Janet R. Cummings

The effect of medical marijuana laws on adolescent and adult use of marijuana, alcohol, and other substances

We estimate the effect of medical marijuana laws (MMLs) in ten states between 2004 and 2012 on adolescent and adult use of marijuana, alcohol, and other psychoactive substances. We find increases in the probability of current marijuana use, regular marijuana use and marijuana abuse/dependence among those aged 21 or above. We also find an increase in marijuana use initiation among those aged 12-20. For those aged 21 or above, MMLs further increase the frequency of binge drinking. MMLs have no discernible impact on drinking behavior for those aged 12-20, or the use of other psychoactive substances in either age group.

Racial/Ethnic Differences in Mental Health Service Use Among Adolescents With Major Depression

OBJECTIVE Little is known about racial/ethnic differences in the receipt of treatment for major depression in adolescents. This study examined differences in mental health service use in non-Hispanic white, black, Hispanic, and Asian adolescents who experienced an episode of major depression. METHOD Five years of data (2004-2008) were pooled from the National Survey on Drug Use and Health to derive a nationally representative sample of 7,704 adolescents (12-17 years old) diagnosed with major depression in the past year. Racial/ethnic differences were estimated with weighted probit regressions across several measurements of mental health service use controlling for demographics and health status. Additional models assessed whether family income and health insurance status accounted for these differences. RESULTS The adjusted percentages of blacks (32%), Hispanics (31%), and Asians (19%) who received any treatment for major depression were significantly lower than those of non-Hispanic whites (40%; p < .001). Black, Hispanic, and Asian adolescents were also significantly less likely than non-Hispanic whites to receive prescription medication for major depression, to receive treatment for major depression from a mental health specialist or medical provider, and to receive any mental health treatment in an outpatient setting (p < .01). These differences persisted after adjusting for family income and insurance status. CONCLUSION Results indicated low rates of mental health treatment for major depression in all adolescents. Improving access to mental health care for adolescents will also require attention to racial/ethnic subgroups at highest risk for non-receipt of services.

Numeracy and Medicare Part D: The Importance of Choice and Literacy for Numbers in Optimizing Decision Making for Medicare's Prescription Drug Program

Studies on decision making have come to challenge the idea that having more choice is necessarily better. The Medicare prescription drug program (Part D) has been designed to maximize choice for the consumer but has simultaneously created a highly complex decision task with dozens of options. In this study, in a sample of 121 adults, we examined the impact that increasing choice options has on decision-making abilities in older versus younger adults. Consistent with our hypotheses, we found that participants performed better with less choice versus more choice, and that older adults performed worse than younger adults across conditions. We further examined the role that numeracy may play in making these decisions and the role of more traditional cognitive variables such as working memory, executive functioning, intelligence, and education. Finally, we examined how personality style may interact with cognitive variables and age in decision making. Regression analysis revealed that numeracy is related to performance across the lifespan. When controlling for additional measures of cognitive ability, we found that although age was no longer associated with performance, numeracy remained significant. In terms of decision style, personality characteristics were not related to performance. Our results add to the mounting evidence for the critical role of numeracy in decision making across decision domains and across the lifespan.

Mental Comorbidity and Quality of Diabetes Care Under Medicaid: A 50-State Analysis

Background:Patients with comorbid medical and mental conditions are at risk for poor quality of care. With the anticipated expansion of Medicaid under health reform, it is particularly important to develop national estimates of the magnitude and correlates of quality deficits related to mental comorbidity among Medicaid enrollees. Methods:For all 657,628 fee-for-service Medicaid enrollees with diabetes during 2003 to 2004, the study compared Healthcare Effectiveness Data and Information Set (HEDIS) diabetes performance measures (hemoglobin A1C, eye examinations, low density lipoproteins screening, and treatment for nephropathy) and admissions for ambulatory care-sensitive conditions (ACSCs) between persons with and without mental comorbidity. Nested hierarchical models included individual, county, and state-level measures. Results:A total of 17.8% of the diabetic sample had a comorbid mental condition. In adjusted models, presence of a mental condition was associated with a 0.83 (0.82–0.85) odds of obtaining 2 or more HEDIS indicators, and a 1.32 (1.29–1.34) increase in odds of one or more ACSC hospitalization. Among those with diabetes and mental comorbidities, living in a county with a shortage of primary care physicians was associated with reduced performance on HEDIS measures; living in a state with higher Medicaid reimbursement fees and department of mental health expenses per client were associated both with higher quality on HEDIS measures and lower (better) rates of ACSC hospitalizations. Conclusions:Among persons with diabetes treated in the Medicaid system, mental comorbidity is an important risk factor for both underuse and overuse of medical care. Modifiable county and state-level factors may mitigate these quality deficits.

Comparing Racial/Ethnic Differences in Mental Health Service Use Among High-Need Subpopulations Across Clinical and School-Based Settings

Racial/ethnic differences in mental health service use among adolescents in clinic and school settings for three high-need populations are examined. Results indicate no racial/ethnic differences in school-based use contrasted with significant differences in clinical settings. Schools may be critical avenues for reduction of unmet mental health need among racial/ethnic minorities.

