Legislative changes improve mental health care access for pregnant and postpartum women

Pregnant and postpartum women suffering from depression or anxiety have recently become slightly more likely to receive psychotherapy, and their out-of-pocket costs for therapy have also fallen, a new study finds.

The analysis found that changes in care and costs have occurred primarily since the enactment of the Affordable Care Act in 2014 and, to a lesser extent, since the enactment of the Mental Health Parity and Addiction Equity Act (MHPAEA) in 2010.

Both laws were intended to reduce insurance-related barriers to mental health care.

Yet a new analysis shows that only about 10% of privately insured women who were diagnosed with a mental illness like anxiety or depression during pregnancy or in the year after giving birth received psychotherapy in 2019-2020.

In 2019, 25% of pregnant women and new mothers were diagnosed with at least one such mental illness, up from 14% in 2007. This means many women are missing out on evidence-based care that could help both themselves and their babies.

Findings from the Maternal Behavioral Health Policy Evaluation Study (MAPLE) JAMA Network Open By a team from the University of Michigan.

Over time, the gap between mental and physical health care has narrowed slightly, and the cost barriers have decreased slightly.”

Dr. Kara Zivin, lead author

However, even after the health law reform, these positive trends emerged slowly, likely due to a combination of a shortage of mental health care providers, under-diagnosis of pregnancy-related mental health disorders, and stigma surrounding seeking mental health help.

“In this high-risk population, given what we know about the impact of mental illness on maternal mortality, many people are being overlooked,” said Zivin, a professor of psychiatry and obstetrics and gynecology at the University of Michigan Medical School. Zivin is a professor of psychiatry and obstetrics and gynecology at the University of Michigan Medical School.

“Even 50% of women diagnosed with depression or anxiety who received psychotherapy during the study period only attended one treatment session, on average,” she added.

Research into the impact of health policies

Zivin and her colleagues focused on the impact of health policy changes on women with perinatal mood and anxiety disorders.

They used sophisticated statistical methods to examine what happened after the MHPAEA and ACA each took effect. Both laws included provisions requiring insurers to cover mental and physical health care equally and to treat mental health care as an essential benefit.

In general, women’s access to psychotherapy began to increase after the MHPAEA and has increased further since the ACA.

The new study also shows that the average out-of-pocket costs for women who received psychotherapy at least once varied widely depending on when they received it.

Those who had a doctor’s visit at the beginning of the year had an average out-of-pocket expense of more than $50, compared with less than $25 for those seen in the last month of 2018 and 2019.

The analysis found that this seasonal variation increased after the implementation of the Affordable Care Act. A society-wide increase in high-deductible health insurance plans in employer-sponsored and Affordable Care Act markets likely contributed to the variation in out-of-pocket expenses throughout the calendar year. In such plans, insureds are required to pay the full amount of their medical expenses at the beginning of each policy year until the plan’s deductible is met.

Research details

Zivin and her colleagues looked at birth data from more than 716,000 women aged 15 to 44 who gave birth in the US between the beginning of 2007 and the end of 2019, for a total of more than 837,000 cases. All had continuous coverage with a single private health plan for at least a year before and after giving birth.

The researchers focused on women who had been diagnosed with a mental illness in the two years before and after giving birth, and within this group, looked at women who had used their insurance to receive at least one psychotherapy visit from a mental health provider.

The findings build on the team’s recently published research that has shown other trends in perinatal mental health diagnosis and care, including an increase in treatment with antidepressants.

The new study did not include women covered by Medicaid, who tend to have lower incomes and account for 42% of births in the United States.

The study also did not include women who did not use their insurance to pay for psychotherapy because their psychiatric care provider did not accept their insurance at all or was not in their insurance plan’s network.

These “privately paid” situations do not appear in the data source the team used: Optum’s anonymized Clinformatics Data Mart database.

Further research needed

Zivin noted that the study’s data comes primarily from the era before the COVID-19 pandemic, when insurers were beginning or expanding coverage for remote mental health care.

Further studies of data from 2020 onward should explore whether access to telehealth has increased the proportion of pregnant and postpartum women receiving psychotherapy, for example if they live in areas with severe shortages of mental health providers, she says.

Zivin also said the insurance-related national health care law does nothing to directly address the continuing shortage of mental health care workers.

This shortage stems in part from the problem the Mental Health Parity Act aims to solve: long-standing disparities in coverage for mental and physical health care in both private insurance and public programs like Medicaid and Medicare.

In addition to Zivin, authors on the study include senior author Vanessa Dalton, MD, MPH, and co-authors Xiaosong Zhang, MD, Anca Tilea, MD, Stephanie V. Hall, PhD, Lindsay Admon, MD, MSc, and Ashlee Vance, PhD.

Zivin is a member of the VA Ann Arbor Healthcare System’s Center for Clinical Management Research, and she, Admon and Dalton are members of the UM Institute for Healthcare Policy and Innovation. Vance, a former IHPI National Clinician Scholar, is now with Henry Ford Health.

This research was funded by the National Institute of Mental Health (R01MH120124) and the National Institute on Minority Health and Health Disparities (R01MD014958).