Millennial Health: Trends in Behavioral Health Conditions
The Blue Cross Blue Shield Association’s 2019 report on the Health of Millennials revealed a downward trend in the health of this population, driven largely by six behavioral health conditions. Since that report, an additional year of data shows that millennial health continues to decline, driven by notable increases in behavioral health conditions, including a 12% increase in major depression, 7% increase in alcohol use disorder and a 5% increase in tobacco use disorder and substance use disorder.
This report, driven by fresh insights into trends in millennials’ behavioral health, dives deeper into the impact of these conditions on millennials. Millennials with a behavioral health condition are at twice the risk of having a chronic physical condition.
- Nearly a third of millennials have a behavioral health condition, and rates are rising by double digits.
- Millennials with a behavioral health condition are at twice the risk of having a chronic physical condition.
- Millennials from majority Black and Hispanic communities have lower rates of behavioral health conditions compared to millennials from white communities—likely due to under-diagnosis.1
- Substance use disorder continues to rise among millennials. Those diagnosed with an opioid use disorder are 46% less healthy than their peers and treatment varies by race with Blacks and Hispanics having lower overall rates of treatment than whites.
BEHAVIORAL HEALTH CONDITIONS CONTINUE TO RISE
An additional year of data shows a continued downward trend in millennial health over a five year period. Rates of behavioral health conditions continue to rise, contributing to a large number of years of healthy life lost. Rates of major depression, alcohol use disorder (AUD), tobacco use disorder (TUD), substance use disorder (SUD) and ADHD rose again from 2017-2018, pushing the five year prevalence change for these conditions to 43% for major depression, 5% for AUD, 10% for TUD and 39% for ADHD (See Exhibit 1).
Exhibit 1: Behavioral Health Conditions Driving Adverse Health for Millennials2
The IMPACT OF COVID-19
The COVID-19 pandemic is likely to further accelerate the rise of behavioral health conditions among millennials. Certain lifestyle behaviors have risen within this group since the outbreak began and these behaviors can lead to the development of behavioral health conditions or worsen existing ones.
Blue Shield of California’s Wellvolution is a health platform that matches participants with individualized health and wellness recommendations. Results to date include enrollment of 2 out of 3 people in disease prevention and treatment programs, with outcomes including reduction in weight of 5% and normalization of A1C levels in about 75%. READ MORE
BEHAVIORAL HEALTH CONDITIONS INCREASE RISK FOR CHRONIC PHYSICAL CONDITIONS
To quantify the link between behavioral and chronic physical health conditions, we analyzed the medical claims of millennials with five years of continuous BCBS health plan coverage. Those with ongoing behavioral health conditions since 2014 were approximately twice as likely to have chronic physical conditions as their peers without a behavioral health diagnosis (see Exhibit 2).
Exhibit 2: Millennials with Behavioral Health Conditions – Likelihood to Have Chronic Physical conditions, 2014-20184
Differing Health Attitudes3
Millennials perceive their mental well being as being worse than older generations. In addition, they believe their mental health impacts their physical health.
BLACK AND HISPANIC MILLENNIALS ARE LESS LIKELY TO BE DIAGNOSED WITH BEHAVIORAL HEALTH CONDITIONS
Compared to millennials in majority white communities, members of majority Black or Hispanic communities5 have substantially lower diagnosis rates of behavioral health conditions. For example, millennials in majority Black and Hispanic communities have 30-60% lower rates of major depression and ADHD compared to millennials in majority white communities (see Exhibit 3).
The large differences may come down to under-diagnosis in communities of color, not necessarily the absence of behavioral health conditions. Under-diagnosis can occur for a number of reasons, including a lack of understanding of cultural differences, stigma around diagnosis or treatment and barriers accessing behavioral health specialists.
