The Costs of Untreated Maternal Mental Health Conditions

[ADRIANA KOHLER]

The first few years of life are so important; and when a parent is suffering, when they can't be at their best to promote their health and well-being, their child's health and development, that has ripple effects in the family and across the community.

[J.B. WOGAN]

I’m J.B. Wogan from Mathematica and welcome back to On the Evidence, a show that examines what we know about today’s most urgent challenges and how we can make progress in addressing them. We’re posting this episode the first week in May, which is Maternal Mental Health Awareness Week, and we have a great episode for that topic.

Perinatal mood and anxiety disorders—which can include depression, suicidal thoughts, and panic attacks—affect women and birthing people during pregnancy and the postpartum period. These disorders affect an estimated one in seven women and birthing people, and there is good reason to believe that the true number is much higher.

In 2019 Mathematica worked with philanthropic partners in three states—California, Washington, and Colorado—to calculate the national economic costs of these maternal mental health conditions. With support from the California Health Care Foundation, the Perigee Fund, and the ZOMA Foundation, Mathematica developed a model that estimated the total societal cost of maternal mental health conditions for all births in 2017 in the United States. That number was $14.2 billion, which came out to roughly $32,000 per mother or birthing person and their child. And those calculations encompassed costs for the parent and child over a six-year time frame. By the way, that analysis in 2019 also included state-level estimates for the three states where the foundations resided.

And just to provide a little background on how they arrived at those figures, the conceptual model behind Mathematica’s estimates assume that untreated maternal mental health conditions affect both the parent and child in ways that cost society, such as lost income and reduced economic output for the parent, increased use of public services for the household, and increased use of health care for the household. According to the model, the biggest driver of those costs is lost productivity associated with higher rates of unemployment, absenteeism, and presenteeism; lower on the list, but still important were outcomes like preeclampsia, preterm births, and child behavioral and developmental disorders.

The research in 2019 inspired a follow-up study by Mathematica in 2021, this time in Texas, which came to similar conclusions in the Lone Star State. The total societal cost of untreated maternal mental health conditions in Texas was $2.2 billion for births that occurred in 2019, which again accounted for costs for the parent and child from conception to five years after birth. The cost for Medicaid-covered births was $962 million. The Texas analysis also revealed some troubling differences in societal costs based on race and ethnicity. The cost for a non-Hispanic Black mother-child pair was $62,000, compared with $43,000 for non-Hispanic White and Hispanic mother-child pairs. And that higher cost reflected greater prevalence of untreated maternal mental health conditions and a higher risk of negative health outcomes like pre-eclampsia and preterm births. Non-Hispanic Black mothers also had lower obstetric health care expenditures. Taken together, the data suggest non-Hispanic Black mothers may have less access to high-quality care.

These modeling exercises at the state and national level are interesting in themselves, but the reason I wanted to make it the focus of this week’s podcast is that the evidence in Texas ended up becoming a part of the debate in Austin as state lawmakers decided whether to extend postpartum Medicaid coverage beyond 60 days. And, spoiler alert, they did. Last year, the Texas governor signed bipartisan legislation that extended postpartum Medicaid coverage to six months.

To discuss Mathematica’s recent research on the societal costs of untreated maternal mental health conditions, I have three guests.

Kara Zivin is a senior health researcher at Mathematica who has conducted research on the societal costs of untreated maternal mental health conditions at the national level and in four states.

Laurie Zephyrin is the vice president for Advancing Health Equity at the Commonwealth Fund and she co-authored an issue brief with Kara that used a similar economic model to estimate the societal costs of maternal morbidity and associated maternal and child outcomes through five years following childbirth. As we’ll discuss in the episode, one of the nine maternal morbidity conditions they examined was maternal mental health conditions, which they found to be the costliest.

Our third guest is Adriana Kohler, the policy director at Texans Care for Children, who successfully advocated for the extension of postpartum Medicaid coverage in Texas after partnering with Mathematica and the St. David’s Foundation to generate the estimates on untreated maternal mental health conditions in the state.

I’ll include links to the research we discuss on the episode in the show notes as well as the Mathematica blog post associated with this episode. We’ll also have a full transcript of the episode on the blog.

I hope you enjoy the episode. To get the conversation started, I asked the group why they became interested in the problem of untreated maternal mental health conditions. Laurie Zephyrin volunteered to go first.

