70 Chapter 3 on patient cost-sharing and mental health care at the transition to adulthood is lacking. In this study, we establish the impact of increased health insurance deductibles on mental health service use during the transition to adulthood. Our quasi-experimental differencein-discontinuity approach [23, 24] exploits that Dutch citizens only start paying annual deductibles in the month following their 18th birthday; and that the deductible amount more than doubled between 2009 and 2014. We further explore heterogeneous effects of cost-sharing during the transition to adulthood on mental health care utilization across socioeconomic groups; and on treatment cessation among patients that differ by the intensity of previous mental health treatment or by the use of medicines for mental health disorders. Our study contributes to the literature in several forms. First, we leverage the ability of the difference-in-discontinuity study design to disentangle the effect of increased deductibles from the disruption in treatment caused by other reasons, as the transition from CAMHS to AMHS. Other empirical methods, such as a regression discontinuity design (RDD), would not have allowed us to distinguish the impact of financial barriers from other factors. We find that cost sharing acts as a financial barrier among youth and contributes to the transition gap in mental health care. Second, we measure income at the individual level and obtain estimates of heterogeneous effects across the entire population of young adults. We find that females in low income are more likely to not use mental health care when facing increased deductibles. Third, we show that cost-sharing increases prorich inequalities in access to mental health care, in a country with a comprehensive mental health care system and low out of pocket expenditures. INSTITUTIONAL SETTING Deductibles in the Netherlands According to the Health Insurance Act of 2006, citizens living or working in the Netherlands are mandated to purchase insurance that covers a comprehensive and legally predefined health benefit package, including mental health care. Since 2008, cost-sharing has the form of a one-off annual deductible that applies to all the health care costs covered by the insurance benefit package, with the exception of primary care, maternity care and home nursing care [25]. Growing health expenditure led the government to increase the compulsory deductible from 170 to 350 euros, between 2011 and 2013. This increase prompted concerns over the imposition of access barriers for vulnerable groups like young adults and low-income individuals, that were already more likely to avoid care due to financial reasons [26]. Table 1 shows the evolution of the deductible between 2009 and 2014, in current and 2015 prices. Our empirical identification strategy exploits that deductibles in 2013 and 2014 (high deductible period) were on average 181 euros (2015 prices) higher than the deductibles in 2009 and 2011 (low deductible period), while the deductible was rather stable within both time periods.
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