Exhibit 3: Difference in Diagnosis Rates of Behavioral Health Conditions for Millennials by Race/Ethnicity, 2018
In the wake of the COVID-19 pandemic, BCBS companies have committed to expanding coverage and access to virtual care solutions—a shift millennials across the country have been seeking from their health plans. READ MORE
MILLENNIALS WITH OPIOID USE DISORDER HAVE WORSE OVERALL HEALTH
Substance use disorder (SUD) has the third highest impact on millennials’ health, just behind major depression and hypertension. In 2018, about 1 million commercially insured millennials in the U.S. were diagnosed with SUD; of those, nearly 340,000 were diagnosed with opioid use disorder (OUD). Millennials with an OUD diagnosis and their treatment are often complicated by the fact that they’re more likely to have adverse health events such as ER visits and hospitalizations and the fact that they have much higher prevalence rates of pain-related conditions, behavioral health conditions and cardiovascular conditions (see Exhibit 4).
Exhibit 4: Adverse Health Events and Condition Prevalence among Millennials Diagnosed with OUD, 20186
The IMPACT OF COVID-19
The current COVID-19 pandemic could further compromise the health of millennials (and people of all ages) who have an OUD diagnosis. People with OUD are at increased risk for complications from COVID-19, according to the National Institute on Drug Abuse.8 Next, social isolation measures could put people with OUD at risk of overdose or, if in recovery, relapse.9
MORE MILLENNIALS ARE RECEIVING OUD TREATMENT THAN OLDER GENERATIONS, BUT THEY’RE DISPROPORTIONATELY WHITE
Compared to Gen Xers and older populations, millennials are more likely to receive evidence-based OUD treatment, such as medication assisted treatment (MAT) and behavioral therapy (BT). Nearly two thirds of millennials diagnosed with OUD received treatment in 2018 compared to less than half of Gen Xers and less than a third of Baby Boomers with an OUD diagnosis. Over 60% of millennials are receiving treatment with 16% receiving both MAT and BT, the current evidence-based recommended standard for treatment (see Exhibit 5).
Exhibit 5: Percent of Diagnosed Millennial Members Receiving Treatment, 2016-2018
Anthem BCBS has more than doubled the number of members with an OUD diagnosis who are receiving both MAT and BT, a best practice for treatment. READ MORE
OUD treatment varies by race/ethnicity. Millennials in majority Black or Hispanic communities have substantially lower rates of treatment across all treatment types compared to millennials in majority white communities (see Exhibit 6).
Exhibit 6: Percent of OUD Diagnosed Millennials Receiving Treatment by Race/Ethnicity, 2018
The Blue Distinction Centers (BDC) for Substance Use Treatment and Recovery program recognizes nationally-accredited treatment facilities that are improving outcomes with evidence-based, patient-focused care. Patients with opioid use disorder who received treatment at BDC eligible facilities had a lower 90-day readmission rate, a higher Medication Assisted Treatment (MAT) continuation rate (at both 30 days and 60 days), and a lower average cost.10
A CALL TO ACTION
Our 2019 report, The Economic Consequences of Millennial Health, detailed how declining millennial health could hamper this generation’s future prosperity. The economic impact of the current COVID-19 pandemic could harm these prospects even more.
The current COVID-19 pandemic will likely exacerbate health challenges for millennials. Because of the pandemic, almost 60% of millennials have canceled a health-related appointment or procedure. In addition, isolation, stress and economic insecurity attributed to the pandemic have had a major impact on millennials. Almost 10% have lost their job due to the pandemic, 25% have seen a reduction in their work hours, and 23% have had to access savings to pay for their day to day needs.3
The implications of the health challenges millennials face touch us all. Addressing this decline in health, including the disproportionate burden of disease experienced by particular groups, is urgent in light of the continued downward trend in well-being. Ensuring the health of this generation will take the work of partners across the health care system. On October 28, 2020, BCBS companies will convene healthcare experts, employers, academic partners and millennials in a virtual forum to explore the issues and identify solutions to improve the health of millennials.
