The changes in care and cost happened mainly after the Affordable Care Act took effect in 2014, and to a lesser extent after the Mental Health Parity and Addiction Equity Act, or MHPAEA, took effect in 2010, the analysis shows.

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

Even so, only about 10% of women with private insurance who had a mental health diagnosis of anxiety or depression during pregnancy or during their postpartum year received psychotherapy in 2019 to 2020, according to the new analysis.

And with 25% of pregnant women and new mothers having at least one of these mental health diagnoses in 2019, up from 14% in 2007, that means a lot of women did not get the evidence-based care that could help both them and their babies.

The findings from the Maternal Behavioral Health Policy Evaluation Study (MAPLE) are published in JAMA Network Open by a University of Michigan team.

“The gap between mental and physical health care closed slightly over time, and cost barriers decreased marginally,” says lead author Kara Zivin, Ph.D.

But these positive trends happened slowly even after insurance laws changed, likely due to a combination of a shortage of mental health care providers, underdiagnosis of pregnancy-related mental health conditions, and stigma against seeking mental health help.

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

“Even among the 50% of women with depression and anxiety diagnoses who attended psychotherapy during this study period, individuals on average only had one visit,” she added.

Studying health policy impacts

Zivin and her colleagues focused on the impact of health policy changes for 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 designed to require insurers to cover mental health care and physical health care equally and to treat mental health as an essential benefit.

In general, women’s chances of receiving psychotherapy began to rise after the MHPAEA and increased even more after the ACA.

The new study also shows wide variation in average out-of-pocket costs for women who received psychotherapy at least once, depending on what time of year they received it.

Those whose appointments happened in the first months of the year paid on average more than $50 out of pocket, compared with under $25 for those who received care during the last month of 2018 and 2019.

The analysis showed that this seasonal variation increased after the Affordable Care Act took effect. Society-wide increases in employer-sponsored and ACA marketplace high-deductible health plans may have contributed to the variation in out-of-pocket costs throughout a calendar year. Such plans require the insured person to pay the full cost of care at the start 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 from more than 716,000 women between the ages of 15 and 44 who gave birth between the start of 2007 and the end of 2019 in the US, for a total of more than 837,000 births. All were continuously enrolled in a single private health insurance plan for at least a year before and after they gave birth.

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

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

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

Nor does the study include women who did not use insurance to pay for psychotherapy, for instance because they saw a mental health provider who does not accept insurance at all, or who does not participate in an insurance plan’s network.

That kind of “private pay” situation does not appear in the data source that the team used, Optum’s deidentified Clinformatics Data Mart Database.

More research needed

Zivin notes that the data in this study come mostly from a time before the COVID-19 pandemic, when insurers began or increased coverage for tele-mental health care.

Further research on data from 2020 onward should examine whether telehealth access increased the percentage of pregnant and postpartum women receiving psychotherapy, she says — for instance, if they live in areas with severe shortages of mental health providers.

Zivin also comments that insurance-related national health care laws cannot directly address the ongoing shortage of mental health providers.

That shortage stems in part from the exact issue that mental health parity laws aim to address: decades of differences in mental health care and physical health care coverage under both private insurance and public programs such as Medicaid and Medicare.

In addition to Zivin, the study’s authors include senior author Vanessa Dalton, M.D., M.P.H., and co-authors Xiaosong Zhang, M.S., Anca Tilea, M.A., Stephanie V. Hall, Ph.D., Lindsay Admon, M.D., M.Sc. and Ashlee Vance, Ph.D.

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

The National Institute of Mental Health (R01MH120124) and the National Institute on Minority Health and Health Disparities (R01MD014958) funded this study.