National Survey on Drug Use and Health
Short Report
January 29, 2015*
Five young adult friends sitting on manicured green lawn looking quite happy.
In Brief
  • Insurance coverage among young adults aged 19 to 26 has trended upward since the extension of dependent care coverage by the Affordable Care Act.
  • Mental health service utilization has shown a similar upward trend, with more young adults reporting that they are receiving mental health treatment.
  • Since the dependent care expansion, overall substance use treatment remains level while fewer uninsured young adults report receiving substance use treatment.
  • Cost barriers associated with mental health service or substance use treatment have fallen in the wake of the dependent care expansion.
  • Payment for treatment has shifted away from public sources, with private insurance becoming a more prevalent source of payment. 
Trends in Insurance Coverage and Treatment Utilization by Young Adults
Authors

Chandler McClellan

In September of 2010, the Patient Protection and Affordable Care Act (ACA) extended dependent care coverage to young adults, allowing individuals under the age of 26 to remain on their parents’ insurance regardless of educational, employment, or marital status. Prior to the ACA, individuals were typically dropped from their parents’ insurance on their 19th birthday or upon their graduation from high school.1 As a result, the cohort aged 19 to 26 suffered from the highest rates of uninsurance, with approximately 30 percent of these individuals lacking coverage in the years before the ACA was enacted.2 Increasing insurance coverage among these individuals became a policy priority because lack of insurance coverage is associated with a number of adverse outcomes, including lower health care utilization rates and delay of care that often exacerbates medical conditions.3,4,5

This short report highlights the trends in mental health and substance use treatment service use by young adults aged 19 to 26 before and after the dependent care coverage extension. Examining the trends in coverage and utilization gives insight into the impact of the ACA’s dependent care coverage expansion. The results are estimates from the National Survey on Drug Use and Health (NSDUH) from 2005 to 2012.6 NSDUH, conducted by the Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) Center for Behavioral Health Statistics and Quality (CBHSQ), is a survey of the civilian, noninstitutionalized U.S. population that covers a wide range of issues, including insurance coverage and use of mental health and substance use treatment services. Standard statistical t-tests of means accounting for NSDUH’s complex survey design have been conducted for all statements appearing in the text that compares estimates between years. Unless otherwise noted, all statements that describe differences are significant at the .05 level.

Trends in Insurance Coverage

Figure 1 shows trends in insurance coverage for 2005 to 2012.7 Prior to passage of the ACA, NSDUH estimates indicate that insurance coverage rates among the cohort aged 19 to 26 hovered around 71 percent. This estimate is largely in line with estimates of insurance rates from other sources.2 After the dependent care coverage expansion in the second half of 2010, the NSDUH data show that young adults began to report higher rates of insurance coverage. Between the dependent care coverage extension and the end of 2012, estimates suggest an increase of 5.5 percent of young adults obtained insurance coverage. These estimates are also in line with data from other sources showing an increase in coverage of between 5.6 and 7.2 percentage points.8,9,10

Figure 1. Health insurance coverage among young adults aged 19 to 26: 2005 to 2012

Year	Data	Pre-Trend	Post-Trend 2005	Jan-June	70.95599	71.15314	  	July-Dec	70.89917	71.08931	  2006	Jan-June	71.38891	71.02549	  	July-Dec	69.71113	70.96166	  2007	Jan-June	71.1042  	70.89783	  	July-Dec	72.3896  	70.834    	  2008	Jan-June	70.62273	70.77017	  	July-Dec	72.07426	70.70634	  2009	Jan-June	70.2856  	70.64251	  	July-Dec	68.90829	70.57868	  2010	Jan-June	70.21717	70.51485	  	July-Dec	71.06795	70.45102	71.38204 2011	Jan-June	73.2979  	 	72.76256 	July-Dec	73.67584	 	74.14307 2012	Jan-June	76.10837	 	75.52358 	July-Dec	76.56528	 	76.90409
Trends in Receipt of Mental Health Services

Treatment service utilization is expected to increase as expanded insurance coverage removes significant cost barriers to seeking treatment.11 Figure 2 details trends in young adults reporting that they received mental health services in the previous year.12 Between the beginning of 2005 and the middle of 2010, there was a slight upward trend in rates of receipt of mental health services, with an average of 11.1 percent reporting receiving mental health services in the previous year. Prior to the coverage extension, approximately 10.9 percent of young adults reported receiving mental health services in the previous year. After the coverage extension, the trend in service rates turned sharply upward, with 11.9 percent of young adults reporting receiving services in the last half of 2012.

