if medications had been excluded from spending for mental and substance use disorder treatment (Exhibit 2). The rapid growth affected treatment spending for mental health conditions more than treatment spending for substance use disorders. This was primarily because of the large share of spending devoted to prescription drug treatment for mental health, compared to the drug spending share for treating substance use disorders (28 percent and 4 percent, respectively, in
Exhibit 1 Growth In Treatment Spending For Mental And Substance Use Disorders And All Health, 1986–2020
SOURCE Authors’ analysis of data created by the authors for the Office of Policy, Planning, and Innovation of the Substance Abuse and Mental Health Services Administration (see Note 5 in text); and data from the National Health Statistics Group of the Office of the Actuary, Centers for Medicare and Medicaid Services (see Note 4 in text). NOTES Growth represents percentage growth from prior year. In the case of 1987, the growth is from 1986 to 1987. Dashed lines denote projections (2010–20).
A u g u s t 201 4
3 3: 8
Downloaded from content.healthaffairs.org by Health Affairs on July 26, 2015 at FLORIDA INTL UNIV
H ea lt h A f fai r s
1409
Spending Trends Exhibit 2 Growth In Treatment Spending For Mental And Substance Use Disorders With And Without Prescription Drugs, 1986–2020
SOURCE Authors’ analysis of data created by the authors for the Office of Policy, Planning, and Innovation of the Substance Abuse and Mental Health Services Administration (see Note 5 in text). NOTES Growth represents percentage growth from prior year. In the case of 1987, the growth is from 1986 to 1987. Dashed lines denote projections (2010–20).
2009). From 2009 through 2020, patent loss will allow the entry into the market of generic products with prices assumed to be about 70 percent lower than the price of the brand-name equivalents. Pharmaceutical benefit managers will use various management techniques to encourage the rapid adoption of generic drugs as soon as they become available.6 The patent expirations affect major therapeutic products, including certain antipsychotics; medications for attention deficit hyperactivity disorder; certain antidepressants (serotoninnorepinephrine reuptake inhibitors); and addiction medications, including buprenorphine naloxone (Suboxone), for the treatment of opioid addiction. The impact on Medicaid will be substantial, because it pays for a disproportionately large share of many of these medications. Prescription drugs account for one-quarter of all treatment spending for mental and substance use disorders (compared with 11 percent of all health spending), and the development pipeline for new medications to treat these conditions is unlikely to produce innovative new drugs before 2020.6 Slow growth in behavioral health treatment spending is also expected to stem from spending trends in state-owned psychiatric hospitals. The 2007–09 recession and the slow recovery that followed produced shortfalls in states’ revenues through 2012. This forced the closure of state hospitals and psychiatric beds in many states— 1410
H e a lt h A f fai r s
A ugus t 201 4
a trend that began in the 1950s and is projected to continue through 2014.14 The ACA is expected to provide coverage for the treatment of mental and substance use disorders for millions of previously uninsured Americans. The Congressional Budget Office estimates that the act will add twenty-five million previously uninsured people to the Medicaid and private insurance rolls by 2020.7 Once uninsured people gain coverage, they tend to use more health care services than when they were uninsured, which increases overall spending. Economists are still debating the size of the increase and whether it is likely to be a onetime occurrence because of pent-up demand.15 We assumed that gaining coverage would result in a 25 percent increase in spending. Given reduced Medicare payments to providers, we project that the combined effects on expenditures in 2020 will be 2.7 percent higher than they would have been without these legislative changes. As described above, this increase is expected to be more than offset by the decrease in spending growth stemming from patent expirations during 2014–16. In addition to increasing expenditures for health care overall, the ACA and other legislative changes are expected to alter the distribution of financing among the major payers. Specifically, higher enrollment in Medicaid and private insurance plans will provide added financial protection to consumers. In 2020 this will result in higher spending for Medicaid (by $7.6 billion)
33 : 8
Downloaded from content.healthaffairs.org by Health Affairs on July 26, 2015 at FLORIDA INTL UNIV
and private insurance (by $2.6 billion) and lower out-of-pocket spending (by $1.0 billion) than we expect would have been the case without these legislative changes. Mental Health Treatment Spending Spending on mental health treatment is projected to increase more slowly than spending on substance use disorder treatment or on all health care from 2009 to 2020. Factors driving the slow growth are the expiration of patents on prescription medications used to treat mental illnesses and a slowdown in spending growth for hospital treatment for mental illnesses—which reflects, in part, the lingering effects of the 2007–09 recession. The expected increase in spending due to the implementation of the ACA is projected to be largely offset by declines in prices for a large number of prescription drugs that are expected to lose patent protection during 2014–16. Hospitals account for the second-largest share of mental health treatment spending among providers, after prescription medications. Specialty hospital expenditure growth is projected to slow through 2014 before regaining some momentum through 2020. The initial slowdown resulted from state hospital closures and reductions in beds between 2009 and 2012. Hospital spending was also affected by Medicare payment rate changes in the ACA and the Budget Control Act of 2011. Nevertheless, for hospitals of all types, mental health spending is expected to increase from $37.8 billion in 2009 to $54.8 billion in 2020 (Exhibit 3). We project that the ACA will increase mental health spending by 1.9 percent ($4.4 billion) in 2020. It will also alter mental health financing, primarily from Medicaid and private insurers. For example, in 2020 Medicaid spending in states that did not decline to expand enrollment is expected to be 7.8 percent ($5.2 billion) higher—and spending by private insurance is expected to be 3.4 percent ($2.0 billion) higher—than would have been the case without the ACA. Medicaid alone is expected to account for 36 percent of the increase in mental health spending from 2009 to 2020. Another 23 percent will come from private insurance, and 18 percent will come from Medicare. The remaining 23 percent will come from out-of-pocket, other private, other state, and other federal spending. Nevertheless, mental health spending by Medicaid is expected to be a small and falling share of Medicaid budgets, accounting for 10.4 percent of Medicaid spending in 2009 and a projected 7.9 percent in 2020.5 The Medicare funding share is expected to increase modestly, from 13 percent in 2009 to 14 percent in 2014, reaching 15 percent in