[LAURIE ZEPHYRIN]

This is a really important and critical issue. I'm an OB GYN by training and so have spent a career really working with women and birthing people throughout the birthing process and just the life course in general. So I've seen many people that have had the experience of a traumatic birth or having a mental health condition worsen by the birthing process. So it's just really something that I'm very committed to, and I think about things through systems and structures now.

I really think about how can we orient our policies from a federal and state level or how, from a systems perspective, we can really do better and ensure that people have access to care that they need and that that care is equitable and high-quality.

[J.B. WOGAN]

That's great, Laurie. Adriana, if you want to take this question now...why were you interested in untreated mental health conditions?

[ADRIANA KOHLER]

Yeah, absolutely, thank you for having me today to talk about this great issue. Let me start by telling you a little bit about Texans Care for Children, so who we are and what we do. We work statewide in Texas. We don't provide direct services; we develop policy solutions on a variety of kids' issues ranging from early childhood to children's mental health, maternal/child health, and foster care.

We know that healthy childhood starts with healthy moms. Healthy kids start with healthy pregnancies, birth, and continue with access to postpartum care and early childhood supports for parents and infants. That's why we, for so many years, have focused on maternal mental health as a priority. The first few years of life are so important; and when a parent is suffering, when they can't be at their best to promote their health and well-being, their child's health and development, that has ripple effects in the family and across the community.

Also, I'm a mom myself. I have a 20-month old. So having a kid during the pandemic has been interesting, and then advocating for postpartum issues and for kids has been such an honor as I've experienced postpartum life myself.

[J.B. WOGAN]

All right, Kara, and now you're up. For you, what's your entry point to this? What motivated you to work on untreated maternal mental health conditions?

[KARA ZIVIN]

Hi, J.B., thanks for having me as well on this podcast. Like my colleagues here, I also have both personal and professional reasons for being interested in this topic. I come to it from the perspective of a mental health policy and services researcher with a background in public health, where I've studied topics related to access to care, quality of care, costs of care for mental illness for many years.

But I also had a pretty severe case of maternal perinatal mood and anxiety disorder when I was pregnant and postpartum. My son is now 11, and I've spent the last several years in my career trying to use some of the language and tools and opportunities based on my experience in this field to focus on reproductive health and well-being and to try to support others who either have gone through this or might in the future.

[J.B. WOGAN]

Okay, great, and part of the impetus for our conversation today is research that Mathematica has conducted both with Texans Care for Children and the Commonwealth Fund around estimating the costs of untreated maternal health care and, in the case of Texas, maternal mental health conditions.

I'm interested in the rationales and motivation behind looking at this issue through that lens, through sort of the economic cost to society lens. Maybe we'll go in reverse order here. I'd love to maybe start with Kara this time and go Adriana and Laurie if you'd like.

[KARA ZIVIN]

Sure, I can go first. So it's an interesting question of why we would focus on the economic component – the cost of care or not receiving care – because I think, for better or worse, that's something maybe not unique but something that more often happens when we're talking about issues such as mental health or reproductive health. I don't know that we necessarily make those same requests or discussions for other more typical chronic health conditions, although these conditions are quite prevalent.

And yet sometimes it is helpful for policymakers to point out to them both the costs of an illness but also the costs of inaction as well. That information is not easily or readily available. It involves compiling a lot of different types of information, not just clinical care and health care visits – that type of thing – but other more indirect costs, such as transportation to and from a provider's office or missed work. We've learned in the last three years since we started doing this work in particular that people are really clamoring for and interested in this information to share with their stakeholders and policymakers.

[J.B. WOGAN]

Adriana, what about in your case in Texas and your work with the St. David's Foundation? Why were you all interested in looking at this issue through the lens of economic costs?

[ADRIANA KOHLER]

Yeah, I've been working on maternal mental health and maternal health broadly for several years. We've had so many advocacy efforts. I sit down with lawmakers or their staff or partners in the community; and we try to highlight the stories, personal experiences, the families who will never be the same because of what they suffered through or families who unfortunately may have lost a loved one – a sibling, a daughter, a wife – as a result of maternal mental health conditions. Those are powerful stories and have really been important.

We also get the questions...

What's the cost?

What's the cost savings?

What's the cost avoidance?

How should the State be involved?

Why is this a state issue or a system's issue?