Figure 2. Receipt of mental health services in the past year among young adults aged 19 to 26: 2005 to 2012

Year	Data	Pre- Trend	Post Trend 2005	Jan-June	11.0123  	10.74937	   	July-Dec	11.26575	10.77603	   2006	Jan-June	10.75359	10.80268	   	July-Dec	10.47373	10.82934	   2007	Jan-June	10.52526	10.856    	   	July-Dec	10.27331	10.88266	   2008	Jan-June	10.5935  	10.90931	   	July-Dec	11.3077  	10.93597	   2009	Jan-June	11.37187	10.96263	   	July-Dec	11.08922	10.98929	   2010	Jan-June	11.14899	11.01594	   	July-Dec	10.9366  	11.0426  	11.04646 2011	Jan-June	11.25366	  	11.29141 	July-Dec	11.79373	  	11.53636 2012	Jan-June	11.8193  	  	11.78131 	July-Dec	11.87853	  	12.02626

Figure 3. Receipt of mental health services in the past year among young adults aged 19 to 26, by health insurance coverage: 2005 to 2012

Year	Uninsured Data	Pre- Trend	Post Trend	Insured Data	Pre- Trend	Post Trend 2005	Jan-June	8.2367     	8.060515	 	12.2	11.86354	  	July-Dec	9.215992	8.004464	 	12.1	11.92747	  2006	Jan-June	7.648877	7.948414	 	12.0	11.99139	  	July-Dec	8.393397	7.892363	 	11.4	12.05532	  2007	Jan-June	6.486404	7.836313	 	12.2	12.11925	  	July-Dec	6.994133	7.780262	 	11.5	12.18318	  2008	Jan-June	6.674502	7.724212	 	12.2	12.2471  	  	July-Dec	7.73356   	7.668161	 	12.7	12.31103	  2009	Jan-June	8.203151	7.612111	 	12.8	12.37496	  	July-Dec	7.901506	7.55606  	 	12.6	12.43889	  2010	Jan-June	8.823334	7.50001  	 	12.1	12.50281	  	July-Dec	6.715289	7.44396  	6.254978	12.7	12.56674	12.97859 2011	Jan-June	5.942933	 	6.246237	13.2	 	13.19623 	July-Dec	5.939265	 	6.237496	13.9	 	13.41387 2012	Jan-June	5.893885	 	6.228756	13.7	 	13.63151 	July-Dec	6.69611   	 	6.220015	13.5	 	13.84915

The increase in service utilization displayed in Figure 2 was primarily driven by newly insured individuals. Figure 3 displays the percentage of young adults receiving mental health services in the previous year by insurance coverage. Receipt of service levels increased among the insured in the post-reform period. Although there appears to be a decline among the uninsured, it is not statistically significant. This suggests that the increase in service utilization was driven by newly insured young adults who previously were unable to get treatment due to lack of insurance coverage.

Trends in Receipt of Substance Use Treatment

Unlike mental health service utilization, substance use treatment utilization did not increase in the wake of the coverage expansion. Figure 4 shows the trend in young adults who reported receiving substance use treatment in the previous year.13  Approximately 2.2 percent of young adults received substance use treatment in the last half of 2012, compared with 2.6 percent in the first half of 2010. While this appears to be a slight downward trend, the difference between the pre- and post-reform treatment levels is not statistically significant for the overall population.

Figure 4. Receipt of substance use treatment in the past year among young adults aged 19 to 26: 2005 to 2012

Year	Data	Pre- Trend	Post Trend 2005	Jan-June	2.508598	2.442915	  	July-Dec	2.657244	2.458036	  2006	Jan-June	2.306137	2.473157	  	July-Dec	2.493644	2.488278	  2007	Jan-June	2.402955	2.5034    	  	July-Dec	2.645116	2.518521	  2008	Jan-June	2.190361	2.533642	  	July-Dec	2.565122	2.548763	  2009	Jan-June	2.688026	2.563884	  	July-Dec	2.549546	2.579005	  2010	Jan-June	2.620794	2.594126	  	July-Dec	2.68543  	2.609247	2.586774 2011	Jan-June	2.459957	 	2.475098 	July-Dec	2.201249	 	2.363421 2012	Jan-June	2.226887	 	2.251744 	July-Dec	2.243582	 	2.140068

Figure 5 displays young adult substance use treatment utilization by insurance coverage. In the post-reform period, treatment among insured young adults remained static, averaging 2.2 percent from 2005 to 2012. However, treatment rates for the uninsured dropped significantly for uninsured young adults. 

