Timing Is Everything: Examining the Impact of Mental Health Diagnosis on Time to Medicaid Disruption for Individuals with Serious Mental Illnesses

Background:  The passage of the Patient Protection Affordable Care Act (ACA) (P.L. 111-148) brought renewed attention to the need to expand access to healthcare. Research has found that access to insurance may be a necessary condition to support people’s efforts to obtain necessary healthcare. However, continuity in Medicaid enrollment is also a necessary step to ensuring optimal health outcomes for vulnerable populations such as people with serious mental illnesses (SMI).  Research has found that disruptions in Medicaid coverage are more common than expected among people with SMI. This study will contribute to our understanding of the volatility in access to Medicaid coverage among people with SMI by examining the time to disruption in Medicaid coverage and how this varies by mental health diagnosis.

Methods:  A retrospective longitudinal cohort study examined the Medicaid enrollment patterns between 2007-2010 for a cohort of people with SMI who received treatment services through the public mental health system in 2006. This cohort included 9,676 adults, age 18-61 living in a large metropolitan area in the Midwest. The mean age of participants was 40 (11.25). Six three percent of participants were women, 48% were black, and 69% and were single. Thirty nine percent had a primary diagnosis of schizophrenia, 33% major depression, 19% bi-polar disorder, and 10% anxiety disorder. The Kaplan-Meier Method was used to conduct a survival analysis that was stratified by mental health diagnosis.

Results: Of participants 6752 (70%) experienced at least one disruption in their Medicaid coverage during the study time period. Thirty-eight percent of individuals with a disruption had a primary diagnosis of schizophrenia, 32% major depression, 20% bi-polar disorder, and 10% had an anxiety disorder.  Survival curves found significant differences in time to first disruption in Medicaid coverage based on mental health diagnosis (Log-Rank X² 44.08, P <.001). The stratified curves showed that people with a diagnosis of schizophrenia spent the longest time on Medicaid before experiencing a disruption (Mdn=618 days) compared to individuals with depression (Mdn = 607), bipolar disorder (Mdn = 547), and anxiety (Mdn = 518).

 Conclusions and Implications: Individuals with SMI are disproportionately represented among Medicaid enrollees. Study findings showed that only 31% of individuals with SMI enrolled in Medicaid maintained continuous enrollment over the study period. Research has found that even relatively small breaks in Medicaid coverage have adverse effects on service use and health outcomes. Understanding the influence of mental health diagnosis on Medicaid enrollment has significant implications for implementing interventions that ensure retention of health insurance coverage as well as continuity in access to adequate healthcare for Medicaid eligible individuals with SMI.