That's where data on broader costs is so important – costs to the healthcare system, productivity, absenteeism – all the stuff that was included in this Mathematica call's model. That has never been brought to light to lawmakers in this way before, and it did help make our case even stronger and provide extra evidence on why the State should care why it's a system's issue that needs a policy solution.

[J.B. WOGAN]

Okay, yeah, I did notice – I mean, I was looking at a report that we published -- I think it was in 2019 – in terms of I just noticed towards the end, in the conclusion, there's this line, "efforts to increase the prevalence of PMADs."

Kara will have to remind me. PMAD stands for what – perinatal mood and...what is it?

[KARA ZIVIN]

Anxiety disorder -- perinatal mood and anxiety disorder, yeah.

[J.B. WOGAN]

Thank you, yeah.

Would not only positively impact the health of mothers and their children, but also be to improvements in women's proactivity in decreased usage of Social Services. I could imagine why making a case purely based on it would improve the health of mothers and their children, but here we're also saying it has other benefits that other stakeholders may care about. The report actually mentions governments, employers, and health insurance, payer groups as some of those stakeholders who stand to benefit beyond the mothers and their families.

Laurie, we haven't heard from you yet. What about from your standpoint? I know that some of the work that you did with Mathematica was looking at the broader issue of maternal morbidity, but maternal mental health is mentioned in that report as well.

[LAURIE ZEPHYRIN]

First, I'd definitely like to echo the opportunity of using cost to get the attention of policymakers and health system leaders in terms of just showing that there's an economic linkage to that. I mean, ultimately we know based on just the work that we've done and the research we've done – we know that there's a lack of investment in maternal health and wellness; and we mentioned that in our report. And that really hurts families across the country.

This study that we supported/funded with Mathematica really just allows us to understand the enormous long-term societal and financial impacts of that neglect. By doing that, hopefully we can help show that prioritizing the health system investments in maternal health and ensuring equitable care will be important. But even if we drill down to what does this mean on the ground, being a coalition at heart, this is work that I've wanted to show for a long time because in the patients that I would see, I would see the long-term impacts; but no one really had made those connections.

I mean, just from a personal experience, I've seen many patients who've had the experience of a traumatic birth and long-term implications of not wanting to come back to the health care system, having untreated mental health conditions, having untreated medical conditions, untreated hypertension, untreated diabetes. All of that has costs to our society; but also when we really think about it, it costs all of us when we can't safely bring children into this world.

Even though the study talks about sort of the dollars and cents of it, it's really beyond that. It's the cost of people not being able to work, of not having to go to health care, of not being fully able to care for their families. So ultimately, that's what we're trying to communicate – is we're talking about sort of the cost in dollars and cents. But really for the societal cost, the individual and their families bear that cost but also society bears it as well.

[J.B. WOGAN]

All right, excellent and, Laurie, if we could stick with you for a second, we've already touched on this a little bit; but how does untreated maternal mental health fit with the larger issue of maternal morbidity in the United States and the work that you and Mathematica have done in this area?

[LAURIE ZEPHYRIN]

Well, you know, we're very good in our society in our health care; the structure is sort of siloing out medical care from mental health care. I think it's great now we're having more conversations about the importance of mental health and really integrating medical and mental health. Integrating mental health into primary care, into maternal health care, is really critical.

So when we think about maternal mental health, it should be and is this part of other health and morbidities, for example, and not separately. In the study that we supported, we looked at nine conditions of causes of maternal morbidity; and maternal mental health conditions were the costliest, costing about $18 billion – and Kara can talk more about it.

So you can't really separate out the mental health impacts or the mental health burden – whether we're talking about depression, anxiety, or even talking about suicide, or we're talking about substance abuse. I think the other piece where we need additional quantification is sort of the post -stress that occurs from experiencing a severe maternal morbidity and how do we address that as well.

So it's not something that we can separate. I think our broader conversations are on mental health now that we're having in our society and the need for integrating that into our health care system. It's definitely heartening to see those conversations and seeing policies move in that direction.

[J.B. WOGAN]

Okay, that's really interesting. So there were nine morbidities. One of the nine was mental health, and it was the costliest of the nine. Did I get that right – in the report? Okay, I'm seeing nodding heads. Kara, what about you? How do you see maternal mental health fitting into the larger maternal morbidity conversation? Anything you would add to what Laurie has just said?