Figure 5. Receipt of substance use treatment in the past year among young adults aged 19 to 26, by health insurance coverage: 2005 to 2012

Year	Uninsured Data	Pre- Trend	Post Trend	Insured Data	Pre- Trend	Post Trend 2005	Jan-June	3.97798   	3.506833	 	1.9	1.995194	  	July-Dec	3.09458   	3.491614	 	2.5	2.024777	  2006	Jan-June	3.279288	3.476395	 	1.9	2.054359	  	July-Dec	3.556902	3.461176	 	2.0	2.083942	  2007	Jan-June	3.224827	3.445957	 	2.0	2.113524	  	July-Dec	4.152875	3.430738	 	2.1	2.143107	  2008	Jan-June	2.412023	3.415519	 	2.1	2.17269  	  	July-Dec	3.837935	3.4003     	 	2.1	2.202272	  2009	Jan-June	3.351403	3.385081	 	2.4	2.231855	  	July-Dec	3.599097	3.369862	 	2.1	2.261437	  2010	Jan-June	3.275111	3.354643	 	2.3	2.29102  	  	July-Dec	3.31552   	3.339424	3.052576	2.5	2.320602	2.446604 2011	Jan-June	2.41001   	 	2.793407	2.5	 	2.379789 	July-Dec	2.412303	 	2.534237	2.1	 	2.312974 2012	Jan-June	2.617349	 	2.275067	2.1	 	2.24616   	July-Dec	1.916002	 	2.015897	2.3	 	2.179345
Trends in Cost as a Barrier to Treatment

Figure 6. Cost as a barrier to treatment among young adults aged 19 to 26: 2005 to 2012

Year	Data	Pre- Trend	Post Trend 2005	Jan-June	45.99952	45.60779	 	July-Dec	46.00769	46.03347	 2006	Jan-June	48.20982	46.45916	 	July-Dec	44.85737	46.88484	 2007	Jan-June	43.57055	47.31053	 	July-Dec	47.4559  	47.73621	 2008	Jan-June	49.90153	48.1619  	 	July-Dec	51.59866	48.58758	 2009	Jan-June	48.06525	49.01327	 	July-Dec	53.62477	49.43895	 2010	Jan-June	47.86882	49.86464	 	July-Dec	48.22877	50.29032	49.62341 2011	Jan-June	49.95252		48.43416 	July-Dec	47.41114		47.24491 2012	Jan-June	46.74668		46.05567 	July-Dec	43.88546		44.86642

Expanded insurance coverage increases treatment utilization by lowering the cost barriers associated with out of pocket payment.11  The NSDUH data can be used to examine whether the reduction in financial barriers may be contributing to the increase in treatment utilization. Figure 6 shows the trends in young adults who reported needing mental health services or substance use treatment but who did not receive it due to cost. From 2005 to the first half of 2010, the trend in individuals who needed but did not receive mental health services or substance use treatment due to cost was increasing, reaching a high of 54 percent of in the latter part of 2009. After the enactment of the ACA, the trend turned downward, with only 44 percent of individuals needing treatment reporting that cost deterred them.

Trends in Source of Payment

In addition to lowering the cost barriers to treatment for young adults, the extension of private insurance coverage could also shift the composition of payment sources.14 Figure 7 represents the trends in the percent of young adults reporting either private insurance or public sources used to pay for mental health services or substance use treatment. 

Figure 7. Selected sources of payment for mental health services or substance use treatment among young adults aged 19 to 26: 2005 to 2012

Year	Private Insurance	Pre- Trend	Post Trend	Public Sources	Pre- Trend	Post Trend 2005	Jan-June	2.6	2.483834		1.7	1.688502	 	July-Dec	2.7	2.485994		2.0	1.687942	 2006	Jan-June	2.5	2.488154		1.7	1.687382	 	July-Dec	2.1	2.490314		1.6	1.686821	 2007	Jan-June	2.6	2.492474		1.5	1.686261	 	July-Dec	2.2	2.494634		1.7	1.685701	 2008	Jan-June	2.7	2.496794		1.6	1.685141	 	July-Dec	2.5	2.498953		1.6	1.68458  	 2009	Jan-June	2.6	2.501113		1.8	1.68402  	 	July-Dec	2.4	2.503273		1.5	1.68346  	 2010	Jan-June	2.6	2.505433		1.8	1.682899	 	July-Dec	2.6	2.507593	2.685653	1.8	1.682339	1.670682 2011	Jan-June	3.0		2.783734	1.4		1.635551 	July-Dec	2.8		2.881816	1.7		1.600419 2012	Jan-June	2.8		2.979897	1.6		1.565288 	July-Dec	3.2		3.077979	1.5		1.530156

Public source payment includes treatment paid for by the treatment center, the courts, and other public sources, or offered free of charge to the patient. Prior to the expansion of dependent care coverage, both trends were flat, with 2.5 percent of young adults reporting private insurance as a source of payment for their services/treatment and 1.8 percent reporting a public source of payment. After the expansion, private insurance began to be used more as source of payment, increasing to more than 3 percent by the end of 2012. Meanwhile, public sources of payment became less important, trending downward to approximately 1.5 percent, although this 0.3 percentage point decline is only significant at the 10 percent level.