2020. The size of the Medicare population is increasing as the baby boomers reach the age of eligibility for Medicare. However, the effects on spending are expected to be tempered by reductions in payments to providers and Medicare Advantage plans that will result from the ACA and the Budget Control Act of 2011.16 Substance Use Disorder Treatment Spending Spending to treat substance use disorders accounted for 1 percent of all health spending in 2009 (Exhibit 4) and is anticipated to remain at that level in 2020 ($42.1 billion out of $4.3 trillion for all health spending). From 2009 through 2020, growth in spending to treat substance use disorders is expected to lag behind growth in spending for all health care (5.1 percent and 5.8 percent, respectively), which will continue a longstanding historical trend. The ACA and other legislative changes are expected to increase spending on substance use disorder treatment by 7.2 percent ($2.8 billion) in 2020, compared with the anticipated 1.9 percent increase in mental health treatment spending. The larger effect of the ACA on substance use disorder treatment spending, compared to mental health treatment spending, reflects the fact that substance use disorders are prevalent among young adults, who are overrepresented among those who are currently uninsured and may gain insurance.11,17 Moreover, many people with severe mental illnesses are already insured through Medicaid or Medicare by virtue of their mental health disability, which lowers the potential increase in treatment spending for mental health conditions after the ACA enrollment expansions.18 Unlike spending on mental health treatment, spending on treatment of substance use disorders is not likely to experience a slowdown in overall spending growth because of prescription medicines’ loss of patent protection. Medications losing patent protection or marketing exclusivity include buprenorphine HCL sublingual (Subutex) in 2009, buprenorphine naloxone sublingual (Suboxone) and acamprosate (Campral) in 2013, and some forms of naltrexone (Vivitrol) in 2017. These patent expirations are not expected to have a significant impact on substance use disorder spending, because prescription drugs accounted for only 4 percent of total spending for these disorders in 2009, and this share is projected to remain constant through 2020. The share of treatment spending on substance use disorders varies widely by payer. Although a major payer of all health care, private insurance is expected to pay only 0.5 percent of its total spending on substance use disorder treatment throughout the projection period. Similarly, August 2014
33:8
Downloaded from content.healthaffairs.org by Health Affairs on July 26, 2015 at FLORIDA INTL UNIV
Health A ffairs
1411
Spending Trends Exhibit 3 Amount Of And Growth In Treatment Spending For Mental And Substance Use Disorders And All Health By Category, Selected Years Expenditures ($ billions) Spending category
1986
2009
Average annual growth (%)
2014
2020
1986–2009
2009–14
2014–20
Mental health All service providers and products All hospitals General hospitals Specialty hospitals All physicians Other professionals Nursing homesa Home healtha Other residential, personal, and public health Retail prescription drugs Insurance administration
32.5 30.9 13.5 5.3 8.3 3.8 1.5 5.0 0.1 4.4 2.6 1.5
147.4 137.1 37.8 22.0 15.9 15.9 7.8 9.0 2.7 21.9 42.0 10.3
179.3 165.1 42.0 26.1 15.9 19.5 10.9 10.5 3.5 28.0 50.6 14.2
238.4 219.5 54.8 36.4 18.4 26.8 16.3 13.9 5.3 40.4 62.0 18.9
6.8 6.7 4.6 6.4 2.9 6.4 7.5 2.6 15.3 7.2 12.9 8.7
4.0 3.8 2.1 3.5 0.1 4.2 6.9 3.2 5.8 5.0 3.8 6.6
4.9 4.9 4.5 5.7 2.4 5.4 6.9 4.8 7.0 6.3 3.5 4.9
Substance use disorders All service providers and products All hospitals General hospitals Specialty hospitals All physicians Other professionals Nursing homesa Home healtha Other residential, personal, and public health Retail prescription drugs Insurance administration
9.1 8.6 4.2 2.8 1.4 0.9 0.7 0.1 0.0 2.7 0.0 0.5
24.3 22.8 7.5 5.4 2.1 1.1 2.6 0.4 0.1 10.1 0.9 1.5
31.3 29.1 8.9 6.8 2.2 1.4 4.2 0.5 0.2 12.1 1.8 2.2
42.1 39.0 12.5 9.9 2.6 1.9 6.2 0.7 0.3 15.6 1.8 3.0
4.4 4.4 2.5 2.9 1.7 1.0 6.3 5.4 18.0 6.0 24.2 4.8
5.2 5.0 3.5 4.5 0.8 4.9 9.7 4.2 7.1 3.5 15.2 8.0
5.1 5.0 5.8 6.6 3.0 5.2 6.9 5.1 7.1 4.4 -0.2 5.3
444.2 421.8 175.7 100.7 23.1 9.3 28.7 6.4 28.4 24.3 25.1 22.4
2,330.1 2,167.1 759.1 505.9 102.2 66.8 137.0 68.3 199.8 249.9 78.1 163.0
3,027.6 2,783.5 985.2 624.3 121.7 88.2 164.5 92.0 274.3 337.9 95.4 244.1
4,337.7 3,995.2 1,410.4 867.7 167.9 128.7 218.4 136.1 425.9 512.6 127.4 342.5
7.5 7.4 6.6 7.3 6.7 8.9 7.0 10.8 8.9 10.7 5.1 9.0
5.4 5.1 5.4 4.3 3.6 5.7 3.7 6.1 6.5 6.2 4.1 8.4
6.2 6.2 6.2 5.6 5.5 6.5 4.8 6.8 7.6 7.2 4.9 5.8
All health All service providers and products All hospitals All physicians Dentists Other professionals Nursing homesa Home healtha Other residential, personal, and public health Retail prescription drugs Durable and other nondurable medical products Insurance administration
SOURCE Authors’ analysis of data created by the authors for the Office of Policy, Planning, and Innovation of the Substance Abuse and Mental Health Services Administration (see Note 5 in text); and data from the National Health Statistics Group of the Office of the Actuary, Centers for Medicare and Medicaid Services (see Note 4 in text). NOTE The gross domestic product deflator was 2.4 for the period 1986–2009, 1.3 for the period 2009–14, and 2.0 for the period 2014–20. a Includes freestanding facilities only. Additional services of this type provided in hospital-based facilities are counted as hospital care.
Medicaid—a major payer for treatment that is projected to increase its enrollment as a result of the ACA—is expected to devote just 1.3 percent of its spending to treat substance use disorders in 2020, which is slightly less than the 1.4 percent share in 2009. As was the case historically, substance use disorder treatment is expected to be much more dependent on public financing (which is expected to account for 71 percent of spending on substance use disorder treatment in 2020), compared to treatment for mental health (63 percent) or all health (53 percent). Medicaid is projected to be responsible for a large—and the most rapidly increasing—share of spending (21 per1412
H e a lt h A f fai r s
A ugus t 201 4
cent in 2009 and 28 percent in 2020), as additional users of substance use disorder treatment services are added to the Medicaid rolls by 2020. The other important payer for treatment of substance use disorders is the category of other state and local government, which is anticipated to account for 28 percent of substance use treatment financing in 2020. New sources of financing for treating substance use disorders will be available through Medicaid and private insurance. This may allow states to more adequately meet the future demand for treatment than has been possible in the past. Sixty-seven percent of treatment spending for substance use disorders is projected to be spent
33 : 8
Downloaded from content.healthaffairs.org by Health Affairs on July 26, 2015 at FLORIDA INTL UNIV
Exhibit 4 Amount Of And Growth In Treatment Spending For Mental And Substance Use Disorders And All Health By Source Of Funds, Selected Years Expenditures ($ billions) Source of funds
1986
Mental and substance use disordersa Private, total Out-of-pocket Private insurance Other private Public, total Medicare Medicaid Other federal Other state and local Mental healthb Private, total Out-of-pocket Private insurance Other private Public, total Medicare Medicaid Other federal Other state and local Substance use disordersc Private, total Out-of-pocket Private insurance Other private Public, total Medicare Medicaid Other federal Other state and local All health Private, total Out-of-pocket Private insurance Other private Public, total Medicare Medicaid Other federal Other state and local
2009
Average annual growth (%) 2014
2020
41.5 18.5 6.9 9.5 2.1 23.1 2.4 6.4 3.0 11.2
171.7 66.6 18.8 42.6 5.2 105.1 20.5 44.2 10.5 29.9
210.5 78.4 21.3 51.2 5.9 132.1 26.5 59.9 12.3 33.4
280.5 101.1 26.4 66.4 8.3 179.4 37.6 84.0 15.0 42.8
32.5 14.0 5.7 6.6 1.8 18.4 2.1 5.6 2.0 8.8 9.1 4.4 1.2 2.9 0.3 4.6 0.3 0.9 1.0 2.5 444.2 262.3 104.1 135.8 22.3 181.9 76.8 45.4 21.0 38.7
147.4 58.9 16.2 38.7 4.0 88.5 19.3 39.1 7.8 22.2 24.3 7.7 2.6 3.9 1.2 16.7 1.2 5.2 2.7 7.6 2,330.1 1,188.8 299.3 801.2 88.3 1,141.3 502.3 376.8 112.0 150.1
179.3 69.0 18.4 46.1 4.5 110.3 24.9 52.0 8.8 24.5 31.3 9.4 3.0 5.1 1.3 21.9 1.6 7.9 3.5 8.9 3,027.6 1,458.6 330.3 1,013.7 114.6 1,569.0 636.8 586.8 157.7 187.6
238.4 88.9 22.7 59.7 6.5 149.5 35.3 72.1 11.0 31.2 42.1 12.2 3.7 6.7 1.8 29.9 2.3 11.9 4.1 11.7 4,337.7 2,020.2 443.8 1,402.0 174.4 2,317.5 922.0 908.1 223.8 263.7
1986–2009
2009–14
2014–20
6.4 5.7 4.4 6.7 4.1 6.8 9.8 8.7 5.6 4.3
4.2 3.3 2.5 3.8 2.4 4.7 5.2 6.3 3.3 2.3
4.9 4.3 3.6 4.4 5.9 5.2 6.0 5.8 3.4 4.2
6.8 6.4 4.7 8.0 3.6 7.1 10.2 8.8 6.1 4.1 4.4 2.4 3.4 1.2 6.3 5.7 5.7 8.2 4.5 5.0 7.5 6.8 4.7 8.0 6.2 8.3 8.5 9.6 7.6 6.1
4.0 3.2 2.5 3.6 2.5 4.5 5.2 5.9 2.5 2.0 5.2 4.2 2.7 5.8 1.9 5.6 5.4 9.0 5.2 3.1 5.4 4.2 2.0 4.8 5.4 6.6 4.9 9.3 7.1 4.6
4.9 4.3 3.6 4.4 6.2 5.2 6.0 5.6 3.6 4.1 5.1 4.4 3.8 4.7 4.7 5.3 6.5 6.9 2.7 4.6 6.2 5.6 5.0 5.6 7.2 6.7 6.4 7.5 6.0 5.8
SOURCE Authors’ analysis of data created by the authors for the Office of Policy, Planning, and Innovation of the Substance Abuse and Mental Health Services Administration (see Note 5 in text); and data from the National Health Statistics Group of the Office of the Actuary, Centers for Medicare and Medicaid Services. a Share of all health for 1986, 9.4 percent; 2009, 7.4 percent, 2014, 7.0 percent; and 2020, 6.5 percent. bShare of all health for 1986, 7.3 percent; 2009, 6.3 percent, 2014, 5.9 percent; and 2020, 5.5 percent. cShare of all health for 1986, 2.0 percent; 2009, 2014, and 2020, 1.0 percent.
