West Virginia did not have Medicaid coverage for low-income,  childless adults prior to its Medicaid expansion in 2014. From 17 to 25 Percent of Expansion Enrollees in Selected States Had a Behavioral Health Diagnosis; Enrollees’ Gender and Age Were Similar across the States From 17 to 25 Percent of Expansion Enrollees had a Behavioral Health Diagnosis in Selected States, Most Commonly a Mental Health Condition

Across our four selected states in 2014, from 17 to 25 percent of  expansion enrollees were diagnosed with a behavioral health condition. Diagnoses of mental health conditions were more common than  diagnoses of substance use conditions. From 11  to 20 percent of expansion enrollees were diagnosed with a mental health  condition, compared with 6 to 8 percent diagnosed with a substance use  condition. The most  common mental health condition categories were mood disorders, such  as depression, and anxiety disorders, such as panic disorder. From 20 to 34 Percent of Expansion Enrollees in Selected States Received Behavioral Health Treatment; Psychotherapy and Antidepressant Medications Were Most Common

Use of behavioral health treatment—services and drugs to address  mental health and substance use conditions—ranged from 20 to 34  percent in selected states in 2014. These rates  exceeded the rates of diagnosed conditions presented above, in part,  because prescription drugs are not recorded with diagnosis codes. Thus,  enrollees who only used behavioral health prescription drugs—and no  outpatient services—were not counted in the diagnosis totals. Officials we spoke with from three of the selected states told us that  expansion enrollees likely had greater access to behavioral health  treatment after enrolling in Medicaid. West Virginia officials said that access to behavioral health  prescription drugs, particularly MAT for substance use conditions,  increased for Medicaid expansion enrollees. By contrast, there was less of a change for expansion enrollees in New  York. The Most Commonly Used Behavioral Health Service Categories were Psychotherapy and Diagnostic Services

Among the 9 to 16 percent of expansion enrollees who used a behavioral  health service in the four selected states, the two most commonly used  service categories were psychotherapy—regular visits with a provider to  help a patient understand, reduce, and manage symptoms—and  diagnostic services. From  67 to 78 percent of expansion enrollees who used a behavioral health  drug took an antidepressant. Agency Comments

We provided a draft of this report to the Department of Health and Human  Services (HHS) for review. HHS provided technical comments, which we  incorporated as appropriate. Step 1: State Selection

We selected four states: Iowa, New York, Washington, and West Virginia. The four selected states  1.  were among the 25 states that expanded Medicaid as allowed under  the Patient Protection and Affordable Care Act (PPACA) as of  January 1, 2014;  2.  had enrollment and utilization data for expansion enrollees in MSIS for  all of calendar year 2014 that were sufficiently reliable for the  purposes of our reporting objectives; and  3.  had available information and documentation on Medicaid behavioral  health benefits, and on how enrollment, service utilization, and  prescription drug data were recorded for expansion enrollees. Step 3: Utilization Analyses

We conducted interviews with officials from our four selected states to  discuss behavioral health benefits for Medicaid expansion enrollees; how  enrollment, service utilization, and prescription drug data were recorded  in MSIS; officials’ perspectives on the results of our analysis; and whether  Medicaid expansion affected the availability of behavioral health  treatment for expansion enrollees, relative to what was available for low- income, uninsured adults prior to the first year of expansion in 2014.
Why GAO Did This Study

Behavioral health conditions disproportionately affect low-income populations. Treatment can improve individuals' symptoms and help avoid negative outcomes. The expansion of Medicaid to cover low-income adults in some states—authorized by PPACA—may have increased the demand for such treatment. However, little is known about the extent to which Medicaid expansion enrollees experienced behavioral health conditions or utilized treatment during the first year of expansion in 2014.
GAO was asked to provide information about the utilization of behavioral health treatment among Medicaid expansion enrollees during the first year of expansion in 2014. For selected states in 2014, this report describes (1) the population of Medicaid expansion enrollees with behavioral health diagnoses, and (2) the use of behavioral health treatment among Medicaid expansion enrollees.
GAO selected four expansion states—Iowa, New York, Washington, and West Virginia—based on, among other criteria, availability and reliability of Medicaid enrollment and utilization data. GAO analyzed Medicaid data on behavioral health diagnoses and treatment use for expansion enrollees for 2014, the most recent year available. GAO also reviewed documents and interviewed Medicaid officials from all selected states to understand how data were recorded, and how treatment for expansion enrollees compared with what was available prior to expansion. The Department of Health and Human Services provided technical comments on a draft of this report, which GAO incorporated as appropriate.

What GAO Found

In four selected states, from 17 to 25 percent of enrollees who were covered by state expansions of Medicaid—authorized by the Patient Protection and Affordable Care Act (PPACA)—had diagnosed behavioral health conditions (mental health and substance use conditions) in 2014. Mental health conditions were more common than substance use conditions; from 11 to 20 percent of expansion enrollees were diagnosed with a mental health condition, compared with 6 to 8 percent diagnosed with a substance use condition. The most common mental health condition category was mood disorders, such as depression. For substance use, substance-related conditions (e.g., addiction to drugs like opioids) were more prevalent than alcohol-related conditions.
From 20 to 34 percent of expansion enrollees in the four selected states received behavioral health treatment in 2014, which includes outpatient services such as psychotherapy or prescription drugs. Treatment rates exceeded rates of diagnosed conditions, in part, because prescription drugs are not recorded with diagnosis codes. Thus, enrollees who only used behavioral health prescription drugs—and no outpatient services—were not counted in the diagnosis totals.
The two most commonly used behavioral health service categories were psychotherapy services (visits with a provider aimed at reducing and managing symptoms) and diagnostic services, such as diagnostic evaluations.
Antidepressants were the most commonly used behavioral health prescription drug category; over two-thirds of expansion enrollees who used a behavioral health drug took an antidepressant.
Officials in three of the four selected states said that expansion enrollees likely had greater access to behavioral health treatment after enrolling in Medicaid. Officials from Iowa, Washington, and West Virginia reported that, compared to being uninsured, expansion enrollees could more easily access treatment, such as community-based mental health services and behavioral health prescription drugs. Officials in New York said expansion enrollees experienced less of a change, because most of its enrollees were previously eligible for Medicaid.