81 Patient cost-sharing, mental health care and inequalities less to the deductible change. Our results are further in line with literature showing a larger impact of co-payments in Dutch adult females using mental health care [33] and in Swedish 20-year old females using primary care [34] compared to their male counterparts. We find effects to be concentrated among females of low-income groups. This might be a direct consequence of low income, due to liquidity and budget constraints to pay for higher deductibles. Additionally, this might also result from other mechanisms associated with low socioeconomic status that influence the way individuals perceive mental health needs and the value of treatment [35], for example low (parental) education. While our main findings relate to overall care utilisation in the population, the role of the deductible increase on treatment discontinuation is especially relevant in the context of poor transitional care. Our results concerning care cessation show higher likelihoods of stopping in high deductible years across the entire spectrum of mental health care needs. This suggests a reduction even for high-intensity users, for whom the transition gap is more likely to result in relapse or recurrence and subsequent functional disability. In terms of medication, we find patients using agents for ADHD to discontinue care the most in the high deductible period. These findings are in line with international studies showing that patients with ADHD experience more pronounced transition difficulties, in particular in a context of sparse ADHD adult services [36]. Altogether, our results highlight financial barriers as a key – but often underrated – contributor to the disruption of care at the transition between CAMHS and AMHS. Our study contributes to the current literature gap by exploring variation in national-level policy to provide quasi-experimental estimates of cost-sharing on mental health care use at the transition to adulthood. This is a narrow but particularly critical period of the life course, which overlaps with a weakness in the configuration of current mental health care systems [7, 9]. Our approach separates the policy of increasing deductibles from other timeinvariant individual or system discontinuities at the age of 18, while the use of highquality administrative records allows studying the entire Dutch population, and conduct a number of subgroup analyses. In terms of heterogeneous impact by socioeconomic status, and although differential effects of cost-sharing by income are supported by theory, our study provides additional contributions to what most studies can measure. First, we use administrative income records rather than relying on selfreported income or area-based measures, which can result in considerable differences in both classification and findings [37, 38]. Second, we are able to directly compare across income groups for the complete population, instead of focusing only on selected subgroups or indirect comparisons [24, 34]. Our results are aligned with the patient cost-sharing literature on health care use for other age groups, that finds negative impacts of copayments and coinsurance on the use of mental health services [33, 39-41]. and of deductibles on “physical” and mental health 3
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