in hospitals and specialty substance abuse or mental health treatment centers in 2020. This is a decrease from the 73 percent share in 2009. The trend reflects a likely increase in the share of spending for office-based physicians and other professionals as expansion of coverage improves access to these providers, beginning in 2014.
Conclusion These data present a twenty-four-year historical view and an eleven-year projection of treatment
spending for mental and substance use disorders. The data reveal some important conclusions about spending to treat these conditions. Many of the same forces that drive all health spending are expected to drive spending for mental and substance use disorders. CMS projects that all health spending growth is expected to accelerate between 2014 and 2020—slowly accelerating from the historically low growth rates experienced from 2009 through 2012. Improving economic conditions, insurance expansions, and the aging population are the main August 2014
33:8
Downloaded from content.healthaffairs.org by Health Affairs on July 26, 2015 at FLORIDA INTL UNIV
Health Affa irs
1413
Spending Trends anticipated drivers of increased spending rates.16 Similarly, we project that expanded coverage and an improving economy will increase spending on mental and substance use disorder treatment. However, slowed spending on medications stemming from generic drugs’ entry into the market is expected to dampen projected growth trends. Many therapeutic classes of medications are expected to be affected by the entry of generics. In addition, the share of mental health spending for medications that is larger than for all health and the concentration of patent expirations for mental health medications within a relatively condensed period make the effect of generics’ entry on spending growth for mental and substance use disorders more acute than it is on spending growth for all health. The role that prescription medications have played in driving mental health spending illustrates a general pattern that results when innovations, including new medications, are introduced. Spending growth rises as higher-priced innovations first become available and diffuse across patient populations. Over time, however, spending tends to return to historical rates, as the price of the innovation falls and the expansion of its use reaches a plateau. Understanding and balancing incentives for innovation with concerns about the affordability and costliness of health care remain key challenges for behavioral health policy, as they are for health care policy in general. We predict that the longstanding trend in payment for the treatment of mental and substance use disorders will continue: The share paid by insurance programs, particularly Medicaid, will increase, and the shares paid by state and local Results from this research were presented at the annual meeting of AcademyHealth, San Diego, California, June 7, 2014. These projections were funded by the Office of Policy, Planning, and Innovation of the Substance Abuse and Mental Health Services Administration (SAMHSA) (Task Order No. HHSS28329979929I/ HHSS29342002T, Center for Financing Research and Innovation). The authors
1414
H ea lt h A f fai r s
A u g u s t 201 4
governments and out of pocket by individuals will decrease. These changes give people with behavioral health conditions access to broader treatment options in general medical care settings, such as primary care physicians’ offices and general hospitals, which facilitates the integration of medical and behavioral health treatment. The ACA will accelerate the trend of increased insurance financing of behavioral health care. Numerous studies have documented that people without insurance have worse access to treatment, lower quality of care, and worse outcomes than their insured peers.19,20 Insurance also provides financial protection, particularly in case of a catastrophic illness. Recent data from the Oregon health study highlighted reduced depression rates as another potential benefit of having insurance—possibly stemming from the sense of improved financial security that it creates.12 The costs and benefits of the ACA are highly uncertain. Even under fairly aggressive assumptions, in which coverage of the uninsured results in a 25 percent increase in their per person spending, we project that the increase in spending on mental and substance use disorders will be only 2.7 percent higher in 2020 than it would have been without the effects of the ACA and other recent legislative changes. Because of the large percentage of people with substance use disorders who are currently uninsured, the effect of the recent changes on spending to treat this population is expected to be larger, at 7.2 percent. It will be critical to track the costs and benefits of the Affordable Care Act and its effects on people with mental and substance use disorders. ▪
acknowledge John Richardson, Sasha Frankel, Anne Pfuntner, Lauren Hughey, and Linda Lee from Truven Health Analytics; Edward King and Holen Chang from Actuarial Research Corporation; Dominic Hodgkin, Margaret O’Brien, and Cindy Parks Thomas from Brandeis University; Ted Lutterman from the National Association of State Mental Health Program Directors Research Institute; Rick Harwood from the
National Association of State Alcohol and Drug Abuse Directors; and staff at the Office of the Actuary of the Centers for Medicare and Medicaid Services for assistance in producing projections and advice and consultation on health spending trends. The opinions expressed in this article are those of the authors and not necessarily those of SAMHSA or the Department of Health and Human Services.
3 3: 8
Downloaded from content.healthaffairs.org by Health Affairs on July 26, 2015 at FLORIDA INTL UNIV
NOTES 1 Mark TL, Levit KR, VandivortWarren R, Buck JA, Coffey RM. Changes in US spending on mental health and substance abuse treatment, 1986–2005, and implications for policy. Health Aff (Millwood). 2011;30(2):284–92. 2 Levit KR, Mark TM, Coffey RM, Frankel S, Santora P, VandivortWarren R, et al. Federal spending on behavioral health accelerated during the recession as individuals lost employer insurance. Health Aff (Millwood). 2013;32(5):952–62. 3 Specifically, we excluded dementias (ICD-9-CM code 290), transient mental disorders caused by conditions classified elsewhere (293), persistent mental disorders caused by conditions classified elsewhere (294), tobacco abuse disorder (305.1), specific delays in development (315), psychic factors associated with disease classified elsewhere (316), and mental retardation (317–19). Cerebral degenerations (such as Alzheimer’s disease, 331.0) were not included. Two types of pregnancy-related complications were included: those mainly related to pregnancy drug dependence (648.3) and those mainly related to mental disorders (648.4). 4 Keehan SP, Sisko AM, Truffer CJ, Poisal JA, Cuckler GA, Madison AJ, et al. National health spending projections through 2020: economic recovery and reform drive faster health spending growth. Health Aff (Millwood). 2011;30(8):1594–605. 5 Substance Abuse and Mental Health Services Administration. Projections of national expenditures for treatment of mental and substance use disorders, 2010–2020. Rockville (MD): SAMHSA; forthcoming. 6 Hodgkin D, Thomas CP, O’Brien P, Levit K, Richardson J, Mark TL. Projections of national spending on psychotropic medications, 2013– 2020. (Manuscript in review). 7 Congressional Budget Office. CBO’s May 2013 estimate of the effects of the Affordable Care Act on health insurance coverage [Internet]. Washington (DC): CBO; [cited 2014 Jun 13]. Table 1. Available from: http://www.cbo.gov/sites/default/ files/cbofiles/attachments/439002013-05-ACA.pdf 8 Downloadable files containing information from the 2011 American
