Mental Health, Substance Abuse, and Pregnancy: Health Spending Following the PPACA Adult-Dependent Mandate

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1 April 2013 No. 385 Mental Health, Substance Abuse, and Pregnancy: Health Spending Following the PPACA Adult-Dependent Mandate By Paul Fronstin, Ph.D., Employee Benefit Research Institute A T A G L A N C E The Patient Protection and Affordable Care Act (PPACA) requires group health plans that offer dependent coverage to make that coverage available to workers children until they reach age 26, regardless of student status, marital status or financial support by the employees. A number of studies found measurable increases in the percentage of young adults with employmentbased coverage soon after the mandate took effect. It has been estimated that 3.1 million young adults have acquired health coverage as a result of this adultdependent mandate (ADM) provision. Overall, 31 percent of employers enrolled adult-dependent children as a result of the mandate, although the percentage of employers enrolling adult dependents as a result of the mandate increased with firm size. Larger employers are much more likely than smaller ones to have enrolled young adults as a result of the ADM. With respect to the experience of the specific large employer examined in this analysis, following implementation of the mandate, health care spending increased by $2 million, representing 0.2 percent of total health care spending. Average spending in the ADM cohort was higher than in the comparison group. The ADM cohort used an average of $2,866 in 2011, 15 percent higher than the comparison group, which used $2,472 on average. The most interesting finding related to the types of health care services used by those in the ADM cohort. The ADM cohort was more likely to incur claims related to mental health, substance abuse, and pregnancy. The ADM cohort was more likely than the comparison group to use retail pharmacies rather than mail order. Eighty-three percent of the prescriptions filled by the ADM cohort and 74 percent of the prescriptions filled by the comparison group were filled in retail pharmacies. There were no notable differences between the ADM cohort and the comparison group when use of prescriptions was examined by therapeutic class. Overall, 23 percent of the prescriptions filled for the two groups were for contraceptives. Another 9 percent were for psychostimulants and antidepressants. A monthly research report from the EBRI Education and Research Fund 2013 Employee Benefit Research Institute

2 Paul Fronstin is director of the Health Research and Education Program at the Employee Benefit Research Institute (EBRI). This Issue Brief was written with assistance from the Institute s research and editorial staffs. Any views expressed in this report are those of the author and should not be ascribed to the officers, trustees, or other sponsors of EBRI, EBRI-ERF, or their staffs. Neither EBRI nor EBRI-ERF lobbies or takes positions on specific policy proposals. EBRI invites comment on this research. Copyright Information: This report is copyrighted by the Employee Benefit Research Institute (EBRI). It may be used without permission but citation of the source is required. Recommended Citation: Paul Fronstin, Mental Health, Substance Abuse, and Pregnancy: Health Spending Following the PPACA Adult-Dependent Mandate, EBRI Issue Brief, no. 385 (Employee Benefit Research Institute, April 2013). Report availability: This report is available on the Internet at Table of Contents Figures... 2 Introduction... 4 The Impact of the ADM... 5 Study Cohorts... 6 Spending... 6 Total Spending... 6 Out-of-Pocket Spending... 9 Differences in Spending... 9 Prescription Drugs... 9 Conclusion... 9 References Endnotes Figures Figure 1, Impact of Adult-Dependent Mandate on Health Care Spending, Figure 2, Percentage of Firms Offering Family Coverage That Enrolled Adult Dependents up to Age 26 as a Result of PPACA, and Average Number of Adult Dependents Enrolled, by Firm Size, Figure 3, Age Distribution of Adult-Dependent Mandate (ADM) Cohort and, Figure 4, Gender Distribution of Adult-Dependent Mandate (ADM) Cohort and, Figure 5, Total Health Spending, Adult-Dependent Mandate (ADM) Cohort and, by Type of Spending, Figure 6, Total Health Spending, Adult-Dependent Mandate (ADM) Cohort and, by Source of Payment, Figure 7, Distribution of Total Health Spending, Adult-Dependent Mandate (ADM) Cohort and, by Source of Payment, Figure 8, Distribution of Total Health Spending, Adult-Dependent Mandate (ADM) Cohort and, by Type of Spending, ebri.org Issue Brief April 2013 No

3 Figure 9, Distribution of Hospital Inpatient Claims, Adult-Dependent Mandate (ADM) Cohort and, by Diagnosis Code, Figure 10, Prescription Drug Use, Adult-Dependent Mandate (ADM) Cohort and, by Source of Supply, Figure 11, Prescription Drug Use, Adult-Dependent Mandate (ADM) Cohort and, by Type of Drug, Figure 12, Prescription Drug Use, Adult-Dependent Mandate (ADM) Cohort and, by Type of Drug, Figure 13, Distribution of Outpatient Pharmacy Claims, Adult-Dependent Mandate Cohort and, by Therapeutic Class, ebri.org Issue Brief April 2013 No

