How did mental health equality laws impact new mothers?

Pregnant and postpartum women with depression and anxiety are slightly more likely to get psychotherapy today, a new study finds. And they pay less out of their own money when they do.

The changes in care and costs occurred primarily after the Affordable Care Act went into effect in 2014, and to a lesser extent after the Mental Health Parity and Addiction Equality Actor MHPAEA, went into effect in 2010, the analysis found.

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

Yet only 10% of women with private insurance who received a mental health diagnosis of anxiety or depression during pregnancy or the postnatal year received psychotherapy between 2019 and 2020, the new analysis found.

And with 25% of pregnant women and new mothers having at least one of these mental health conditions in 2019, up from 14% in 2007, this means many women weren’t receiving the evidence-based care that could have helped both them and their babies.

The findings from the Maternal Behavioral Health Policy Evaluation Study (MAPLE) are published in JAMA Network Opened by a team from the University of Michigan, in a paper titled “Perinatal Psychotherapy Use and Costs Before and After Federally Mandated Health Insurance Coverage.”

“The gap between mental and physical health care has narrowed slightly over time, and the cost barriers have gone down slightly,” said lead author Kara Zivin, Ph.D.

But these positive trends were slow to develop, even after insurance laws changed. This was likely due to a combination of a shortage of mental health providers, underdiagnosis of pregnancy-related mental health problems, and the stigma of seeking help for mental health problems.

“In this high-risk group, and in the context of what we know about the impact of mental illness on maternal mortality, many people are being overlooked,” said Zivin, a professor in the Department of Psychiatry and the Department of Obstetrics and Gynecology at Michigan Medicine, U-M’s academic medical center.

“Even among the 50% of women with depression or anxiety disorder who received psychotherapy during this study period, individuals had an average of only one visit,” she added.

Research into the impact of health policy

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

They used advanced statistical methods to examine what happened after the MHPAEA and ACA both went into effect. Both laws included provisions that required insurers to cover mental health care equally with physical health care and to treat mental health care as an essential benefit.

Overall, women’s chances of receiving psychotherapy increased after the MHPAEA, and increased further after the ACA.

The new research also shows that the average out-of-pocket costs for women who have had psychotherapy at least once vary greatly depending on the time of year.

People who had an appointment in the first months of the year paid an average of more than $50 out of pocket, compared with less than $25 for people who received care in the last month of 2018 and 2019.

The analysis found that this seasonal variation increased after the Affordable Care Act went into effect. Societal increases in employer-sponsored and ACA marketplace high-deductible health plans may have contributed to the variation in out-of-pocket costs over the calendar year. Such plans require the insured individual to pay the full cost of care at the beginning of each coverage year until they reach the amount set as their plan’s deductible.

More about the study

Zivin and her colleagues looked at data on more than 716,000 women between the ages of 15 and 44 who gave birth in the U.S. between early 2007 and late 2019, for a total of more than 837,000 births. All were continuously enrolled in one private health insurance plan for at least a year before and after giving birth.

The team focused on those who had a mental health diagnosis in the two years surrounding their delivery. Within this group, they looked at those who used their insurance to pay for at least one psychotherapy visit with a mental health provider.

The findings build on the team’s recently published work describing other trends in mental health diagnosis and care in the perinatal period, including an increase in antidepressant treatment.

The new study excludes women on Medicaid, who tend to have lower incomes and account for 42 percent of births in the United States.

Women who did not have insurance to pay for psychotherapy were also not included in the study, for example because they went to a mental health provider who did not accept insurance at all or who was not affiliated with an insurance network.

Such a “private pay” situation does not exist in the data source the team used, Optum’s anonymized Clinformatics Data Mart Database.

More research needed

Zivin notes that the data in this study largely comes from the period before the COVID-19 pandemic, when insurers were beginning to offer or expand coverage for tele-mental health care.

Further research into data from 2020 onwards should reveal whether access to telehealth has increased the percentage of pregnant and postpartum women receiving psychotherapy, she says, for example if they live in areas with a severe shortage of mental health providers.

Zivin also notes that national health care laws regarding insurance do not directly address persistent shortage of mental health care providers.

That shortage stems in part from the very problem that mental health equity laws seek to address: decades-long disparities in coverage for mental health and physical health care, both through private insurance and public programs like Medicaid and Medicare.