9
10
11
12
13
14
Community Survey are available from Census Bureau. American Community Survey [home page on the Internet]. Washington (DC): Census Bureau; [cited 2014 Jun 13]. Available from: http://www.census .gov/acs/www/data_ documentation/2011_release/ Centers for Medicare and Medicaid Services. Medicaid program; eligibility changes under the Affordable Care Act of 2010 [Internet]. Baltimore (MD): CMS; 2012 Mar [cited 2014 Jun 13]. Available from: http:// www.medicaid.gov/Affordable CareAct/downloads/CMS-2349-FRegulatoryImpactAnalysis.pdf Foster RS. Estimated financial effects of the “Patient Protection and Affordable Care Act,” as amended [Internet]. Baltimore (MD): Centers for Medicare and Medicaid Services; 2010 Apr 22 [cited 2014 Jun 13]. Available from: http://www.cms .gov/Research-Statistics-Data-andSystems/Research/Actuarial Studies/Downloads/PPACA_201004-22.pdf Substance Abuse and Mental Health Services Administration. Results from the 2012 National Survey on Drug Use and Health: summary of national findings [Internet]. Rockville (MD): SAMHSA; 2013 Sep [cited 2014 Jun 16]. (Publication No. SMA 13-4795). Available from: http://www.samhsa.gov/data/ NSDUH/2012SummNatFindDet Tables/NationalFindings/NSDUH results2012.pdf Finkelstein A, Taubman S, Wright B, Bernstein M, Gruber J, Newhouse JP, et al. The Oregon health insurance experiment: evidence from the first year [Internet]. Cambridge (MA): National Bureau of Economic Research; 2011 Jul [cited 2014 Jun 13]. (NBER Working Paper No. 17190). Available from: http:// www.nber.org/papers/w17190.pdf Day R. Health insurance exchanges: lessons learned in Massachusetts [Internet]. Slides presented at: CareCore National 2012 Healthcare Summit; Hilton Head, SC; 2012 Apr 12 [cited 2014 Jun 13]. Available from: http://www.carecore national.com/healthcaresummit/ powerpoints/RosemarieDay.pdf Lutterman T. The impact of the state fiscal crisis on state mental health systems: winter 2011–2012 update
15
16
17
18
19
20
[Internet]. Falls Church (VA): National Association of State Mental Health Program Directors Research Institute; 2012 Mar [cited 2014 Jun 13]. Available from: http:// www.nri-inc.org/reports_pubs/ 2012/BudgetShortfalls_2011_ 2012.pdf State Health Access Data Assistance Center. Pent-up demand for health care services among the newly insured [Internet]. Minneapolis (MN): SHADAC; 2005 Aug [cited 2014 Jun 13]. Available from: http://www .azahcccs.gov/reporting/ Downloads/HRSAgrant/ publications/SHADAC_FINAL_ REPORT.pdf Cuckler GA, Sisko AM, Keehan SP, Smith SD, Madison AJ, Poisal JA, et al. National health expenditure projections, 2012–22: slow growth until coverage expands and economy improves. Health Aff (Millwood). 2013;32(10):1820–31. Todd SR, Sommers BD. Overview of the uninsured in the United States: a summary of the 2012 current population survey report [Internet]. Washington (DC): Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation; 2012 Sep [cited 2014 Jun 13]. (ASPE Issue Brief). Available from: http://aspe.hhs.gov/ health/reports/2012/uninsured intheus/ib.shtml Substance Abuse and Mental Health Services Administration. National and state estimates of the prevalence of behavioral health conditions among the uninsured [Internet]. Rockville (MD): SAMHSA; 2013 Jul [cited 2014 Feb 10]. Available for download from: http://store .samhsa.gov/product/PEP13BHPREV-ACA Institute of Medicine. America’s uninsured crisis: consequences for health and health care [Internet]. Washington (DC): National Academies Press; 2009 Feb 23 [cited 2014 Feb 6]. Available for download from: http://www.iom.edu/Reports/ 2009/Americas-Uninsured-CrisisConsequences-for-Health-andHealth-Care.aspx Gresenz CR, Escarce JJ. Spillover effects of community uninsurance on working-age adults and seniors: an instrumental variables analysis. Med Care. 2011;49(9):e14–21.
August 2014
33:8
Downloaded from content.healthaffairs.org by Health Affairs on July 26, 2015 at FLORIDA INTL UNIV
Health Affa irs
1415
The online version of this article, along with updated information and services, is available at: http://content.healthaffairs.org/content/33/8/1407.full.html
For Reprints, Links & Permissions: http://healthaffairs.org/1340_reprints.php E-mail Alerts : http://content.healthaffairs.org/subscriptions/etoc.dtl To Subscribe: http://content.healthaffairs.org/subscriptions/online.shtml
Health Affairs is published monthly by Project HOPE at 7500 Old Georgetown Road, Suite 600, Bethesda, MD 20814-6133. Copyright © 2014 by Project HOPE - The People-to-People Health Foundation. As provided by United States copyright law (Title 17, U.S. Code), no part of Health Affairs may be reproduced, displayed, or transmitted in any form or by any means, electronic or mechanical, including photocopying or by information storage or retrieval systems, without prior written permission from the Publisher. All rights reserved.
Not for commercial use or unauthorized distribution Downloaded from content.healthaffairs.org by Health Affairs on July 26, 2015 at FLORIDA INTL UNIV
Spending Trends By Tami L. Mark, Katharine R. Levit, Tracy Yee, and Clifton M. Chow 10.1377/hlthaff.2014.0163 HEALTH AFFAIRS 33, NO. 8 (2014): 1407–1415 ©2014 Project HOPE— The People-to-People Health Foundation, Inc.
doi:
Spending On Mental And Substance Use Disorders Projected To Grow More Slowly Than All Health Spending Through 2020
Tami L. Mark is a vice president at Truven Health Analytics in Bethesda, Maryland.
Spending on mental and substance use disorders will likely grow more slowly than all health spending through 2020. We project that spending on mental and substance use disorders, as a share of all health spending, will fall from 7.4 percent in 2009 ($172 billion out of $2.3 trillion) to 6.5 percent in 2020 ($281 billion out of $4.3 trillion). This trend is the projected result of reduced spending on mental health drugs because of patent expirations, the low likelihood of innovative drugs entering the market, and a slowdown in spending growth for hospital treatment. By 2020 the expansion of coverage to previously uninsured Americans under the Affordable Care Act (ACA), combined with the projected slowdown in Medicare provider payment rates under the ACA and the Budget Control Act of 2011, are expected to add 2.7 percent to behavioral health spending, compared to spending without these changes. ABSTRACT
S
ince 1998 the Substance Abuse and Mental Health Services Administration (SAMHSA) has published historical estimates of spending for the treatment of mental and substance use disorders. Through this work SAMHSA has measured levels of spending and trends over time by payers and providers, using a framework analogous to the one used by the Centers for Medicare and Medicaid Services (CMS) to create estimates of all health spending. The historical spending estimates for mental and substance use disorders have revealed important trends in the financing and delivery of behavioral health treatment in the United States, such as the growth in spending for prescription medications to treat these conditions and the important role played by Medicaid in financing treatment.1,2 In this article we present spending projections through 2020 that are designed to anticipate how past trends based on data since 1986 may evolve or change in the future. These projections of spending for mental and substance use disor-
Katharine R. Levit (katharine [email protected]) is a director at Truven Health Analytics. Tracy Yee is a research leader at Truven Health Analytics. Clifton M. Chow is a research leader at Truven Health Analytics.
der treatment incorporate trends in spending for provider services and its payer sources as well as the expected impacts of the Affordable Care Act (ACA), both overall and by payer and provider.
