Park Sungchul, Koh Katherine A, Liu Michael, Wadhera Rishi K
Department of Health Policy and Management, College of Health Science, Korea University, Seoul, Republic of Korea.
BK21 FOUR R&E Center for Learning Health Systems, Korea University, Seoul, Republic of Korea.
JAMA Health Forum. 2025 May 2;6(5):e251089. doi: 10.1001/jamahealthforum.2025.1089.
Although Medicare provides nearly universal health insurance coverage for individuals aged 65 years or older, clinicians and policymakers have expressed concern about access to and coverage of mental health services in the program. It is unclear how transitioning to Medicare affects adults with psychological distress, who may be particularly vulnerable to changes in mental health services.
To examine the association of Medicare eligibility with use of mental health care, general health care, and acute care services among adults with psychological distress.
DESIGN, SETTING, AND PARTICIPANTS: In this cross-sectional study using the 2009-2019 Medical Expenditure Panel Survey and a regression discontinuity design, health care use among adults aged 59 to 64 years and those aged 66 to 71 years with psychological distress, defined as those who scored 3 or higher on the 2-item Patient Health Questionnaire or 13 or higher on the 6-item Kessler Psychological Distress Scale, was evaluated. Data were analyzed from March 2023 to February 2025.
Medicare eligibility at age 65 years.
Mental health care use, including outpatient mental heath visits and psychotropic medication fills, general health care use, and acute care use.
The study population included 3970 adults with psychological distress (mean [SD] age, 64.0 [3.6] years; 59.7% [n = 2370] female). Medicare eligibility at age 65 years was associated with a decrease in outpatient mental health visits with any health care professional (adjusted change of -3.4 percentage points [95% CI, -5.4 to -1.4 percentage points]), no change in mental health visits with psychiatrists (-0.7 percentage points [95% CI, -4.1 to 2.6 percentage points]), and a decrease in psychotropic medication fills (-5.3 percentage points [95% CI, -10.3 to -0.3 percentage points]) among adults with psychological distress. There was no change in general health care use, including all outpatient visits (0.6 percentage points [95% CI, -5.4 to 6.5 percentage points]) and prescription drug use (0.1 percentage points [95% CI, -2.2 to 2.5 percentage points]). In contrast, Medicare eligibility was associated with increases in acute care use, such as inpatient admissions (5.5 percentage points [95% CI, 2.2-8.9 percentage points]) and emergency department visits (8.1 percentage points [95% CI, 3.3-13.0 percentage points]) among adults with psychological distress.
These findings suggest that Medicare eligibility at age 65 years was associated with decreased use of mental health outpatient services and increased acute care use among adults with psychological distress. These findings highlight the need for policies that address gaps in mental health care in the Medicare program.
尽管医疗保险为65岁及以上的个人提供了几乎普及的医疗保险覆盖范围，但临床医生和政策制定者对该计划中精神卫生服务的可及性和覆盖范围表示担忧。目前尚不清楚向医疗保险过渡如何影响有心理困扰的成年人，他们可能特别容易受到精神卫生服务变化的影响。
研究医疗保险资格与有心理困扰的成年人使用精神卫生保健、一般医疗保健和急性护理服务之间的关联。
设计、设置和参与者：在这项横断面研究中，使用2009 - 2019年医疗支出面板调查和回归断点设计，评估了年龄在59至64岁以及66至71岁且有心理困扰的成年人的医疗保健使用情况，心理困扰定义为在两项患者健康问卷中得分3分或更高或在六项凯斯勒心理困扰量表中得分13分或更高的人。数据于2023年3月至2025年2月进行分析。
65岁时的医疗保险资格。
精神卫生保健使用，包括门诊精神科就诊和精神药物配药、一般医疗保健使用和急性护理使用。
研究人群包括3970名有心理困扰的成年人（平均[标准差]年龄，64.0[3.6]岁；59.7%[n = 2370]为女性）。65岁时获得医疗保险资格与有心理困扰的成年人中与任何医疗保健专业人员进行的门诊精神卫生就诊减少相关（调整后变化为 - 3.4个百分点[95%置信区间，-5.4至-1.4个百分点]），与精神科医生的精神卫生就诊无变化（-0.7个百分点[95%置信区间，-4.1至2.6个百分点]），以及精神药物配药减少相关（-5.3个百分点[95%置信区间，-10.3至-0.3个百分点]）。一般医疗保健使用没有变化，包括所有门诊就诊（0.6个百分点[95%置信区间，-5.4至6.5个百分点]）和处方药使用（0.1个百分点[95%置信区间，-2.2至2.5个百分点]）。相比之下，医疗保险资格与有心理困扰的成年人急性护理使用增加相关，如住院入院（5.5个百分点[95%置信区间，2.2 - 8.9个百分点]）和急诊科就诊（8.1个百分点[95%置信区间，3.3 - 13.0个百分点]）。
这些发现表明，65岁时获得医疗保险资格与有心理困扰的成年人精神卫生门诊服务使用减少和急性护理使用增加相关。这些发现凸显了制定政策以解决医疗保险计划中精神卫生保健差距的必要性。