Race/Ethnicity and Geographic Access to Medicaid Substance Use Disorder Treatment Facilities in the United States

IMPORTANCE Although substance use disorders (SUDs) are prevalent and associated with adverse consequences, treatment rates remain low. Unlike physical and mental health problems, treatment for SUDs is predominantly provided in a separate specialty sector and more heavily financed by public sources. Medicaid expansion under the Patient Protection and Affordable Care Act has the potential to increase access to treatment for SUDs but only if an infrastructure exists to serve new enrollees. OBJECTIVE To examine the availability of outpatient SUD treatment facilities that accept Medicaid across US counties and whether counties with a higher percentage of racial/ethnic minorities are more likely to have gaps in this infrastructure. DESIGN, SETTING, AND PARTICIPANTS We used data from the 2009 National Survey of Substance Abuse Treatment Services public use file and the 2011-2012 Area Resource file to examine sociodemographic factors associated with county-level access to SUD treatment facilities that serve Medicaid enrollees. Counties in all 50 states were included. We estimated a probit model with state indicators to adjust for state-level heterogeneity in demographics, politics, and policies. Independent variables assessed county racial/ethnic composition (ie, percentage black and percentage Hispanic), percentage living in poverty, percentage living in a rural area, percentage insured with Medicaid, percentage uninsured, and total population. MAIN OUTCOMES AND MEASURES Dichotomous indicator for counties with at least 1 outpatient SUD treatment facility that accepts Medicaid. RESULTS Approximately 60% of US counties have at least 1 outpatient SUD facility that accepts Medicaid, although this rate is lower in many Southern and Midwestern states than in other areas of the country. Counties with a higher percentage of black (marginal effect [ME],  -3.1; 95% CI,  -5.2% to -0.9%), rural (-9.2%; -11.1% to -7.4%), and/or uninsured (-9.5%; -13.0% to -5.9%) residents are less likely to have one of these facilities. CONCLUSIONS AND RELEVANCE The potential for increasing access to SUD treatment via Medicaid expansion may be tempered by the local availability of facilities to provide care, particularly for counties with a high percentage of black and/or uninsured residents and for rural counties. Although states that opt in to the expansion will secure additional federal funds for the SUD treatment system, additional policies may need to be implemented to ensure that adequate geographic access exists across local communities to serve new enrollees.

Improving Access to Mental Health Services for Youth in the United States

In the wake of the Connecticut school shooting, a public dialogue emerged about the accessibility of mental health (MH) care in the United States. Policy makers have called for a more critical examination of the MH treatment system, and advocates are rallying around federal legislation that would strengthen community-based MH services -- especially for children and adolescents.1 Although the implementation of recent federal policies (i.e., Mental Health Parity and Addiction Equity Act and the Affordable Care Act) will expand insurance coverage for MH disorders among many U.S. children, these expansions will not improve access if communities lack a sufficient infrastructure to serve those in need of care. Mental health facilities that provide outpatient specialty services for youth comprise a critical element of the treatment infrastructure for those with MH problems, especially for youth who are living in poverty, uninsured, and/or publicly insured. To inform the current dialogue, we present data from the 2008 National Survey of Mental Health Treatment Facilities (NSMHTF) and examine the extent to which gaps exist in this infrastructure. The NSMHTF is a national facility-level survey of entities that provide specialty MH services such as psychiatric hospitals, residential treatment centers, freestanding outpatient clinics/partial care facilities, and multiservice MH facilities.2 A response rate of 74% was achieved from the 13,068 facilities that were surveyed. Results from supplemental analyses restricting the sample of counties to those with complete facility-level data were similar to those presented below. Using these data, we examine the percentage of U.S. counties that have at least one outpatient MH facility offering: (1) services for children and adolescents; and (2) any specially designed programs to treat youth with the most severe MH problems (i.e., severe emotional disturbance). Only 63% of U.S. counties have a MH facility that provides outpatient treatment for children/adolescents, and fewer than half of U.S. counties have a MH facility with any special programs for youth with severe emotional disturbance. [Figure] These gaps in infrastructure are especially pronounced in rural communities; fewer than half of rural counties have a MH facility that provides outpatient treatment for children/adolescents and only one-third have an outpatient facility with special programs for youth with severe emotional disturbance. Figure 1 Percentage of U.S. Counties with Outpatient Facilities Providing MH Specialty Services to Youth These data likely represent conservative estimates of the extent of the problem because state funding for MH services has been reduced since 2008. Between 2009 and 2012, states eliminated more than

The Effects of Varying Periods of Uninsurance on Children's Access to Health Care