4 Mental Health, Substance Abuse, and Pregnancy: Health Spending Following the PPACA Adult-Dependent Mandate By Paul Fronstin, Ph.D., Employee Benefit Research Institute Introduction The Patient Protection and Affordable Care Act (PPACA) requires group health plans that offer dependent coverage to now provide coverage for adult children up to age 26 regardless of employment status, student status, marital status or financial dependency on the employee, if the employee chooses to cover them. 1 This is known as the adult-dependent mandate, (ADM) although dependency is not a condition of the coverage. PPACA does not extend the mandate for access to coverage to the married child s spouse and/or children. Grandfathered group health plans are not required until Jan. 1, 2014 to offer coverage to adult children who currently have their own employment-based coverage or are eligible for such coverage. 2 The Internal Revenue Service (IRS) clarified the tax treatment of employment-based health benefits for adult children in Notice , extending the preferential tax treatment of coverage for adult children, even if the children do not qualify as the worker s dependents for income tax purposes. 3 In addition, tax-free distributions from flexible spending accounts (FSAs) are allowed to cover these adult children s out-of-pocket expenses. Employers are allowed to continue to provide coverage to adult dependents past age 25 if they choose to do so. However, the preferential tax treatment is extended only until the end of the calendar year in which the child turns age 26. Beyond that, the worker portion of the premium to cover adult children would be paid with after-tax dollars and any employer subsidy would be reported as imputed income on the worker s W-2. The mandate to offer coverage to adult children ages took effect in policy years that began on or after Sept. 23, 2010, six months after PPACA was signed into law. Since January is the beginning of the plan year for most employment-based health plans, most plans extended coverage to adult dependents on January 1, Many insurers adopted the requirements of the law early, 4 but it was up to employers to decide whether or when to offer that extended coverage. Recent evidence suggests that the ADM provision in PPACA had an immediate impact. A number of studies found measurable increases in the percentage of young adults with employment-based coverage soon after the mandate took effect (Collins, et al. 2012) (Fronstin 2012) (Sommers 2012). The ADM is expected to increase employer spending on the health coverage of worker dependents. One survey found that 28 percent of employers expected an increase of less than 2 percent, 13 percent expected an increase of 2 5 percent, and 9 percent expected an increase of more than 5 percent (Figure 1). Over one-quarter (27 percent) did not expect any change in health spending, while 21 percent did not know what to expect. While most employers expect their spending to increase, no work has been done to quantify the actual impact on costs. This Issue Brief examines the impact of the ADM from the experience of one large national employer on total spending, average spending, out-of-pocket costs, and use of health care services. The employer examined for this analysis covered over 200,000 individuals (both workers and their dependents) in both 2010 and 2011, and use of health care services amounted to more than $1 billion in each of those years. This study provides a sense of the magnitude of the impact that the ADM has had on health care spending and provides a detailed sense of the types of health care services used among young adults enrolled as a result of the mandate and how they might differ from already-enrolled individuals. ebri.org Issue Brief April 2013 No

5 Figure 1 Expected Impact of Adult Dependent Mandate on Health Care Spending, % Increase in Cost, 13% Up to 2% Increase in Cost, 28% Decrease in Cost, 1% More Than 5% Increase in Cost, 9% Unknown, 21% No Change, 27% Source: Calculations based on data from Table 3 in The Impact of the ADM Only a few studies have examined the number of individuals that gained health insurance as a result of the ADM. Fronstin (2012) found that the ADM provision of PPACA had an immediate impact. Using data from the Current Population Survey (CPS), it was found that the percentage of people ages with employment-based coverage as dependents increased from 24.7 percent in 2009, the year before PPACA was signed into law, to 27.7 percent in 2010, and the number in that demographic with coverage increased from 7.3 million to 8.2 million soon after the PPACA provision took effect. This immediate impact may have occurred because many insurers adopted this provision of PPACA early. Collins, et al. (2012) found that 6.6 million young adults who had enrolled in their parents health plans since November 2010 were unlikely to have been eligible for those plans before the PPACA provision took effect, but further analysis by Sommers (2012) suggested that only 2.6 million gained coverage, with the remainder having switched from their own plan. Sommers (2012) own estimates from 2011 data suggested that 3.1 million young adults gained coverage as a result of the law. Sommers, et al. (2013) found that the largest gains in coverage were seen among unmarried adults, nonstudents, and men. They also found strong evidence of increased access to health care in the significant reductions in the percentage of young adults who delayed getting care and in the percentage of those who did not receive needed health care services because of the cost. However, none of these studies examined the type of health care services received or whether it was different than health care services used by a comparison group. Overall, 31 percent of employers enrolled adult-dependent children as a result of the mandate (Figure 2), although the percentage of employers enrolling adult dependents as a result of the mandate increased with firm size: Among firms with three to 24 employees, 18 percent reported enrolling at least one adult dependent, while among firms with 5,000 or more workers, nearly all (97 percent) reported doing so. Average enrollment of an adult dependent also increased with firm size: Overall average enrollment was seven, increasing from an average of two adult-dependent enrollees in firms with three to 24 workers to an average of 478 in firms with 5,000 or more workers. ebri.org Issue Brief April 2013 No