[KARA ZIVIN]

Well, one of the things that concerns me in this space is that the CDC, the Centers for Disease Control and Prevention, collects statistics on maternal morbidity and mortality; but they do not include mental health conditions, including suicidality and overdose, as well as other things like accidents, homicide, as part of these national statistics.

So when you hear numbers about the rates of maternal morbidity and mortality and the disparities, those are all underestimates of the true burden because they're excluding these certain categories of illnesses and experiences. Yet, we know that they are problematic; and individual state maternal mortality review committees have investigated this and seen that mental health and substance use conditions are a significant contributor to these outcomes; and yet that often gets left out of the discussion.

I also want to echo what Laurie said about this idea about not separating your head from the rest of your body. We are whole people; and so to try to put things in silos, I think, is dangerous.

I also want to comment on the part about the number of conditions. We initially had a much longer list, and part of the challenge for this project is data availability. So having information on the outcomes and experiences and costs and relationships between these different types of illnesses can get really complex in the context of maternal morbidity – how, say, mental health and hypertension and gestational diabetes and stroke – like how all those different things work together.

I think another key message of our work – which may be true for many research projects – is that we need more data and more information. So probably what we identified in that case also represents an underestimate because we couldn't capture every single possible condition that could happen.

[J.B. WOGAN]

Okay, excellent, and I will say listeners should check out – in addition to the research we're talking about today, Kara, you also had a really excellent op ed in STAT. I forget -- "First Opinion" I believe it's called in STAT talking about this issue of undercounting and tying it back to your own personal experience with suicidal thoughts during your pregnancy. I would recommend everyone read that.

[KARA ZIVIN]

Yeah, Laurie and I worked on that together; so, yeah, we can put that link in the Notes.

[J.B. WOGAN]

Okay, excellent.

Laurie and Kara, I noticed in the Issue Brief that you co-authored last year, you mentioned the importance of extending postpartum Medicaid coverage for up to one year to help ensure that key physical and mental health needs following birth are identified and met.

In a minute, I want to talk specifically about Texas and get back to Adriana and your experience there; but setting aside Texas for a moment and the policy change that's been made in Texas, is this a policy change that must be made at the state level; or could there be a national policy change implemented as well? And not to throw too many questions at you but if it is left to the states, how many states currently offer postpartum Medicaid coverage for up to one year?

[LAURIE ZEPHYRIN]

I can start and turn it over to you, Kara.

To your question, in terms of like is this important – I'm just adlibbing – yeah, I think it is important to really think about postpartum Medicaid coverage. I mean if we think about where did 60 days of coverage postpartum come from, it was just or the most part pretty random. Even when we look at the data or if we ask people on the ground, their care needs extend even beyond birth up to a year.

When we look at some of our data around maternal mortality and morbidity, about half of maternal deaths, for example, occur after birth. So if one stops care after the child is born and doesn't think about mom, we're missing a lot there. So this focus on postpartum expansion is really critical. On the Clinical Guide, the Fourth Trimester Movement sort of came out a few years ago where researchers and clinicians came together to pull together a model around how can we ensure that birthing people – women and their children and their families – receive care after birth.

I think finally the policy conversation is catching up – definitely in Medicaid where people aren't left stranded after 60 days postpartum without coverage. I mean, I would like to say that coverage is really the start of it. As we know, with like Medicaid expansion just more broadly we know that more coverage is necessary to improve outcomes but definitely not sufficient. Definitely ensuring quality and safety and equity of care and prioritizing them is also critical.

To your question around – and I'll stop after this – around should states do this or should the Federal Government do this, I say, "Yes" to both. You kind of need both, I think, hand-in-hand working together, from the federal side helping providing the financial incentive to be able to do that; but Medicaid is obviously at that state very local. So there are different policy plays and contingencies across each state.

Having said that, there shouldn't be really different care from one state to another. Like birthing mom in A state should really be able to have equitable high-quality care compared to a birthing person in B state. So I think it's really important to ensure just across all states that everyone has access to high-quality, equitable health care.

I'll turn it over to Kara in terms of the postpartum aspect.

[KARA ZIVIN]

Well, with respect to this issue of whether it's a state policy or federal policy, that's a very active space literally as we speak because as part of the American Rescue Plan states as of April 1, 2022 – so just recently – had the opportunity to expand Medicaid from 60 days to one year's postpartum or rather to extend. Different states are coming at that in different ways; and for all I know by the time this recording comes out, there will be another state that has been approved – which is really great.