Study Data And Methods Definitions Treatment services for mental and substance use disorders were defined by a subset of “mental disorders” codes—290 through 319— in the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9CM). We used principal diagnosis only to determine whether or not to include a treatment. We excluded dementias, tobacco use disorder, developmental delays, and intellectual disabilities.3 Our projections excluded costs not directly related to treatment, such as those stemming from lower productivity, missed workdays, or drug-related crimes. They also excluded expenditures for treating medical conditions that are caused by mental and substance use disorders, such as liver cirrhosis. We did not include serAugust 2014
33:8
Downloaded from content.healthaffairs.org by Health Affairs on July 26, 2015 at FLORIDA INTL UNIV
Health A ffairs
1407
Spending Trends vices through self-help groups such as Alcoholics Anonymous because these programs are free to participants. We included drugs that were administered for the treatment of mental and substance use disorders if their major indication was for the treatment of these conditions, regardless of the associated diagnosis. Baseline Methods We prepared the forecasts in two steps that were similar to those used to produce the national health spending projections.4 First, we calculated baseline projections using historical trends from 1986 through 2009 and selected additional information for 2010 through 2012. Second, we separately modeled the impacts of the ACA, which were added to the baseline projections. To create the baseline projections of spending on mental and substance use disorder treatment for each provider, we used five-factor and production models. The five-factor model allocates spending growth to changes in population, utilization, general inflation, net price increases specific to the service (net of general inflation), and residual changes in remaining influences. The production model was employed when suitable utilization and service-specific price measures required for the five-factor model were not available. This model develops projections from estimates of the costs of inputs used to produce services. For both types of models, each factor’s growth was projected using regression or actuarial techniques. Next, the growth rates were multiplied together in each year to forecast annual spending growth for that year. These annual growth rates were then applied to the previous year’s spending to produce the forecast. Forecasted spending was partitioned for each payer, and for mental health and substance use disorders separately, for 2010–20, based on relationships or trends found in historical estimates.5 Projections of prescription drug spending were developed separately by evaluating price per prescription, price inflation, population growth, and the timing of patent expirations and their impact on prices.6 Effects Of The Affordable Care Act Following the lead of CMS, we modeled the effects of the ACA separately and added those impacts to our baseline projections. We used two methods. First, we estimated the effects of the major insurance enrollment expansion on Medicaid, private insurance, and out-of-pocket spending as additional people become insured. Second, we estimated the legislative impacts that affected other payers, which included reductions in Medicare payment updates to certain providers and Medicare payment reductions from the Budget Con1408
H e a lt h A f fai r s
A ugus t 201 4
trol Act of 2011. In the first method we simulated the health care costs associated with people becoming newly insured under Medicaid or through the health insurance exchanges (Marketplaces) in 2014 and beyond. We used information from the Congressional Budget Office from May 2013 and data from the 2011 American Community Survey to estimate the number of people eligible for Medicaid and the Marketplaces.7,8 We estimated the number of eligible people expected to enroll based primarily on information from the Congressional Budget Office and a CMS actuarial report and memo.7,9,10 Data from the National Survey on Drug Use and Health11 provided statistics on the percentage of enrollees by income and insurance status who are current users of mental and substance use disorder treatment. For uninsured people gaining coverage under the ACA, we assumed an increase in spending of 25 percent, which reflects additional service use if the cost of treatment is partially paid by a third party.12 This increase is based on a similar assumption used by CMS. We estimated insurance treatment spending per user for mental and substance use disorders for Medicaid recipients based on 2008 Medicaid Analytic eXtract claims and for private insurance enrollees using the 2011 Truven Health MarketScan Research Databases. These point-in-time estimates of spending per user were escalated through 2020 using our baseline projections of Medicaid and private insurance spending for mental and substance use disorders and enrollment projections from the Congressional Budget Office. Out-of-pocket cost sharing for employer-sponsored insurance plans was based on information included in MarketScan claims; for Marketplace plans, it was based on information from the Massachusetts health reform efforts.13 To project the effects of the ACA on Medicare, other federal payers, and other private payers, we used trends exhibited in all health spending.4 More detailed information on our methods is available in a report we prepared under contract for SAMHSA.5 Limitations Projections always involve some level of uncertainty. Uncertainty increases when the projection period includes a new law, such as the ACA, that has not been fully implemented. Implementation usually reveals consequences that were not anticipated and may require a course correction to achieve the desired effect, which could change the trajectory of the projections. Assumptions regarding enrollment will be influenced by outreach efforts, ease of enrollment, and other factors that may alter spending
33 : 8
Downloaded from content.healthaffairs.org by Health Affairs on July 26, 2015 at FLORIDA INTL UNIV
trends. Although the prevalence of behavioral health conditions among uninsured adults is expected to be disproportionately high, this population’s ability to navigate the enrollment process may dampen the rate of enrollment for people with mental and substance use disorders. Also, treatment use rates for mental and substance use disorders may vary from expectations, and states that have declined to expand Medicaid may change that decision in the future. We have not attempted to estimate the effect of workforce shortages on the price of treatment. Nevertheless, these projections provide a reasonable scenario of treatment spending trends for mental and substance use disorders that can help policy makers anticipate and plan for the future.
Study Results Spending Projections Annual growth in treatment spending for mental and substance use disorders is expected to slow in relation to all health spending from 2009 through 2020 (Exhibit 1). From 1986 through 1998, spending on the treatment of mental and substance use disorders grew at an average annual rate that was 2 percentage points slower than spending on all health (6.0 percent and 8.1 percent, respectively). From 1998 through 2009, average annual growth rates in spending were similar for mental and substance use disorders (6.7 percent) and
for all health (6.8 percent).2 Between 2009 and 2020 we expect to see a return to slower spending growth for the treatment of mental and substance use disorders (4.6 percent annual average increase) than existed in the previous eleven years (6.7 percent) and growth that is slower than the average annual growth in all health spending (5.8 percent). Thus, the downward trend in the share of all health spending for treatment of these conditions—from 7.4 percent in 2009 to 6.5 percent in 2020—is expected to resume. This growth pattern is heavily influenced by the introduction and use of new medications to treat mental health conditions in the late 1990s, followed by the expiration of patents on important prescription drugs during 2010–20. Purchases of newly introduced medications boosted spending growth between 1998 and 2002 to rates 2.9 percentage points higher than they would have been if medications had been excluded from spending for mental and substance use disorder treatment (Exhibit 2). The rapid growth affected treatment spending for mental health conditions more than treatment spending for substance use disorders. This was primarily because of the large share of spending devoted to prescription drug treatment for mental health, compared to the drug spending share for treating substance use disorders (28 percent and 4 percent, respectively, in
Exhibit 1 Growth In Treatment Spending For Mental And Substance Use Disorders And All Health, 1986–2020
SOURCE Authors’ analysis of data created by the authors for the Office of Policy, Planning, and Innovation of the Substance Abuse and Mental Health Services Administration (see Note 5 in text); and data from the National Health Statistics Group of the Office of the Actuary, Centers for Medicare and Medicaid Services (see Note 4 in text). NOTES Growth represents percentage growth from prior year. In the case of 1987, the growth is from 1986 to 1987. Dashed lines denote projections (2010–20).
A u g u s t 201 4
3 3: 8
Downloaded from content.healthaffairs.org by Health Affairs on July 26, 2015 at FLORIDA INTL UNIV
H ea lt h A f fai r s
1409
Spending Trends Exhibit 2 Growth In Treatment Spending For Mental And Substance Use Disorders With And Without Prescription Drugs, 1986–2020
SOURCE Authors’ analysis of data created by the authors for the Office of Policy, Planning, and Innovation of the Substance Abuse and Mental Health Services Administration (see Note 5 in text). NOTES Growth represents percentage growth from prior year. In the case of 1987, the growth is from 1986 to 1987. Dashed lines denote projections (2010–20).
