Did Medicaid Expansion Impact Caregivers' Mental Health Quality of Life?

Background/Purpose:

Caregivers play a crucial role in the lives of those in their care; yet, the majority of research on caregivers tends to focus on only one or two aspects of the caregiver’s identity or experience. Few studies have taken an intersectional approach to understanding the health and employment impacts of caregiving on individuals while also taking into consideration the state level policy context.  Using BRFSS data collected between 2015-2017, we sought to better understand differences among caregivers, paying particular attention to the caregiver’s age, race, gender and state.

Using state’s decision to expand Medicaid benefits under the Affordable Care Act, or not, as an opportunity for a natural experiment, this research will examine the impact of Medicaid expansion on caregivers paying particular attention to caregivers from oppressed populations.

Methods:

Of the 36 states that had caregiving data in the BRFFS: 23 states chose to expand benefits and 13 states chose not to expand Medicaid benefits. We excluded the remaining 15 states (and D.C.) that either did not have caregiving data or measured caregiving before Medicaid expansion.

We used indicator variables to determine caregiver and expansion state status. Mental health quality of life (MHQOL) was assessed as a self-report of the number of days in the past 30 days where the respondent’s mental health was not good; we also dichotomized that variable to reflect >=14 days of poor mental health.

We examined descriptive statistics of respondents’ demographics, socioeconomic status, health care and health behaviors, and caregiving behaviors by Medicaid expansion state status, testing for differences between groups with one-way ANOVA and chi-square tests. Lastly, we estimated regression models of caregivers’ MHQOL by expansion state status with two and three way interaction terms (caregiving x expansion; and caregiving x expansion x race/ethnicity).

Results:

Caregivers in Medicaid expansion states significantly differed from caregivers in non-Medicaid expansion states on nearly all demographic, socioeconomic, and health characteristics. Caregivers in Medicaid expansion states were more likely to be caring for a parent/parent in law, caregiving <8 hours per week, having been a caregiver for a shorter duration (<1 month), and more likely to be caring for someone with old age or dementia than those in non-expansion states. Notably, there were no significant differences in the types or frequency of supportive services that caregivers reported wanting between caregivers’ expansion state residence. However, there were significant differences in MHQOL: caregivers in Medicaid expansion states had significantly fewer days of poor mental health in the previous 30 days. This pattern of caregiver mental health by expansion state residence did not vary by race.

Conclusions and Implications:

Expansion state status had a significant impact on caregivers.  It may be that Medicaid expansion is a proxy for a larger health care policy environment. Recognizing the substantial impact caregivers have on their care recipient, understanding the differences observed may provide useful insights about the intended and unintended consequences of policies on individuals, communities, and systems of care.