Ideally, people from our perspective might argue it would be great if all states just had this; and it didn't have to be these one-off – this state deciding and that state deciding and debating and whatnot. But I think that it's gained a lot of attention, and I think the pandemic in some ways has facilitated that as well because the public health emergency allowed for a postpartum Medicaid extension as part of the public health emergency.

So I think this is an active area, and I echo what Laurie said. We know that a mother's needs do not end 60 days after delivering a baby. So for that person to lose access to care in such a short time, we don't always necessarily know because we don't have claims data to identify what happens to those individuals. But it's potentially likely that they're not getting access to the care that they need, and yet I also fully agree that insurance is a floor not a ceiling because it doesn't guarantee access to available providers or the most appropriate care or care close by. But without, it can be cost prohibitive.

So it's an exciting time to be thinking about this topic.

[J.B. WOGAN]

Adriana, I referenced Texas in my previous question. I understand Texas recently passed legislation that does extend Medicaid coverage to postpartum birthing people. Analysis from Mathematica actually played a role in informing debate about that legislation. Let's talk about that for a second. Would you mind explaining what the legislation does and what your role was in advocating for that legislation?

[ADRIANA KOHLER]

Yeah, absolutely, it has truly been an exciting year or more in this space. What the bill does – you may or may not know, but Medicaid in Texas is available mainly to children from low-income households, pregnant people, seniors, and people with severe disabilities. So in order to qualify for Medicaid, it's only upon pregnancy and that 60 days afterwards.

We know that about one in four women of reproductive age are uninsured in our state. That's the highest rate across the country, and that's 1.4 million people. So Medicaid is such a vital insurance option for a healthy pregnancy, a healthy birth, and healthy postpartum life; and the Texas Legislature did pass a bill extending Medicaid postpartum coverage.

The trajectory of the bill did have some ups and downs. The state's Maternal Mortality and Morbidity Review Committee said its number one recommendation is 12 months postpartum coverage. That's the top recommendation from medical societies, experts across the board. And we know that mental health conditions in Texas are tied with heart conditions as the leading cause of death for moms. Unfortunately, those maternal deaths happen between 40 days and a year postpartum most frequently.

So the Texas House passed 12 months postpartum with a strong bipartisan vote and really great leadership from the Texas House Speaker. We truly appreciate the leadership there. But then, it was reduced to six months in the Senate before it was ultimately passed and signed by the governor. It's a great step in the right direction, but we know more work is needed. It's not in place right now. The State is asking for federal matching funds through a waiver application. So it's going to be many, many months before this becomes a reality for Texans.

You asked about our role. We used all the tools in our advocacy toolbox to make this happen. This has been a priority for our organization for so long. We partnered with amazing legislative champions who fought the good fight inside the building, and we helped build momentum during hearings for debates, et cetera. We rallied an amazing coalition of partners from Chambers of Commerce to March of Dimes, Children's Advocates, health partners, and even the conservative think tank here in Austin.

But this new data from Mathematica – this was new evidence to make our argument. It was a new hook. Releasing the report was a hook that we could use to talk to reporters and say, "Look, here's new evidence showing why this bill needs to happen now." We spent a lot of time building relationships with local reporters in various media outlets across the state to do TV news, radio segments on this, a write-up in their local paper because we know that legislators are reading that, watching that on the news, et cetera. So it was a really good timing for the new report to help build momentum.

[J.B. WOGAN]

You mentioned the evidence and the way that that provided a new hook. Would you mind giving us a little bit of a back story about how that Mathematica analysis came to be and why?

[ADRIANA KOHLER]

Yeah, in Texas lawmakers meet every other year for legislative sessions. So that gives us a little time to think, a little time to dream, about what evidence we want to make our case. So I saw the national report that Mathematica put out about untreated mental health conditions across the country. I also saw that another state – I think it was Colorado – had an analysis. So I thought, oh, this would just be perfect! This would really help us.

We partnered with the St. David's Foundation; and with their amazing investment and support as a dedicated partner, they allowed us to partner with Mathematica to get this data out the door. So that partnership was key because we could kind of do some new and creative stuff. We're used to doing reports and publishing them through a blog and talking to lawmakers, writing testimony. Well, we got to do some new stuff.