2009). From 2009 through 2020, patent loss will allow the entry into the market of generic products with prices assumed to be about 70 percent lower than the price of the brand-name equivalents. Pharmaceutical benefit managers will use various management techniques to encourage the rapid adoption of generic drugs as soon as they become available.6 The patent expirations affect major therapeutic products, including certain antipsychotics; medications for attention deficit hyperactivity disorder; certain antidepressants (serotoninnorepinephrine reuptake inhibitors); and addiction medications, including buprenorphine naloxone (Suboxone), for the treatment of opioid addiction. The impact on Medicaid will be substantial, because it pays for a disproportionately large share of many of these medications. Prescription drugs account for one-quarter of all treatment spending for mental and substance use disorders (compared with 11 percent of all health spending), and the development pipeline for new medications to treat these conditions is unlikely to produce innovative new drugs before 2020.6 Slow growth in behavioral health treatment spending is also expected to stem from spending trends in state-owned psychiatric hospitals. The 2007–09 recession and the slow recovery that followed produced shortfalls in states’ revenues through 2012. This forced the closure of state hospitals and psychiatric beds in many states— 1410
H e a lt h A f fai r s
A ugus t 201 4
a trend that began in the 1950s and is projected to continue through 2014.14 The ACA is expected to provide coverage for the treatment of mental and substance use disorders for millions of previously uninsured Americans. The Congressional Budget Office estimates that the act will add twenty-five million previously uninsured people to the Medicaid and private insurance rolls by 2020.7 Once uninsured people gain coverage, they tend to use more health care services than when they were uninsured, which increases overall spending. Economists are still debating the size of the increase and whether it is likely to be a onetime occurrence because of pent-up demand.15 We assumed that gaining coverage would result in a 25 percent increase in spending. Given reduced Medicare payments to providers, we project that the combined effects on expenditures in 2020 will be 2.7 percent higher than they would have been without these legislative changes. As described above, this increase is expected to be more than offset by the decrease in spending growth stemming from patent expirations during 2014–16. In addition to increasing expenditures for health care overall, the ACA and other legislative changes are expected to alter the distribution of financing among the major payers. Specifically, higher enrollment in Medicaid and private insurance plans will provide added financial protection to consumers. In 2020 this will result in higher spending for Medicaid (by $7.6 billion)
33 : 8
Downloaded from content.healthaffairs.org by Health Affairs on July 26, 2015 at FLORIDA INTL UNIV
and private insurance (by $2.6 billion) and lower out-of-pocket spending (by $1.0 billion) than we expect would have been the case without these legislative changes. Mental Health Treatment Spending Spending on mental health treatment is projected to increase more slowly than spending on substance use disorder treatment or on all health care from 2009 to 2020. Factors driving the slow growth are the expiration of patents on prescription medications used to treat mental illnesses and a slowdown in spending growth for hospital treatment for mental illnesses—which reflects, in part, the lingering effects of the 2007–09 recession. The expected increase in spending due to the implementation of the ACA is projected to be largely offset by declines in prices for a large number of prescription drugs that are expected to lose patent protection during 2014–16. Hospitals account for the second-largest share of mental health treatment spending among providers, after prescription medications. Specialty hospital expenditure growth is projected to slow through 2014 before regaining some momentum through 2020. The initial slowdown resulted from state hospital closures and reductions in beds between 2009 and 2012. Hospital spending was also affected by Medicare payment rate changes in the ACA and the Budget Control Act of 2011. Nevertheless, for hospitals of all types, mental health spending is expected to increase from $37.8 billion in 2009 to $54.8 billion in 2020 (Exhibit 3). We project that the ACA will increase mental health spending by 1.9 percent ($4.4 billion) in 2020. It will also alter mental health financing, primarily from Medicaid and private insurers. For example, in 2020 Medicaid spending in states that did not decline to expand enrollment is expected to be 7.8 percent ($5.2 billion) higher—and spending by private insurance is expected to be 3.4 percent ($2.0 billion) higher—than would have been the case without the ACA. Medicaid alone is expected to account for 36 percent of the increase in mental health spending from 2009 to 2020. Another 23 percent will come from private insurance, and 18 percent will come from Medicare. The remaining 23 percent will come from out-of-pocket, other private, other state, and other federal spending. Nevertheless, mental health spending by Medicaid is expected to be a small and falling share of Medicaid budgets, accounting for 10.4 percent of Medicaid spending in 2009 and a projected 7.9 percent in 2020.5 The Medicare funding share is expected to increase modestly, from 13 percent in 2009 to 14 percent in 2014, reaching 15 percent in
2020. The size of the Medicare population is increasing as the baby boomers reach the age of eligibility for Medicare. However, the effects on spending are expected to be tempered by reductions in payments to providers and Medicare Advantage plans that will result from the ACA and the Budget Control Act of 2011.16 Substance Use Disorder Treatment Spending Spending to treat substance use disorders accounted for 1 percent of all health spending in 2009 (Exhibit 4) and is anticipated to remain at that level in 2020 ($42.1 billion out of $4.3 trillion for all health spending). From 2009 through 2020, growth in spending to treat substance use disorders is expected to lag behind growth in spending for all health care (5.1 percent and 5.8 percent, respectively), which will continue a longstanding historical trend. The ACA and other legislative changes are expected to increase spending on substance use disorder treatment by 7.2 percent ($2.8 billion) in 2020, compared with the anticipated 1.9 percent increase in mental health treatment spending. The larger effect of the ACA on substance use disorder treatment spending, compared to mental health treatment spending, reflects the fact that substance use disorders are prevalent among young adults, who are overrepresented among those who are currently uninsured and may gain insurance.11,17 Moreover, many people with severe mental illnesses are already insured through Medicaid or Medicare by virtue of their mental health disability, which lowers the potential increase in treatment spending for mental health conditions after the ACA enrollment expansions.18 Unlike spending on mental health treatment, spending on treatment of substance use disorders is not likely to experience a slowdown in overall spending growth because of prescription medicines’ loss of patent protection. Medications losing patent protection or marketing exclusivity include buprenorphine HCL sublingual (Subutex) in 2009, buprenorphine naloxone sublingual (Suboxone) and acamprosate (Campral) in 2013, and some forms of naltrexone (Vivitrol) in 2017. These patent expirations are not expected to have a significant impact on substance use disorder spending, because prescription drugs accounted for only 4 percent of total spending for these disorders in 2009, and this share is projected to remain constant through 2020. The share of treatment spending on substance use disorders varies widely by payer. Although a major payer of all health care, private insurance is expected to pay only 0.5 percent of its total spending on substance use disorder treatment throughout the projection period. Similarly, August 2014
33:8
Downloaded from content.healthaffairs.org by Health Affairs on July 26, 2015 at FLORIDA INTL UNIV
Health A ffairs
1411
Spending Trends Exhibit 3 Amount Of And Growth In Treatment Spending For Mental And Substance Use Disorders And All Health By Category, Selected Years Expenditures ($ billions) Spending category
1986
2009
Average annual growth (%)
2014
2020
1986–2009
2009–14
2014–20
Mental health All service providers and products All hospitals General hospitals Specialty hospitals All physicians Other professionals Nursing homesa Home healtha Other residential, personal, and public health Retail prescription drugs Insurance administration
32.5 30.9 13.5 5.3 8.3 3.8 1.5 5.0 0.1 4.4 2.6 1.5
147.4 137.1 37.8 22.0 15.9 15.9 7.8 9.0 2.7 21.9 42.0 10.3
179.3 165.1 42.0 26.1 15.9 19.5 10.9 10.5 3.5 28.0 50.6 14.2
238.4 219.5 54.8 36.4 18.4 26.8 16.3 13.9 5.3 40.4 62.0 18.9
6.8 6.7 4.6 6.4 2.9 6.4 7.5 2.6 15.3 7.2 12.9 8.7
4.0 3.8 2.1 3.5 0.1 4.2 6.9 3.2 5.8 5.0 3.8 6.6
4.9 4.9 4.5 5.7 2.4 5.4 6.9 4.8 7.0 6.3 3.5 4.9
Substance use disorders All service providers and products All hospitals General hospitals Specialty hospitals All physicians Other professionals Nursing homesa Home healtha Other residential, personal, and public health Retail prescription drugs Insurance administration
9.1 8.6 4.2 2.8 1.4 0.9 0.7 0.1 0.0 2.7 0.0 0.5
24.3 22.8 7.5 5.4 2.1 1.1 2.6 0.4 0.1 10.1 0.9 1.5
31.3 29.1 8.9 6.8 2.2 1.4 4.2 0.5 0.2 12.1 1.8 2.2
42.1 39.0 12.5 9.9 2.6 1.9 6.2 0.7 0.3 15.6 1.8 3.0
4.4 4.4 2.5 2.9 1.7 1.0 6.3 5.4 18.0 6.0 24.2 4.8
5.2 5.0 3.5 4.5 0.8 4.9 9.7 4.2 7.1 3.5 15.2 8.0
5.1 5.0 5.8 6.6 3.0 5.2 6.9 5.1 7.1 4.4 -0.2 5.3
444.2 421.8 175.7 100.7 23.1 9.3 28.7 6.4 28.4 24.3 25.1 22.4
2,330.1 2,167.1 759.1 505.9 102.2 66.8 137.0 68.3 199.8 249.9 78.1 163.0
3,027.6 2,783.5 985.2 624.3 121.7 88.2 164.5 92.0 274.3 337.9 95.4 244.1
4,337.7 3,995.2 1,410.4 867.7 167.9 128.7 218.4 136.1 425.9 512.6 127.4 342.5
7.5 7.4 6.6 7.3 6.7 8.9 7.0 10.8 8.9 10.7 5.1 9.0
5.4 5.1 5.4 4.3 3.6 5.7 3.7 6.1 6.5 6.2 4.1 8.4
6.2 6.2 6.2 5.6 5.5 6.5 4.8 6.8 7.6 7.2 4.9 5.8
All health All service providers and products All hospitals All physicians Dentists Other professionals Nursing homesa Home healtha Other residential, personal, and public health Retail prescription drugs Durable and other nondurable medical products Insurance administration
SOURCE Authors’ analysis of data created by the authors for the Office of Policy, Planning, and Innovation of the Substance Abuse and Mental Health Services Administration (see Note 5 in text); and data from the National Health Statistics Group of the Office of the Actuary, Centers for Medicare and Medicaid Services (see Note 4 in text). NOTE The gross domestic product deflator was 2.4 for the period 1986–2009, 1.3 for the period 2009–14, and 2.0 for the period 2014–20. a Includes freestanding facilities only. Additional services of this type provided in hospital-based facilities are counted as hospital care.