6 Study Cohorts Pharmacy and medical administrative-claims data and insurance-enrollment information were obtained from a large employer, covering the two-year period of Jan. 1, 2010 through Dec. 31, This employer offered a combination of various health plans, including preferred provider organizations (PPOs), exclusive provider organizations (EPOs), and health savings account (HSA)-eligible, high-deductible plans. Prior to 2011, this large employer allowed workers to cover unmarried, dependent children until they reached age 23 if they were full-time students. Unmarried, dependent children unable to attend school because of temporary illnesses were also allowed to remain in the plan until they reached age 23, and permanently disabled children could remain in the plan beyond age 19 as long as they meet enrollment criteria related to their disability. Otherwise, unmarried, dependent children could remain in the plan only until their 19th birthday. Starting in 2011, in accordance with the ADM, workers could cover all adult children until age 26 regardless of the children s marital status. On Jan. 1, 2011, nearly 700 adult children enrolled in the employer plan examined for this study. Overall, these young adults used about $2 million in health care services in A comparison group of young adults was examined as well, comprised of dependent children ages who were covered prior to Jan. 1, The comparison group consisted of slightly more than 13,000 young adults. Both groups had health coverage for the entire 2011 calendar year through the employer examined in this study. The age composition of the ADM cohort and the comparison group is shown in Figure 3. The ADM cohort was older than the comparison group: Nearly 41 percent (40.9 percent) of the ADM cohort was years old and 58.7 percent was years old. In contrast, 60.9 percent of the comparison group was years old, and 38.6 percent of the comparison group was years old. Despite the fact that PPACA extended eligibility for coverage until age 26, the ADM group included very few year olds during the period. The gender composition of the two groups was similar, though the ADM cohort was more likely to be male than the comparison group, which is consistent with the findings of Sommers, et al. (2013). Just over 54 percent of the ADM cohort was male compared with 50.9 percent of the comparison group (Figure 4). Spending Total Spending Use of health care services accounted for over $1 billion in the population covered by the employer examined in this study, of which the ADM cohort used $2 million in health care services. Thus, overall, the ADM cohort increased total spending by 0.2 percent. Average spending in the ADM cohort was higher than in the comparison group. The ADM cohort used an average of $2,866 in 2011, 15 percent higher than the comparison group, which used $2,472, on average (Figure 5). When use of outpatient prescription drugs is examined separately from other medical services (such as inpatient hospital stays, outpatient health care services, office visits, laboratory services, imaging, and other services), it can be seen that spending was higher for the ADM cohort because, other than prescription drugs, these members used more medical services than those in the comparison group. The ADM cohort used an average of $2,393 in medical services in 2011, compared with $1,885 among the comparison group, 27 percent higher in the ADM cohort. On the other hand, the ADM group spent less on prescription drugs than the comparison group, accounting for $474 in prescription-drug spending compared with $587 among the comparison group, 19 percent lower in the ADM cohort. ebri.org Issue Brief April 2013 No

7 Figure 2 Percentage of Firms Offering Family Coverage That Enrolled Adult Dependents up to Age 26 as a Result of PPACA,* and Average Number of Adult Dependents Enrolled, by Firm Size, 2012 Percent of FIrms That Enrolled Adult Dependents Because of PPACA % Percentage of Firms That Enrolled Adult Dependents Average Number Enrolled 18% 57% % 12 95% 97% Total ,000 4,999 5,000 or more workers % 3 Small Firms (3 199 Workers) 9 41 Large Firms (200 or More Workers) Average Number of Adult Dependents Enrolled Sources: and * Patient Protection and Affordable Care Act. Figure 3 Age Distribution of Adult-Dependent Mandate (ADM) Cohort and, % 58.7% % 38.6% % 0.5% Source: EBRI estimates based on administrative claims data. ebri.org Issue Brief April 2013 No

