Medicaid Expansion and Veterans’ Reliance on the VA for Depression Care

At the state level, reliance on the VA for inpatient depression care in NY decreased by 13.53 pp (95% CI, -22.58 to -4.49) for income-eligible veterans and 16.67 pp (95% CI, -24.53 to -8.80) for service-connected veterans. No relative differences were observed in the outpatient comparisons for both income-eligible (-0.58 pp; 95% CI, -2.13 to 0.98) and service-connected (0.05 pp; 95% CI, -1.00 to 1.10) veterans. In AZ, Medicaid expansion was associated with decreased VA reliance for outpatient depression care among income-eligible veterans (-8.60 pp; 95% CI, -10.60 to -6.61), greater than that for service-connected veterans (-2.89 pp; 95% CI, -4.02 to -1.77). This decrease in VA reliance was significant in the inpatient context only for service-connected veterans (-4.55 pp; 95% CI, -8.14 to -0.97), not income-eligible veterans (-8.38 pp; 95% CI, -17.91 to 1.16).

By applying the aggregate pp changes toward the postexpansion number of visits across both expansion and nonexpansion states, we found that expansion of Medicaid across all our study states would have resulted in 996 fewer hospitalizations and 10,109 fewer outpatient visits for depression at VA in the postexpansion period vs if no states had chosen to expand Medicaid.

Dual Use/Per Capita Utilization

Overall, Medicaid expansion was associated with greater dual use for inpatient depression care—a 0.97-pp (95% CI, 0.46 to 1.48) increase among service-connected veterans and a 0.64-pp (95% CI, 0.35 to 0.94) increase among income-eligible veterans.
At the state level, NY similarly showed increases in dual use among both service-connected (1.48 pp; 95% CI, 0.80 to 2.16) and income-eligible veterans (0.73 pp; 95% CI, 0.39 to 1.07) after Medicaid expansion. However, dual use in AZ increased significantly only among service-connected veterans (0.70 pp; 95% CI, 0.03 to 1.38), not income-eligible veterans (0.31 pp; 95% CI, -0.17 to 0.78).

Among outpatient visits, Medicaid expansion was associated with increased dual use only for income-eligible veterans (0.16 pp; 95% CI, 0.03-0.29), and not service-connected veterans (0.09 pp; 95% CI, -0.04 to 0.21). State-level analyses showed that Medicaid expansion in NY was not associated with changes in dual use for either service-connected (0.01 pp; 95% CI, -0.16 to 0.17) or income-eligible veterans (0.03 pp; 95% CI, -0.12 to 0.18), while expansion in AZ was associated with increases in dual use among both service-connected (0.42 pp; 95% CI, 0.23 to 0.61) and income-eligible veterans (0.83 pp; 95% CI, 0.59 to 1.07).

Concerning per capita utilization of depression care after Medicaid expansion, analyses showed no detectable changes for either inpatient or outpatient services, among both service-connected and income-eligible veterans. However, while this pattern held at the state level among hospitalizations, outpatient visit results showed divergent trends between AZ and NY. In NY, Medicaid expansion was associated with decreased per capita utilization of outpatient depression care among both service-connected (-0.25 visits annually; 95% CI, -0.48 to -0.01) and income-eligible veterans (-0.64 visits annually; 95% CI, -0.93 to -0.35). In AZ, Medicaid expansion was associated with increased per capita utilization of outpatient depression care among both service-connected (0.62 visits annually; 95% CI, 0.32-0.91) and income-eligible veterans (2.32 visits annually; 95% CI, 1.99-2.65).