- American Psychiatric Association: Mental Health Disparities: Diverse Populations
- (1) The change in top 10 conditions from 2019 Millennial Health report is due in large part to changes in the mortality and disability impact of health conditions from IHME Global Burden of Diseases and CDC mortality data. (2) Years of life lost measures the disability and mortality impact by converting the disease impact as the number of healthy years of life lost due to the burden of disease. (3) The age range used in this year’s report is 22-37 (the age range of Millennials as of 2018 based on Pew Research’s generational definition), one year older than that in last year’s report. As a result, the 2014 prevalence rates are slightly different in this report and the previous The Health of Millennials report.
- BCBSA. Generation Survey. September 2020.
- Millennials with five years continuous enrollment are divided into two groups - members without any behavioral health (BH) diagnoses in the five years (1.5M) vs. members with on-going BH diagnoses for all five years (0.56M), represent 73% of all millennials with five years continuous coverage with BCBS. Increase in prevalence rate (per 100) of top physical conditions are compared here to show the impact of BH condition on physical health.
- The race/ethnicity of a community is determined by the race/ethnicity of the majority of household heads within the community. For example, when over 50% of the household heads are Black in a ZIP code, it is classified as a majority Black community. Only 38 zip codes are identified as majority Asian communities thus the results are not shown in the report.
- The conditions studied are informed by NIH research.
- The Blue Cross Blue Shield Health Index quantifies over 300 different health conditions to identify which diseases and conditions most affect Americans’ longevity and quality of life. It is powered by annual data from more than 41 million BCBS commercially insured members.
- National Institute on Drug Abuse, COVID-19 Resources
- Nora D. Volkow, MD, “Collision of the COVID-19 and Addiction Epidemics,” Annals of Internal Medicine, 173:1 (2020): 61-62.
- The results are based on BDC eligible facilities that can be identified in 2018 claims data.
This is the 34th study of the Blue Cross Blue Shield, The Health of America Report® series, a collaboration between Blue Cross Blue Shield Association and Blue Health Intelligence (BHI), which uses a market-leading claims database to uncover key trends and insights in healthcare affordability and access to care. Millennials are defined as people ages 22-37 in 2018, based on the definition developed by Pew Research Center. This report provides an update of the overall health of millennials and conducts a deep-dive on the impact of behavioral health.
This report examines the health of millennials using the BCBS Health Index. The BCBS Health Index quantifies the health of a population using a score between 0 and 100. A score of 100 represents optimal health—a population’s greatest potential lifespan in the absence of disability and premature death. The presence of health conditions that cause disability and premature death reduces a population’s optimal health. This reduction is described in this report as “adverse health impact” and is measured on the same 0 to 100 scale as the Health Index. The sum of adverse health impacts across all conditions is described in this report as “total adverse health.” The BCBS Health Index calculation as a function of total adverse health can be written as follows:
BCBS Health Index = 100 – Total Adverse Health
Likewise, the calculation for total adverse health can be written as:
Total Adverse Health = 100 – BCBS Health Index
For example, millennials had a Health Index of 94.5 in 2018. This means that their total adverse health for that year was 100 – 94.5 or 5.5.
Race/ethnicity were defined at the ZIP code level using Acxiom data. The race/ethnicity of a community is determined by the race/ethnicity of the majority of head of households within the ZIP code. For example, when over 50% of the household heads are Black in a ZIP code, it is classified as a community with a majority Black population.
FIGURE A: TOP 10 CONDITIONS AFFECTING MILLENNIALS AND PREVALENCE INCREASES
* Tobacco Use Disorder was ranked #9 in the top 10 conditions impacting millennials in 2017.
The adverse health impact of a condition is defined as the reduction in future healthy years due to the presence of the condition. Total adverse health across all conditions can be derived by subtracting the Health Index of a population from 100 (the score the population would receive if no conditions were present). See Methodology for further detail.
FIGURE B: PREVALENCE RATES OF TOP TEN CONDITIONS FOR MILLENNIALS – MAJORITY BLACK/ HISPANIC VS. MAJORITY WHITE COMMUNITIES, 2018