8 Figure 4 Gender Distribution of Adult Dependent Mandate Cohort and, % % 45.7% 49.1% 4 3 Male Female Source: EBRI estimates based on administrative claims data. Figure 5 Total Health Spending, Adult Dependent Mandate Cohort and, by Type of Spending, 2011 $3,500 $3,000 $2,866 $2,500 $2,472 $2,393 $2,000 $1,885 $1,500 $1,000 $500 $474 $587 $- Total Medical Rx ebri.org Issue Brief April 2013 No

9 Out-of-Pocket Spending The ADM cohort spent more out of pocket than the comparison group. Overall, the ADM cohort spent $654, and the comparison group spent $513 out of pocket (Figure 6). In percentage terms, the ADM cohort spent slightly more out of pocket than the comparison group: The ADM cohort covered 23 percent of their spending through cost sharing and the comparison group covered 21 percent of their spending through cost sharing (Figure 7). Differences in Spending To better understand the types of services that could account for the differences in health spending, health care spending was divided into the following components: inpatient hospital stays, outpatient services, physician office visits, emergency-department services, laboratory services, and prescription drugs. Differences in hospital-inpatient spending represented most of the higher average spending in the ADM cohort relative to the comparison group, accounting for 22 percent of total spending among the ADM cohort and 17 percent among the comparison group (Figure 8). Hospital inpatient claims were examined further to determine if there was any difference in the types of services used by the ADM cohort and the comparison group. The ADM cohort was found to be much more likely to use services for mental health, substance abuse, and pregnancy. In fact, in the ADM cohort, those treatments accounted for 60 percent of all inpatient claims, whereas in the comparison group they accounted for just one-third of such claims. More specifically, mental health and substance abuse accounted for 42 percent of inpatient claims in the ADM cohort and 28 percent of inpatient claims in the comparison group (Figure 9). Similarly, pregnancy-related claims accounted for 19 percent of inpatient claims in the ADM cohort, compared with 5 percent in the comparison group. Treatment for injuries accounted for 10 percent in the ADM cohort and 8 percent in the comparison group, and treatment for infections accounted for 6 percent in the ADM cohort and 4 percent in the comparison group. While 25 percent of claims in the ADM cohort and 54 percent of claims in the comparison group were combined into other inpatient claims, no single diagnosis accounted for more than 4 percent of total inpatient claims, and most for far less than that. Prescription Drugs Notable differences between the ADM cohort and the comparison group were also found for prescription drug use. Both groups were much more likely to use retail pharmacies than mail order: Overall, 83 percent of the prescriptions filled by the ADM cohort and 74 percent of the prescriptions filled by the comparison group were filled in retail pharmacies (Figure 10). This is not surprising as both groups are young, generally healthy, and do not tend to have the kinds of chronic conditions that would require maintenance drugs that might be more efficiently filled through mail-order pharmacies. The ADM cohort was slightly less likely than the comparison group to use maintenance drugs. Fifty-seven percent of the prescriptions filled by the ADM cohort were for maintenance drugs, as were 60 percent of the prescriptions filled by the comparison group (Figure 11). Both the ADM cohort and the comparison group were much more likely to use generic drugs than brand-name drugs. Overall, 82 percent of the prescriptions filled by the ADM cohort and 77 percent of the prescriptions filled by the comparison group were for generic drugs (Figure 12). There were, however, no notable differences between the ADM cohort and the comparison group when use of prescriptions was examined by therapeutic class the grouping of similar medications used to treat a specific condition or disease. As a result, the two groups are combined for purposes of examining the data. Overall, two therapeutic classes accounted for one-third (32 percent) of all prescription drug fills, and six therapeutic classes accounted for onehalf of all prescription-drug fills. One-quarter (23 percent) of the prescriptions filled for the two groups were for contraceptives (Figure 13). Another 9 percent of the prescriptions filled were for psychostimulants and antidepressants. Conclusion The Patient Protection and Affordable Care Act (PPACA) requires group health plans that offer dependent coverage to make that coverage available to workers children until they reach age 26, regardless of student status, marital status or financial support by the employees. It has been estimated that 3.1 million young adults have acquired health ebri.org Issue Brief April 2013 No