1.6 billion in general funds from their state MH agency budgets.3 These budgetary reductions have resulted in decreased services for children and adults with serious mental illness and closures of community MH programs, especially in states that have consistently reduced their budgets since 2009.3 These gaps in the MH facility infrastructure are part of a larger problem of geographic access to MH services for those with limited financial resources. Although some youth may seek treatment from MH clinicians in solo or small group practices, the accessibility of these services is limited for youth who are either uninsured or publically insured. For example, only 3% to 8% of patient caseloads for psychiatrists in solo or group practice, respectively, are covered by Medicaid.4 While services delivered through school-based MH programs could help address geographic and financial barriers to the MH care system, many school systems have also faced substantial budgetary reductions since the economic downturn;5 these budgetary reductions have affected the availability of school-based MH programs. Even if schools can offer MH services, they may lack the resources and personnel necessary to provide comprehensive services for youth with severe emotional disturbance for whom medication, intensive psychotherapy services, or both may be indicated. One option for addressing these gaps in geographic accessibility for low-income youth is to expand the capacity of primary care safety-net facilities such as federally qualified health centers (FQHCs) or rural health clinics (RHC) to provide youth MH services. Nearly three-fourths of counties have at least one of these clinics,6 most of which offer some type of MH services.7 Rural communities, in particular, may have the capacity to support these primary care facilities even if they do not have the capacity to support a specialty MH treatment facility. However, these primary care safety-net facilities typically care for patients with less severe MH disorders,7 suggesting that they may require additional resources to be able to provide comprehensive services to youth with the most severe MH problems. Telepsychiatry programs are one promising approach for providing specialty expertise for the treatment of complex patients in these primary care facilities. In addition to expanding the number of facilities that can provide MH services for children, efforts to improve access will also need to address the national shortage of MH providers – especially those who specialize in providing services to youth. The Health Resources and Services Administration has designated four-fifths of U.S. counties as partial or whole Mental Health Professional Shortage Areas.6 Policy makers should work to ensure there is an adequate workforce to serve this population through mechanisms such as supplementary training grants and loan forgiveness programs. The delivery system reforms considered above are necessary but not sufficient to ensure access to needed MH services for youth. Research has shown that knowledge, attitudes, beliefs, and stigma about MH problems and treatment greatly affect whether, when, and how youth access the treatment system.8 Many youth do not receive treatment for MH problems because they and/or their parents do not perceive a need for services, do not believe treatment will be helpful, or they are worried about what others will think if they receive treatment. Educational outreach efforts about MH problems and available treatment options are key tools for overcoming these gaps in knowledge and attitudes. School health curricula should be expanded to better address mental health problems and treatments. Although the implementation of recent federal policies expands insurance coverage for MH problems among many youth, the data presented above highlight large gaps in geographic access to a critical element of the MH infrastructure for youth with severe MH problems. These structural problems in access are compounded by ongoing shortages of MH providers, lack of knowledge about MH problems and available treatments, and stigma. The national dialogue that emerged from the Connecticut school shooting has provided an opportunity to address these challenges and achieve meaningful improvements in our children’s MH system. Improving access to MH services for this vulnerable population will require an ongoing national dialogue, sustained commitment from policy makers, and a comprehensive approach that addresses the complex array of barriers to treatment that exist in the current system.

Who Thinks That Part D Is Too Complicated? Survey Results on the Medicare Prescription Drug Benefit

OBJECTIVE. Many studies have documented the adverse consequences of uninsurance for children, but less is known about the differential effects of varying periods of uninsurance. This study examines the relative effects of varying periods of uninsurance (uninsured for 1–4 months, 5–11 months, or all year) on childrens access to care. METHODS. Using data from the 2005 California Health Interview Survey Childrens File (ages 0–11), we estimated logistic regressions to examine the effect of insurance status on 6 measures of health care access, controlling for child demographics, child health status, family characteristics, and urban residence. Indicators for insurance status included the following categories: (1) privately insured all year (reference); (2) Medicaid all year; (3) State Childrens Health Insurance Program all year; (4) uninsured for 1 to 4 months; (5) uninsured for 5 to 11 months; (6) uninsured all year; and (7) other insurance all year. RESULTS. We found that children who experience short spells of uninsurance (1–4 months) are less likely to have a usual source of care and are more likely to experience delays in needed care than those with continuous private or public insurance. The consequences are even worse for children who experience more substantial periods of uninsurance, because they are also less likely to receive preventive care (well-child visits and flu shots) or visit the doctor during the year and are more likely to experience delays in receiving needed medical care and prescriptions than those with continuous coverage. The Medicaid program and State Childrens Health Insurance Program in California both seem to have ensured levels of health care access similar to that obtained by children with year-round private coverage. CONCLUSIONS. These findings highlight the benefits gained through continuous health insurance, whether public or private. Public policies should be adopted to ensure continuity of coverage and retention in public insurance programs.

Insurance Status, Use of Mental Health Services, and Unmet Need for Mental Health Care in the United States

Evidence suggests that Medicare Part D plan ownership is “sticky”; beneficiaries are unlikely to change plans from year to year, even when it would be in their financial interest to do so. The complexity of the program may contribute to this problem. Using data from a national survey, the authors examine the characteristics of those who believe that Part D is too complicated as well as the characteristics of those who endorse one of two policies to simplify the program. The results indicate that a great majority of adults believe that the program is too complicated and most favor some form of simplification. In multivariate analyses, one of the most consistent predictors is political orientation. Republicans are significantly less likely to think that Part D is too complicated, and liberals and moderates are significantly more likely to favor allowing beneficiaries the option of purchasing a plan directly from the government.