Conditional Medicaid Expansion and Mental Health

Key Takeaways

• Compared with neighboring nonexpansion states, low-income adults in Georgia reported more days in the past month when mental health was not good after Pathways began.
• A second primary outcome also moved in the same direction, with more respondents reporting that they had ever been told they had a depressive disorder.

Among low-income adults aged 18 to 64 years, Pathways implementation was associated with 4.0 additional past-month days when mental health was not good (95% CI, 2.0-6.0; P < .001). In a JAMA Network Open study, investigators compared Georgia with neighboring nonexpansion states after the program began on July 1, 2023. The analysis focused on adults aged 18 to 64 years with household income at or below 100% of the federal poverty level. Pathways conditions eligibility on at least 80 hours each month of work or other qualifying community engagement activities.

The health policy original investigation used a cross-sectional difference-in-differences design and Behavioral Risk Factor Surveillance System data. Georgia was compared with Alabama, Mississippi, Tennessee, and South Carolina, neighboring states without Medicaid expansion. The analytic population included adults aged 18 to 64 years with income at or below 100% of the federal poverty level, excluding respondents who were currently pregnant or reported caregiving for relatives. Across 5 states, there were 8138 total observations, analytic samples of 7071 to 7259, and a mean respondent age of 46.4 years. The preintervention period ran from January 2, 2017, through March 28, 2023, and responses from March 29 through July 10, 2023, were excluded before the postintervention period through December 31, 2024.

The primary endpoints were past-month days when mental health was not good and self-report of ever being told one had a depressive disorder. The adjusted analysis found a 7.2 percentage-point higher probability of ever being told one had a depressive disorder (95% CI, 2.4-12.0; P = .003), and the days-based outcome also worsened after implementation. Models adjusted for race and ethnicity, marital status, and income relative to the federal poverty level, with state, age, and calendar-date fixed effects.

Event-study analyses showed some isolated significant prepolicy coefficients, but joint tests indicated that the prepolicy estimates were not statistically different from zero. Robustness analyses found no significant associations among respondents with income above 100% of the federal poverty level or among those with private insurance. No significant associations appeared in a placebo analysis using a false intervention date of July 2019, and results were similar with the preperiod restricted to January 2020 onward.

The authors interpreted the findings as showing that Georgia’s Pathways program was associated with worsening mental health among low-income adults. They also said that conditioning eligibility on work or community engagement activities may create barriers to coverage and mental health care access.