Editor’s note: This blog is a condensed version of a blog originally published by Texans Care for Children describing the findings of a new report, “Untreated Maternal Mental Health Conditions in Texas: Costs to Society and to Medicaid,” published by Mathematica, in collaboration with the St. David’s Foundation. The new report is a state-specific look at the cost of untreated maternal depression and other maternal mental health conditions in Texas, using a national cost model created by Mathematica researchers in 2019.

 In the national study, which CCF blogged on here, the researchers found that untreated mood and anxiety disorders among pregnant women and new moms cost about $14.2 billion for births in 2017, when following the mom and child pair for five years after birth. The costs come not just from health care services for mothers, but also in lost workforce productivity and increases in child developmental and behavioral disorders. Mathematica researchers have published similar state-level analyses for Colorado, California and Washington.

Supporting maternal health doesn’t only help moms. A new report published by Mathematica, in collaboration with St. David’s Foundation, shows that our whole Texas community — kids, schools, local businesses, the health care system, and beyond — urgently needs policies that improve moms’ access to care.

For one year of childbirths in Texas, failure to treat maternal mental health conditions (MMHCs) such as postpartum depression creates an estimated $2.2 billion in societal costs from conception through five years postpartum, the report found. The calculations are based on pre-pandemic data.

The largest costs are productivity losses ($610 million), child behavioral and developmental disorders ($556 million), maternal health expenditures ($445 million), and preterm births ($372 million). The report also notes there are human costs beyond the costs quantified in the analysis. For example, as noted in the report, untreated MMHCs increase the risk of babies being born preterm, dying of SIDS, or growing up with health, emotional, or behavioral challenges. Similarly, untreated MMHCs by definition hurt the mental well-being of moms, in addition to placing them at a higher risk of suicide and health challenges.

These costs and the prevalence of untreated MMHCs show that addressing mental health is central to supporting maternal health. The report notes that “MMHCs are among the most common complications of pregnancy and childbirth.” Maternal health policy discussions in Texas often focus on the important topics of maternal mortality, access to family planning, and addressing a mother’s physical health needs before, during, and after pregnancy. Mental health — which affects all of these areas — must also be a top maternal health priority in Texas.

Racial disparities in maternal mental health conditions

Untreated MMHCs are common and costly among Texas families of all backgrounds. However, the report shows that families of color — especially Black families — are disproportionately affected. Untreated MMHCs affect an estimated 19% of Black moms in Texas, compared to 15% of Hispanic moms and 12% of White moms.

Other research, as summarized here, has shown that factors contributing to disparities in maternal health outcomes include: implicit bias in the health care system; chronic stress, including the physical toll of stress related to structural racism; the impact of past and present discrimination on social determinants of health such as housing, food scarcity, and education; and a disproportionate lack of access to health insurance.

Costs for children

The report shows that allowing MMHCs to go untreated takes a toll on children, making clear that addressing maternal mental health is central to nurturing healthy and successful children.

One huge finding: Of the $2.2 billion in costs for untreated MMHCS, 45% is directly related to kids, such as child behavioral and developmental disorders, preterm births (which can have long-term consequences for health and development), and asthma. For example, Mathematica estimates that failing to treat maternal mental health conditions results in an additional 7,472 preterm births.

The report notes there are consequences for children’s education beyond the costs quantified in the analysis. Untreated MMHCs “can lead to reduced educational attainment in the longer term” because children are “more likely to have a behavioral or developmental disorder, such as attention deficit hyperactivity disorder, depression, anxiety, and behavioral or conduct disorders such as oppositional defiant disorder.” These findings are consistent with the research showing that early childhood is a critical time for brain development.

Costs to Texas Medicaid

The report shows also the Texas state government pays a financial price when MMHCs go untreated — highlighting the return on investment of state maternal health efforts. Of the $2.2 billion in costs, $1 billion is a cost to Medicaid, meaning it is paid by a combination of the state and federal government.

Many of the state’s costs associated with untreated MMHCs occur in the short term, meaning that treating those MMHCs would pay immediate dividends to the state budget. The report found that “Overall, 48% of the total health system costs [of MMHCs], 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.”

Lack of access

The report noted that women are often unable to receive a screening or treatment for MMHCs — and that lack of access to health insurance is often an obstacle. “Nationally, half of perinatal women with a diagnosis of depression do not get the treatment they need,” the authors write. The report notes that under current state policy, Texas is one of the states where women are often left with no viable insurance options 60 days after pregnancy. Texas has the highest uninsured rate for adults and children in the nation.

Opportunities for action

The report addresses the costs of untreated MMHCs. To reduce those costs, the Texas Legislature and maternal health stakeholders must ensure more moms have access to treatment and screening.

While the report does not include policy recommendations, it is clear that one of the main steps policymakers can take is to allow Texas mothers to remain enrolled in Medicaid insurance for 12 months after pregnancy rather than removing them from insurance after 60 days. (In many cases, MMHCs must be diagnosed and treated after the 60-day window.)

This step — which is the top recommendation from the Texas Maternal Mortality and Morbidity Review Committee appointed by the Governor — passed the Texas House (but not the Senate) during the last legislative session. Several Texas legislators have filed bills to implement the recommendation this year. The legislative session ends on May 31, 2021.

Lengthening coverage to those uninsured or underinsured in the postpartum period in a child’s first five years of life, the report authors write, could benefit the Texas Health and Human Services Commission, employers, private health insurers, and the health care system more generally by saving at least $1 billion over a six-year period.

Other steps Texas could take to boost access to screening and treatment for MMHCs include:

• • Improving access to group-based prenatal care and pediatric care, such as CenteringPregnancy and CenteringParenting;
  • Leveraging the existing structure of Texas’ Child Psychiatry Access Network (CPAN) to serve moms with MMHCs. CPAN enables health providers and trained psychiatrists to connect via teleconsultation so they can better manage and serve clients with mental health conditions;
  • Fully funding Medicaid, CHIP, Healthy Texas Women, the Family Planning Program, and the state staff to enroll eligible women in these programs;
  • Accepting federal Medicaid expansion funding at a 90 percent match to provide an insurance option to low-wage workers, and
  • Ensuring that health care and mental health services are developed and provided in a culturally responsive way that reflects the input and needs of Black women and other women of color who are at higher risk of experiencing untreated MMHCs.

Additional information on postpartum maternal behavioral health challenges and recommendations specifically in Central Texas is available in this 2019 report published by Texans Care for Children in collaboration with the St. David’s Foundation.

Adriana Kohler is the policy director for Texans Care for Children. She also leads the organization’s work on maternal health policy. Follow Adriana @AKohlerTX