83 Patient cost-sharing, mental health care and inequalities interpret our estimates as patient, and less as provider responses, as the binary outcome of care utilisation is mostly decided by patients. On the other hand, providers could have a larger influence on how much care patients use. While providers’ revenues could be indirectly affected by the increase of the deductible, we hypothesize that they had limited incentives and means to react to this change, because the deductible amount does not directly impact their payment, and is charged to patients by insurers. CONCLUSION Our results indicate that financial barriers contribute to the transition gap identified in the mental health sector. We find a disproportional impact of the deductible increase on the most vulnerable groups, who are likely to have greater needs of mental health treatment. This suggests that cost-sharing might be widening inequalities in mental health from the early age of 18. Such disproportional effect of cost-sharing was identified in a country with universal health care coverage and relatively low levels of out-of-pocket expenditure. This positions our findings for the Netherlands as a possible lower bound among other high-income countries, raising concerns for countries where deductibles are a prominent feature of insurance plans, or where financial arrangements change at the transition to adulthood. Our results show that blunt forms of costsharing are detrimental for vulnerable groups, suggesting that policy-makers should look to value-based insurance design and establish patient costsharing structures that consider patients benefiting the most. Complementary strategies include increasing the perceived value of mental health treatment during the transition to adulthood and among young adults; and raising awareness of the financial barriers among clinicians and researchers working on the CAMHS-AMHS transition. 3
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