Medicaid—a major payer for treatment that is projected to increase its enrollment as a result of the ACA—is expected to devote just 1.3 percent of its spending to treat substance use disorders in 2020, which is slightly less than the 1.4 percent share in 2009. As was the case historically, substance use disorder treatment is expected to be much more dependent on public financing (which is expected to account for 71 percent of spending on substance use disorder treatment in 2020), compared to treatment for mental health (63 percent) or all health (53 percent). Medicaid is projected to be responsible for a large—and the most rapidly increasing—share of spending (21 per1412
H e a lt h A f fai r s
A ugus t 201 4
cent in 2009 and 28 percent in 2020), as additional users of substance use disorder treatment services are added to the Medicaid rolls by 2020. The other important payer for treatment of substance use disorders is the category of other state and local government, which is anticipated to account for 28 percent of substance use treatment financing in 2020. New sources of financing for treating substance use disorders will be available through Medicaid and private insurance. This may allow states to more adequately meet the future demand for treatment than has been possible in the past. Sixty-seven percent of treatment spending for substance use disorders is projected to be spent
33 : 8
Downloaded from content.healthaffairs.org by Health Affairs on July 26, 2015 at FLORIDA INTL UNIV
Exhibit 4 Amount Of And Growth In Treatment Spending For Mental And Substance Use Disorders And All Health By Source Of Funds, Selected Years Expenditures ($ billions) Source of funds
1986
Mental and substance use disordersa Private, total Out-of-pocket Private insurance Other private Public, total Medicare Medicaid Other federal Other state and local Mental healthb Private, total Out-of-pocket Private insurance Other private Public, total Medicare Medicaid Other federal Other state and local Substance use disordersc Private, total Out-of-pocket Private insurance Other private Public, total Medicare Medicaid Other federal Other state and local All health Private, total Out-of-pocket Private insurance Other private Public, total Medicare Medicaid Other federal Other state and local
2009
Average annual growth (%) 2014
2020
41.5 18.5 6.9 9.5 2.1 23.1 2.4 6.4 3.0 11.2
171.7 66.6 18.8 42.6 5.2 105.1 20.5 44.2 10.5 29.9
210.5 78.4 21.3 51.2 5.9 132.1 26.5 59.9 12.3 33.4
280.5 101.1 26.4 66.4 8.3 179.4 37.6 84.0 15.0 42.8
32.5 14.0 5.7 6.6 1.8 18.4 2.1 5.6 2.0 8.8 9.1 4.4 1.2 2.9 0.3 4.6 0.3 0.9 1.0 2.5 444.2 262.3 104.1 135.8 22.3 181.9 76.8 45.4 21.0 38.7
147.4 58.9 16.2 38.7 4.0 88.5 19.3 39.1 7.8 22.2 24.3 7.7 2.6 3.9 1.2 16.7 1.2 5.2 2.7 7.6 2,330.1 1,188.8 299.3 801.2 88.3 1,141.3 502.3 376.8 112.0 150.1
179.3 69.0 18.4 46.1 4.5 110.3 24.9 52.0 8.8 24.5 31.3 9.4 3.0 5.1 1.3 21.9 1.6 7.9 3.5 8.9 3,027.6 1,458.6 330.3 1,013.7 114.6 1,569.0 636.8 586.8 157.7 187.6
238.4 88.9 22.7 59.7 6.5 149.5 35.3 72.1 11.0 31.2 42.1 12.2 3.7 6.7 1.8 29.9 2.3 11.9 4.1 11.7 4,337.7 2,020.2 443.8 1,402.0 174.4 2,317.5 922.0 908.1 223.8 263.7
1986–2009
2009–14
2014–20
6.4 5.7 4.4 6.7 4.1 6.8 9.8 8.7 5.6 4.3
4.2 3.3 2.5 3.8 2.4 4.7 5.2 6.3 3.3 2.3
4.9 4.3 3.6 4.4 5.9 5.2 6.0 5.8 3.4 4.2
6.8 6.4 4.7 8.0 3.6 7.1 10.2 8.8 6.1 4.1 4.4 2.4 3.4 1.2 6.3 5.7 5.7 8.2 4.5 5.0 7.5 6.8 4.7 8.0 6.2 8.3 8.5 9.6 7.6 6.1
4.0 3.2 2.5 3.6 2.5 4.5 5.2 5.9 2.5 2.0 5.2 4.2 2.7 5.8 1.9 5.6 5.4 9.0 5.2 3.1 5.4 4.2 2.0 4.8 5.4 6.6 4.9 9.3 7.1 4.6
4.9 4.3 3.6 4.4 6.2 5.2 6.0 5.6 3.6 4.1 5.1 4.4 3.8 4.7 4.7 5.3 6.5 6.9 2.7 4.6 6.2 5.6 5.0 5.6 7.2 6.7 6.4 7.5 6.0 5.8
SOURCE Authors’ analysis of data created by the authors for the Office of Policy, Planning, and Innovation of the Substance Abuse and Mental Health Services Administration (see Note 5 in text); and data from the National Health Statistics Group of the Office of the Actuary, Centers for Medicare and Medicaid Services. a Share of all health for 1986, 9.4 percent; 2009, 7.4 percent, 2014, 7.0 percent; and 2020, 6.5 percent. bShare of all health for 1986, 7.3 percent; 2009, 6.3 percent, 2014, 5.9 percent; and 2020, 5.5 percent. cShare of all health for 1986, 2.0 percent; 2009, 2014, and 2020, 1.0 percent.
in hospitals and specialty substance abuse or mental health treatment centers in 2020. This is a decrease from the 73 percent share in 2009. The trend reflects a likely increase in the share of spending for office-based physicians and other professionals as expansion of coverage improves access to these providers, beginning in 2014.
Conclusion These data present a twenty-four-year historical view and an eleven-year projection of treatment
spending for mental and substance use disorders. The data reveal some important conclusions about spending to treat these conditions. Many of the same forces that drive all health spending are expected to drive spending for mental and substance use disorders. CMS projects that all health spending growth is expected to accelerate between 2014 and 2020—slowly accelerating from the historically low growth rates experienced from 2009 through 2012. Improving economic conditions, insurance expansions, and the aging population are the main August 2014
33:8
Downloaded from content.healthaffairs.org by Health Affairs on July 26, 2015 at FLORIDA INTL UNIV
Health Affa irs
1413
Spending Trends anticipated drivers of increased spending rates.16 Similarly, we project that expanded coverage and an improving economy will increase spending on mental and substance use disorder treatment. However, slowed spending on medications stemming from generic drugs’ entry into the market is expected to dampen projected growth trends. Many therapeutic classes of medications are expected to be affected by the entry of generics. In addition, the share of mental health spending for medications that is larger than for all health and the concentration of patent expirations for mental health medications within a relatively condensed period make the effect of generics’ entry on spending growth for mental and substance use disorders more acute than it is on spending growth for all health. The role that prescription medications have played in driving mental health spending illustrates a general pattern that results when innovations, including new medications, are introduced. Spending growth rises as higher-priced innovations first become available and diffuse across patient populations. Over time, however, spending tends to return to historical rates, as the price of the innovation falls and the expansion of its use reaches a plateau. Understanding and balancing incentives for innovation with concerns about the affordability and costliness of health care remain key challenges for behavioral health policy, as they are for health care policy in general. We predict that the longstanding trend in payment for the treatment of mental and substance use disorders will continue: The share paid by insurance programs, particularly Medicaid, will increase, and the shares paid by state and local Results from this research were presented at the annual meeting of AcademyHealth, San Diego, California, June 7, 2014. These projections were funded by the Office of Policy, Planning, and Innovation of the Substance Abuse and Mental Health Services Administration (SAMHSA) (Task Order No. HHSS28329979929I/ HHSS29342002T, Center for Financing Research and Innovation). The authors
1414
H ea lt h A f fai r s
A u g u s t 201 4
governments and out of pocket by individuals will decrease. These changes give people with behavioral health conditions access to broader treatment options in general medical care settings, such as primary care physicians’ offices and general hospitals, which facilitates the integration of medical and behavioral health treatment. The ACA will accelerate the trend of increased insurance financing of behavioral health care. Numerous studies have documented that people without insurance have worse access to treatment, lower quality of care, and worse outcomes than their insured peers.19,20 Insurance also provides financial protection, particularly in case of a catastrophic illness. Recent data from the Oregon health study highlighted reduced depression rates as another potential benefit of having insurance—possibly stemming from the sense of improved financial security that it creates.12 The costs and benefits of the ACA are highly uncertain. Even under fairly aggressive assumptions, in which coverage of the uninsured results in a 25 percent increase in their per person spending, we project that the increase in spending on mental and substance use disorders will be only 2.7 percent higher in 2020 than it would have been without the effects of the ACA and other recent legislative changes. Because of the large percentage of people with substance use disorders who are currently uninsured, the effect of the recent changes on spending to treat this population is expected to be larger, at 7.2 percent. It will be critical to track the costs and benefits of the Affordable Care Act and its effects on people with mental and substance use disorders. ▪
acknowledge John Richardson, Sasha Frankel, Anne Pfuntner, Lauren Hughey, and Linda Lee from Truven Health Analytics; Edward King and Holen Chang from Actuarial Research Corporation; Dominic Hodgkin, Margaret O’Brien, and Cindy Parks Thomas from Brandeis University; Ted Lutterman from the National Association of State Mental Health Program Directors Research Institute; Rick Harwood from the
National Association of State Alcohol and Drug Abuse Directors; and staff at the Office of the Actuary of the Centers for Medicare and Medicaid Services for assistance in producing projections and advice and consultation on health spending trends. The opinions expressed in this article are those of the authors and not necessarily those of SAMHSA or the Department of Health and Human Services.
