Background: Private equity (PE) and other for-profit firms have fueled a growing wave of healthcare consolidation through acquisitions. Behavioral healthcare has been a target, as serial acquisitions of its smaller, independent providers can generate market power while avoiding antitrust scrutiny. Understanding implications for vulnerable populations such as Medicare beneficiaries is particularly important, as over 20% of Medicare beneficiaries are affected by a mental illness or substance use disorder (SUD). Objective: To determine whether for-profit acquisitions of behavioral healthcare facilities were associated with changes in Medicare beneficiaries’ care access and outcomes. Design: Cohort study using Medicare fee-for-service claims (2014-2021) and difference-in-differences models comparing acquired and non-acquired facilities before and after acquisition, overall and by acquirer type (private equity, other for-profit). Setting: Specialty behavioral health treatment facilities with Medicare patients. Participants: 34 PE acquired and 59 other for-profit acquired facilities matched to 829 never-acquired comparator facilities, serving ~2.5 million beneficiaries between 2014 and 2021. We required acquired facilities to be observed at least one-year pre-and-post acquisition, non-acquired to be in counties with at least one acquisition, and beneficiaries to be at least 18 years old with calendar-year continuous enrollment. Main Outcomes and Measures: Beneficiary volume; total and per-beneficiary spending; and quality measures such as follow-up after an acute care event, care continuity, and medication adherence. Results: There were no significant associations between PE acquisition and measures of spending, utilization, or quality. Acquisition by other for-profit firms was associated with significant increases in annual beneficiary spending 53.3% (95% CI: 44.7%, 61.9%), volume 31.5% (95% CI: 21.1%, 42.0%), and spending per beneficiary 16.1% (95% CI: 2.3%, 30.0%) compared to matched never-acquired facilities pre-post-acquisition. Conclusions and Relevance: PE acquisition was associated with small, insignificant increases in beneficiary spending and volume while other for-profit acquisitions were associated with large, significant increases, highlighting differences that may help policymakers anticipate whether an acquisition is likely to increase Medicare volume and service intensity.

Chronically low Medicaid participation among psychiatrists, one of the only mental health specialists eligible to manage medication treatments, has contributed to widespread unmet need. Psychiatric mental health nurse practitioners (PMHNPs) are specialist prescribers who may help close this treatment gap, but their practice patterns in Medicaid are unknown. Using 2018-2022 national Medicaid claims data, we assessed the PMHNP and psychiatrist workforces and their utilization across 34 states plus DC. Over the five-year study period, PMHNPs more than doubled from 6,354 to 13,026 providers. Psychiatrists grew more slowly, from 14,963 to 16,014 providers. Similarly, unique patients seeing PMHNPs increased from 14 to 23 per thousand enrollees and decreased among psychiatrists from 27 to 24 per thousand enrollees. PMHNPs’ share of new patient visits also increased, from 42.2% to 55.5%. By 2022, Medicaid enrollees had near-equal outpatient utilization rates with PMHNPs compared to psychiatrists. Growth in the PMHNP workforce was consistent across rural and urban counties and by state scope-of-practice policies. Policies addressing mental healthcare workforce development and care delivery should reflect the growing role of PMHNPs as specialist prescribers in Medicaid.

Using national data on outcomes of the National Resident Matching Program between 2019-2024 and a difference-in-differences approach, this study examines the effects of state abortion restrictions enabled by the US Supreme Court Decision in Dobbs v. Jackson on the supply of medical residents to training programs located in states restricting abortion. There was a significant decline in the supply of medical residents to abortion restricting states, primarily among those training in obstetrics and gynecology. Less able to fill quotas for new residents, residency programs entered subsequent Match cycles with smaller quotas and relied on comparatively less-competitive applicants to fill them. The share of female residents practicing in restrictive states also declined with the exception of more prestigious hospitals, which maintained similar cohort sex composition pre-post restriction. Findings carry both short and long-term implications for care access. Residents are a key provider for vulnerable populations, commonly staffing free and student-run clinics and taking on large shares of Medicaid and charity care patients in hospital settings, and, residency location is highly predictive of future practice patterns, so impacts on resident labor can drive long term consequences for future provider availability. Incentive programs such as loan repayment and location-specific subsidies may be useful tools in correcting reductions in the resident workforce across states where abortion is illegal.