10 Figure 6 Total Health Spending, Adult Dependent Mandate Cohort and, by Source of Payment, 2011 $2,500 $2,212 $2,000 $1,959 $1,500 $1,000 $500 $654 $513 $- Plan paid Out of pocket 9 Figure 7 Distribution of Total Health Spending, Adult Dependent Mandate Cohort and, by Source of Payment, % 79% % 21% Plan paid Out of pocket ebri.org Issue Brief April 2013 No

11 Figure 8 Distribution of Total Health Spending, Adult Dependent Mandate Cohort and, by Type of Spending, % 3 28% 29% 25% 24% 22% 22% 17% 17% 15% 9% 7% 5% 4% 1% Hospital Inpatient Lab Outpatient Services Emergency Department Physician Office Visit Prescription Drugs Figure 9 Distribution of Hospital Inpatient Claims, Adult Dependent Mandate Cohort and, by Diagnosis Code, % % 3 28% 25% 19% 5% 8% 6% 4% Mental health and substance abuse Pregnancy Injury Infection Other ebri.org Issue Brief April 2013 No

12 coverage as a result of this provision. Larger employers are much more likely than smaller ones to have enrolled young adults as a result of the provision. However, the implementation of the adult dependent mandate (ADM) provision of the law does not come without costs. While under PPACA, employers are not allowed to directly charge higher premiums for the cost of adult-dependent coverage, employers and workers will share the higher cost of health care services associated with the mandate provision through claims payments, cost sharing, and worker premiums. With respect to the experience of the specific large employer examined in this analysis, following implementation of the mandate, health care spending increased by $2 million, representing 0.2 percent of total health care spending. Workers paid for some of that spending through cost sharing and their share of the premium, and employers paid for the remainder. The most interesting finding related to the types of health care services used by those in the ADM cohort, which used more inpatient services than the comparison group, was that they were more likely to incur claims related to mental health, substance abuse, and pregnancy. References Collins, Sara R., Ruth Robertson, Tracy Garber, and Michelle M. Doty. "Young, Uninsured, and in Debt: Why Young Adults Lack Health Insurance and How the Affordable Care Act Is Helping Findings from the Commonwealth Fund Health Insurance Tracking Survey of Young Adults, Commonwealth Fund pub. 1604, Vol. 14 (The Commonwealth Fund, June 2012). Fronstin, Paul. "The Impact of PPACA on Employment-Based Health Coverage of Adult Children to Age 26. EBRI Notes, no. 1 (Employee Benefit Research Institute, January 2012). Sommers, Benjamin D. "Number of Young Adults Gaining Insurance Due to the Affordable Care Act Now Tops 3 Million. ASPE Issue Brief (Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation, June 2012). Sommers, Benjamin D., Thomas Buchmueller, Sandra L. Decker, Colleen Cary, and Richard Kronick. "The Affordable Care Act Has Led To Significant Gains In Health Insurance And Access To Care For Young Adults. Health Affairs 32, no. 1 (January 2013): Endnotes 1 Ohio requires that coverage be extended to age 28 in certain situations. More information about the Ohio law and how it differs from PPACA can be found at 2 Grandfathered health plans are plans that existed on March 23, 2010, and are exempt from certain requirements of PPACA. Health plans can lose grandfathered status if they make a number of changes, including reducing benefits, increasing cost sharing, or raising premiums. More specifics can be found at 3 See Also, tax-free distributions from a health savings account (HSAs) for qualified medical expenses are not allowed for children covered by the ADM who are not dependents on the employee s federal tax return. 4 A main reason for adopting this provision early was to avoid de-enrolling college graduates only to re-enroll them ( See for a list of early adopters. 5 The estimates for health care services used in this paper are based on allowed charges. ebri.org Issue Brief April 2013 No

13 Figure 10 Prescription Drug Use, Adult Dependent Mandate Cohort and, by Source of Supply, % 8 74% % 14% Retail Mail order Other 2% 1% Figure 11 Prescription Drug Use, Adult Dependent Mandate Cohort and, by Type of Drug, % % 4 3 Not a Maintenance Drug Maintenance Drug ebri.org Issue Brief April 2013 No

14 Figure 12 Prescription Drug Use, Adult Dependent Mandate Cohort and, by Type of Drug, % 8 77% % 23% Generic drug Non-generic drug Figure 13 Distribution of Outpatient Pharmacy Claims, Adult Dependent Mandate Cohort and, by Therapeutic Class, % 23% 15% 9% 5% 5% 4% 4% 3% Contraceptives Psychostimulants & Antidepressants Amphetamine Preparations Dermatologicals Pain management Anticonvulsants ebri.org Issue Brief April 2013 No

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