Discussion

One objective of the ACA is to address the lack of insurance as a primary cause of delaying or failing to seek care. Extending dependent care coverage to young adults is one of the tools by which the ACA attempts to accomplish this objective. After implementation of the dependent care coverage extension, insurance coverage among the targeted population increased substantially. A potential explanation for this pattern is that mental illness can be a co-morbid condition associated with substance use because individuals with mental health conditions may seek to self-medicate.15 Since individuals with both mental illness and substance use disorders frequently seek treatment in substance use programs,16, 17  

this result could indicate that uninsured young adults with mental health problems sought treatment in substance use programs prior to the reform, but shifted into mental health service options once they obtained coverage in the post-reform period. Exploring this potential shift provides an opportunity for additional research.  As more individuals receive mental health services, fewer may resort to illicit drugs for relief, leading to less substance use and need for substance use treatment services.18 In addition to receiving more appropriate treatment, fewer young adults reported the cost of treatment as being a barrier to seeking treatment or services. Finally, costs for treatment or services may have shifted away from the public sector and to private insurance sources.

End Notes
  1. Nicholson, J. L. (2009). Rite of passage? Why young adults become uninsured and how new policies can help, 2009 update. New York, NY: Commonwealth Fund.
  2. DeNavas-Walt, C., Proctor, B. D., & Smith, J. C. (2010). Income, poverty, and health insurance coverage in the United States: 2009 (Current Population Reports, /P60–238). Washington, DC: U.S. Census Bureau.
  3. Ayanian, J. Z., Weissman, J. S., Schneider, E. C., Ginsburg, J. A., & Zaslavsky, A. M. (2000). Unmet health needs of uninsured adults in the United States. JAMA, 284(16), 2061–2069.
  4. Callahan, S. T., & Cooper, W. O. (2005). Uninsurance and health care access among young adults in the United States. Pediatrics, 116(1), 88–95.
  5. Weissman, J. S., Gatsonis, C., & Epstein, A. M. (1992). Rates of avoidable hospitalization by insurance status in Massachusetts and Maryland. JAMA, 268(17), 2388–2394.
  6. Results are shown for biannual periods to smooth variation in quarterly averages, but still allow for distinction between the pre- and post-implementation in 2010.
  7. Insurance coverage is defined as being covered by any type of insurance, public or private, at the time of the interview.
  8. Barbaresco, S., Courtemanche, C. J., & Qi, Y. (2014). Impacts of the Affordable Care Act dependent coverage provision on health-related outcomes of young adults (NBER Working Paper No. 20148). Cambridge, MA: National Bureau of Economic Research.
  9. Chua, K.-P., & Sommers, B. D. (2014). Changes in health and medical spending among young adults under health reform. JAMA, 311(23), 2437–2439. doi: 10.1001/jama.2014.2202
  10. Levine, P. B., McKnight, R., & Heep, S. (2011). How effective are public policies to increase health insurance coverage among young adults? American Economic Journal: Economic Policy, 3(1), 129–156.
  11. Manning, W. G., Newhouse, J. P., Duan, N., Keeler, E. B., & Leibowitz, A. (1987). Health insurance and the demand for medical care: evidence from a randomized experiment. The American economic review, 251-277.
  12. Mental health services is defined as having received inpatient care or outpatient care or having used prescription medication for problems with emotions, nerves, or mental health. Respondents were not to include treatment for drug or alcohol use.
  13. Substance use treatment is defined as receiving treatment at any location for alcohol or illicit drug use in the past year.
  14. Source of payment measures are constructed from separate NSDUH variables on source of payment for in-patient mental health treatment, out-patient mental health treatment, and substance use treatment.
  15. Bizzarri, J. V., Rucci, P., Sbrana, A., Miniati, M., Raimondi, F., Ravani, L., . . . Massei, G. (2009). Substance use in severe mental illness: self-medication and vulnerability factors. Psychiatry research, 165(1), 88-95.
  16. Harris, K. M., & Edlund, M. J. (2005). Use of mental health care and substance abuse treatment among adults with co-occurring disorders. Psychiatric Services, 56(8), 954–959. 
  17. Wu, L.-T., Ringwalt, C. L., & Williams, C. E. (2003). Use of substance abuse treatment services by persons with mental health and substance use problems. Psychiatric Services, 54(3), 363–369.
  18. Carroll, K. M. (2004). Behavioral therapies for co-occurring substance use and mood disorders. Biological psychiatry, 56(10), 778-784.
Suggested Citation

Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. (January 2013). The NSDUH Report: Trends in Insurance Coverage and Treatment Utilization by Young Adults. Rockville, MD.