Inequalities in access to mental health care for young adults: higher deductibles play a role

Author: Francisca Vargas Lopes, PhD Candidate
Joice Kelly

Turning 18 and becoming an adult, changes several aspects of life. For those that receive mental health treatment it implies moving from the system designed for children/adolescents to the system designed for adults. This transition often leads to disruption and discontinuation of care. But why? In this study we proved that the fact that young adults have to pay more for their treatment is one of the reasons leading to the transition gap in the Netherlands.

This is particularly the case for young females of lower-income households, increasing the inequalities in access to mental health care.

In a study recently published by Social Science & Medicine, researchers from Smarter Choices for Better Health show how an increase in the deductible in the Netherlands led to a decrease in use of mental health services by young adults. The deductible corresponds to the initial amount of health care costs that have to be paid by Dutch adults in each year, before the insurance coverage begins (in Dutch: eigen risico).

Paying more for health care at 18 impacted mostly low-income females

We find that the deductible increase of approximately 180 euros between 2011 and 2013 led girls turning 18 to use mental treatment less because they start paying this form of cost-sharing. From 8.1% of young women using mental health services, on average, only 7% did so when the deductible increased. This corresponds to a reduction of 13.6%. We also found that it was mostly young women coming from lower-income households that did not receive treatment anymore, in a reduction of around 20%.

Financial barriers, inequalities and the transition gap

Our findings highlight that making young adults pay higher amounts of their treatment increases inequalities in access to mental health care. This happens at crucial period of life, with potential long-term consequences on mental health and development.

These effects are concerning because mental disorders are the main cause of disability in youth. It is also around adolescence that about ¾ of the adult mental disorders have their onset. Furthermore, the financial barriers appear at a time when a lot of adolescents turning into adults would already have their treatment disrupted or stopped. This is the so-called transition gap, often triggered by the change between the mental health care system for children/adolescents and the one for adults. Cost-sharing is therefore contributing to an unequal transition gap in the Netherlands, because the deductible increase impacted lower-income girls the most.

Who, where and how

We study the entire youth population living in the Netherlands in 2009, and compare individuals just before and after turning 18, and between the periods of low (2009-2011) and high deductible (2013-2014). By doing this, we disentangle the effects of the deductible increase from any other changes at the age of 18. Studying this natural experiment allowed us to find comparable groups and investigate the cause-effect of the deductible policy, by observing what happened in the real-world.

About the author

Francisca Vargas Lopes is a PhD candidate at the Department of Public Health at Erasmus MC, with joint supervision from the Department of Applied Economics of Erasmus School of Economics (ESE). Working at the interface of these two disciplines has provided her with the tools to conduct evaluation of policies and programs using natural experiments, and with a focus on health care inequalities. You can contact Francisca via or learn more about her work here.

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