Note: This is a plain text version of the study referenced in the article
The Cost of Untreated Maternal Mental Health Conditions.

Context

MMHCs are common in the United States, affecting 13.2% of women from pregnancy through five years post-delivery and are among the most common obstetric complications in Texas. These conditions often go undiagnosed and untreated, despite the existence of screening tools and effective treatments. In fact, only half of perinatal women who are diagnosed with depression receive any treatment. In Texas, Medicaid for Pregnant Women covers an estimated 47.5% of births. When coverage through this program ends after 60 days post-delivery, many women withlow income who do not meet the income requirements for Medicaid or for subsidies through the Affordable Care Act Marketplace become uninsured and unable to access screening and treatment because of the cost.

When left untreated, MMHCs can become a multigenerational issue, negatively affecting the mother and child’s long-term physical, emotional, and developmental health.

Conceptual model and research rationale

To our knowledge, this mathematical model, an adaptation of our national model,10 presents the most comprehensive analysis to date of the economic burden of MMHCs in Texas. To construct the model, we compiled the most recent peer-reviewed literature and secondary data sources to quantify the societal costs of not treating MMHCs. We collected data on the prevalence of MMHCs, the outcomes associated with untreated MMHCs, and the costs and baseline rates of each outcome. With this information, we created cost estimates for all Texas births in 2019 when following the mother–child pair from pregnancy through five years post-delivery.

Untreated MMHCs are linked to an increased likelihood of absenteeism, presenteeism, and unemploy- ment. Mothers with MMHCs also have an increased risk of suicide, pre-eclampsia, and delivery via cesarean section.

Children born to mothers with MMHCs have an increased risk of preterm birth and child behavioral and developmental disorders.

All women

We estimated that the prevalence of untreated MMHCs among all Texas women is 13.2%, not accounting for the increased prev- alence of MMHCs arising from the COVID-19 pandemic. Using this prevalence estimate, we estimated that the total societal cost of MMHCs in Texas for all births in 2019 is $2.2 billion. This amounts to more than $44,000 in societal costs per mother with an MMHC and her child from con- ception to age 5, which is higher than the national average of $32,000. About 55% of the societal costs can be attributed to maternal outcomes, with the largest costs coming from productivity losses ($610 million), non-obstetric health expenditures ($445 million), and obstetric-specific health expenditures. 45% of costs are related to child outcomes, with the largest costs coming from child behavioral and developmental disorders ($556 mil- lion), preterm births ($372 million), and asthma ($33 million). Reduced attendance at well-child care visits could partially offset the cost of child outcomes in the short term (-$11.2 million) but, in the long term, might lead to an increase in health care costs through worse child health.

Nearly half of the societal costs occur between pregnancy and the child’s first birthday and are associated with pregnancy, birth complications such as preterm birth, and other obstetric health expenditures.

Medicaid

We estimated that the prevalence of untreated MMHCs among mothers enrolled in Texas’ Medicaid for Pregnant Women program is 17.2%. We also estimated that the total cost of untreated MMHCs in Texas for all Medicaid for Pregnant Women-covered births in 2019, excluding costs for productivity losses, maternal suicide, and sudden infant death syndrome, is $962 million. This amounts to more than $31,000 in health care system costs per mother enrolled in Medicaid for Pregnant Women and her child from conception to five years after birth. Within the Medicaid population, 35% of costs are related to maternal outcomes, with the largest costs coming from non-obstetric health expenditures ($276 million). When Medicaid for Pregnant Women ends after 60 days post-delivery, the health care system (for women who cannot afford to self-pay or purchase health insurance) or private insurers (for women who are able to purchase insurance in the Affordable Care Act Market- place) bear the costs of maternal outcomes.

A total of 65% of costs relate to child outcomes, with the largest costs coming from child behavioral and developmental disorders ($345 million) and preterm birth ($231 million). The health care system (for children whose parents no longer meet Medicaid or Children’s Health Insurance Program income eligi- bility requirements) or Medicaid (for children whose parents meet the income eligibility requirements) bear the costs of these child outcomes. Overall, 48% of the total health system costs, beyond Medicaid, for mothers enrolled in Medicaid for Pregnant Women and their children are associated with pregnancy and birth complications and occur between conception and the child’s first birthday.