3 3: 8
Downloaded from content.healthaffairs.org by Health Affairs on July 26, 2015 at FLORIDA INTL UNIV
NOTES 1 Mark TL, Levit KR, VandivortWarren R, Buck JA, Coffey RM. Changes in US spending on mental health and substance abuse treatment, 1986–2005, and implications for policy. Health Aff (Millwood). 2011;30(2):284–92. 2 Levit KR, Mark TM, Coffey RM, Frankel S, Santora P, VandivortWarren R, et al. Federal spending on behavioral health accelerated during the recession as individuals lost employer insurance. Health Aff (Millwood). 2013;32(5):952–62. 3 Specifically, we excluded dementias (ICD-9-CM code 290), transient mental disorders caused by conditions classified elsewhere (293), persistent mental disorders caused by conditions classified elsewhere (294), tobacco abuse disorder (305.1), specific delays in development (315), psychic factors associated with disease classified elsewhere (316), and mental retardation (317–19). Cerebral degenerations (such as Alzheimer’s disease, 331.0) were not included. Two types of pregnancy-related complications were included: those mainly related to pregnancy drug dependence (648.3) and those mainly related to mental disorders (648.4). 4 Keehan SP, Sisko AM, Truffer CJ, Poisal JA, Cuckler GA, Madison AJ, et al. National health spending projections through 2020: economic recovery and reform drive faster health spending growth. Health Aff (Millwood). 2011;30(8):1594–605. 5 Substance Abuse and Mental Health Services Administration. Projections of national expenditures for treatment of mental and substance use disorders, 2010–2020. Rockville (MD): SAMHSA; forthcoming. 6 Hodgkin D, Thomas CP, O’Brien P, Levit K, Richardson J, Mark TL. Projections of national spending on psychotropic medications, 2013– 2020. (Manuscript in review). 7 Congressional Budget Office. CBO’s May 2013 estimate of the effects of the Affordable Care Act on health insurance coverage [Internet]. Washington (DC): CBO; [cited 2014 Jun 13]. Table 1. Available from: http://www.cbo.gov/sites/default/ files/cbofiles/attachments/439002013-05-ACA.pdf 8 Downloadable files containing information from the 2011 American
9
10
11
12
13
14
Community Survey are available from Census Bureau. American Community Survey [home page on the Internet]. Washington (DC): Census Bureau; [cited 2014 Jun 13]. Available from: http://www.census .gov/acs/www/data_ documentation/2011_release/ Centers for Medicare and Medicaid Services. Medicaid program; eligibility changes under the Affordable Care Act of 2010 [Internet]. Baltimore (MD): CMS; 2012 Mar [cited 2014 Jun 13]. Available from: http:// www.medicaid.gov/Affordable CareAct/downloads/CMS-2349-FRegulatoryImpactAnalysis.pdf Foster RS. Estimated financial effects of the “Patient Protection and Affordable Care Act,” as amended [Internet]. Baltimore (MD): Centers for Medicare and Medicaid Services; 2010 Apr 22 [cited 2014 Jun 13]. Available from: http://www.cms .gov/Research-Statistics-Data-andSystems/Research/Actuarial Studies/Downloads/PPACA_201004-22.pdf Substance Abuse and Mental Health Services Administration. Results from the 2012 National Survey on Drug Use and Health: summary of national findings [Internet]. Rockville (MD): SAMHSA; 2013 Sep [cited 2014 Jun 16]. (Publication No. SMA 13-4795). Available from: http://www.samhsa.gov/data/ NSDUH/2012SummNatFindDet Tables/NationalFindings/NSDUH results2012.pdf Finkelstein A, Taubman S, Wright B, Bernstein M, Gruber J, Newhouse JP, et al. The Oregon health insurance experiment: evidence from the first year [Internet]. Cambridge (MA): National Bureau of Economic Research; 2011 Jul [cited 2014 Jun 13]. (NBER Working Paper No. 17190). Available from: http:// www.nber.org/papers/w17190.pdf Day R. Health insurance exchanges: lessons learned in Massachusetts [Internet]. Slides presented at: CareCore National 2012 Healthcare Summit; Hilton Head, SC; 2012 Apr 12 [cited 2014 Jun 13]. Available from: http://www.carecore national.com/healthcaresummit/ powerpoints/RosemarieDay.pdf Lutterman T. The impact of the state fiscal crisis on state mental health systems: winter 2011–2012 update
15
16
17
18
19
20
[Internet]. Falls Church (VA): National Association of State Mental Health Program Directors Research Institute; 2012 Mar [cited 2014 Jun 13]. Available from: http:// www.nri-inc.org/reports_pubs/ 2012/BudgetShortfalls_2011_ 2012.pdf State Health Access Data Assistance Center. Pent-up demand for health care services among the newly insured [Internet]. Minneapolis (MN): SHADAC; 2005 Aug [cited 2014 Jun 13]. Available from: http://www .azahcccs.gov/reporting/ Downloads/HRSAgrant/ publications/SHADAC_FINAL_ REPORT.pdf Cuckler GA, Sisko AM, Keehan SP, Smith SD, Madison AJ, Poisal JA, et al. National health expenditure projections, 2012–22: slow growth until coverage expands and economy improves. Health Aff (Millwood). 2013;32(10):1820–31. Todd SR, Sommers BD. Overview of the uninsured in the United States: a summary of the 2012 current population survey report [Internet]. Washington (DC): Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation; 2012 Sep [cited 2014 Jun 13]. (ASPE Issue Brief). Available from: http://aspe.hhs.gov/ health/reports/2012/uninsured intheus/ib.shtml Substance Abuse and Mental Health Services Administration. National and state estimates of the prevalence of behavioral health conditions among the uninsured [Internet]. Rockville (MD): SAMHSA; 2013 Jul [cited 2014 Feb 10]. Available for download from: http://store .samhsa.gov/product/PEP13BHPREV-ACA Institute of Medicine. America’s uninsured crisis: consequences for health and health care [Internet]. Washington (DC): National Academies Press; 2009 Feb 23 [cited 2014 Feb 6]. Available for download from: http://www.iom.edu/Reports/ 2009/Americas-Uninsured-CrisisConsequences-for-Health-andHealth-Care.aspx Gresenz CR, Escarce JJ. Spillover effects of community uninsurance on working-age adults and seniors: an instrumental variables analysis. Med Care. 2011;49(9):e14–21.
August 2014
33:8
Downloaded from content.healthaffairs.org by Health Affairs on July 26, 2015 at FLORIDA INTL UNIV
Health Affa irs
1415