Health disparities by race and ethnicity in Texas

Accounting for differences in the prevalence of MMHCs, population size, and societal and health outcomes revealed that untreated MMHCs occur most often among Non-Hispanic Black mothers (18.2%), followed by Hispanic mothers (12%) and Non-Hispanic White mothers (11.4%). Non-His- panic Black mothers are more likely than their Hispanic or Non-Hispanic White mothers to experience pre-eclampsia, cesarean delivery, or preterm birth but have lower obstetric health care expenditures, suggesting Non-Hispanic Black mothers’ having less access to high-quality care.Health disparities result in higher societal costs per Non-Hispanic Black mother-child pair ($62,000) than for Non-Hispanic White and Hispanic mother-child pairs ($43,000). Identifying and closing the gap in these health disparities could lead to lower societal costs for all.

Non-Hispanic White mothers

Untreated MMHCs affect an estimated 11.4% of Non-Hispanic White mothers, and the cost for births in 2019 is $599 million. This amounts to more than $43,000 in costs per Non-Hispanic White mother and her child over a six-year period. A total of 56% of costs for Non-Hispanic White mother–child pairs relate to maternal outcomes, and 44% relate to child outcomes.

The largest maternal costs come from productivity losses ($170 million) and non-obstetric health expenditures ($123 million), and the largest child costs come from child behavioral and develop- mental disorders ($155 million) and preterm birth ($89 million).

Non-Hispanic Black mothers

Untreated MMHCs affect an estimated 18.2% of Non-Hispanic Black mothers, and the cost for births in 2019 is $521 million. This amounts to nearly $62,000 in costs per Non-Hispanic Black woman and her child over the period between conception and age 5. A total of 65% of costs for Non-Hispanic Black mother–child pairs relate to maternal outcomes, and 35% relate to child outcomes. The largest maternal costs come from productivity losses ($189 million) and non-obstetric health expenditures ($118 million), and the largest child costs come from child behavioral and devel- opmental disorders ($94 million) and preterm birth ($74 million).

Hispanic mothers

Untreated MMHCs affect an estimated 12% of Hispanic mothers, and the cost for births in 2019 is $928 million. This amounts

to more than $43,000 per Hispanic mother and her child over the period between conception and age 5. A total of 55% of costs for Hispanic mother–child pairs relate to maternal outcomes, and 45% relate to child outcomes. The largest maternal costs come from productivity losses ($229 million) and non-obstetric health expenditures ($211 million), and the largest child costs come from child behavioral and developmental disorders ($239 million) and preterm birth ($149 million).

Comparable conditions

MMHCs remain among the most costly conditions during pregnancy and through five years post-delivery. Examining only medical costs (excluding labor force and non-medical social services costs), MMHCs cost $20,342 per mother–child pair over the period between conception and age 5. In comparison, other perinatal conditions, such as post-delivery hemorrhage and gestational diabetes, each cost up to $3,300 per mother.

Conclusion

Our model demonstrates that the total societal cost of not treating MMHCs is substantial ($2.2 billion overall and $962 million to Medicaid). It also shows that employers, through reduced maternal produc- tivity, and health insurers, through increased health care costs for mother and child, bear most of these costs. In addition, our model shows substantial vari- ation in the prevalence of MMHCs and the resulting costs for women of different racial and ethnic back- grounds. One explanation for this variation could involve poorer access to screening and high quality care among groups experiencing systemic racism and other socioeconomic disadvantages. Providing better screening and earlier intervention for groups disproportionately impacted by MMHCs could lead to better long-term outcomes and cost savings to society.

The Texas Health and Human Services Commission’s efforts to increase awareness of MMHCs among providers and the public, establish referral networks, and increase access to care represent an important step toward improving the health of mothers and their children. In addition, these efforts will help increase women’s productivity, reduce the utilization of high-cost obstetric and non-obstetric care, and decrease women’s use of social services. Lengthening coverage to those uninsured or underinsured

in the post-delivery period through the child’s first five years of life could benefit the Texas Health and Human Services Commission, employers, private health insurers, and the health care system more generally. Public and private sector stakeholder col- laboration to ensure and expand access to equitable and consistent screening and high quality treatment for pregnant and post-delivery women regardless of race, income, or other socioeconomic factors will not only lead to potential immediate cost savings, but assist in bolstering health of generations to come.