We did some great social media – used visuals and graphics kind of to highlight the main findings. Then we did some ads that went in the local paper and local media that we know that lawmakers are reading and the state papers that we know they're reading, especially during legislative sessions, so that they could get that in their Inbox and kind of get all the information in front of their eyeballs.

[J.B. WOGAN]

Okay, that's great. That's really interesting just to hear about the creative tactics for taking the evidence that an organization like Mathematica generates and then figuring out how do you most effectively present that to people in the right context, using the right messengers, in the right spaces.

Kara, it's unusual to see evidence leading to policy change – especially this quickly. What do you think are the lessons – or at least some of the lessons – from Texas about how and why evidence sometimes does play a role in policy change?

[KARA ZIVIN]

As someone who's studied health policy for a long time, we now about the idea of windows of opportunity to try to effect change; and I think it was fortunate that Texas came to us. They were very explicit. The St. David's Foundation was our original connection; and they said, "Look, we know this legislative session is coming in some number of months, and we would like to be able to share this information with them."

So as a researcher, it's exciting to feel like you're creating something that can be used, that is not just going to sit in a journal on a shelf somewhere. Not that that's not nice, to have published journal articles; but it's a different kind of purpose. You know, it was actually quite a tight timeline to pull all that together; but I think we were all sort of singularly focused on this information for this session, for this purpose, talking about postpartum Medicaid extension.

So we tailored our work accordingly, adapting it from our prior work. Texas had asked us to do some tweaks based on what we had done before looking at different racial and ethnic groups, looking at Medicaid separately from non-Medicaid, these types of things.

Then, it was interesting also because – so we were working with the St. David's Foundation because they were connecting us to Adriana and her group through Texans Care for Children, where they were working on this communications angle. That was nice for us too because then we would hear back from them, "Okay, they're talking about the bill today," or "Here's this blurb in the newspaper," or "Here we've talked to this reporter." So I think it was kind of a win/win all the way around to try to have this kind of relationship that brings together data, evidence, resources, advocacy, communications and sort of the brass ring of this kind of work.

[LAURIE ZEPHYRIN]

Just to add to that, the Commonwealth Funds – we're a national foundation, and our audience tends to be policymakers and delivery system leaders. Part of our strategy is really thinking about how to provide high-quality evidence that's packaged in a way that's digestible for policymakers and delivery system leaders that are very busy, having been on the policy and delivery system side -- so information that they can digest quickly having these windows of opportunity, like Kara mentioned – so like the right information at the right time.

In terms of time, it's really exciting now – just the attention to maternal health, to health equity, to maternal mortality and morbidity as systems change. So like the right information, the right people, the right time, and being able to provide credible information that can help influence policy and systems change. So that was also our thinking in terms of nationally around the partnership with Mathematica and Kara and So (O’Neil) and team in really providing credible information about maternal morbidity – the challenges, the costs.

It was interesting – I saw that study first that Kara had done previously on maternal mental health; and then I was thinking, "Well, what if we could do something similar and broaden it out for other aspects of maternal morbidities to provide this broader context on how big the problem is and be able to share that information with policymakers?"

The other piece – and I think, Adriana, you mentioned it too – is also the media as well and getting credible information that's of high-quality and evidence-based to media partners so that they can also share that because that also trickles down not only to the federal level but also to the state level to and helps drive policy change.

[J.B. WOGAN]

That's right, and if people do go and look at the Commonwealth Fund Report that Mathematica worked on about maternal morbidity, they'll see there are a lot of very nice and accessible infographics. It's very easy to scan. You can pick up the main messages just by skimming. There are nice headlines, a lot of things that would be easy to retweet and put out in your social media.

I noticed one best practice that you employed was it's not a PDF that you have to download – like the whole brief is the webpage, like a blog, which is just a little bit more user-centered.

Adriana, were there other ingredients to success – things that helped make sure that evidence is impactful?

[ADRIANA KOHLER]

I would say – you know, Kara alluded to this – but just being able to tailor and kind of work with you as researchers who know the data, to be able to pull out what makes sense for Texas. So lawmakers don't look at the 20-year outcome, unfortunately. They're looking at the two-year cycle because that's their budget for the biennium. They're looking at the cost to Medicaid, not necessarily the cost to an employer of private health, for example.

So working with you all, we were able to kind of narrow down a two-year cost – what it would cost, and what it would cost Medicaid specifically, like really drill down on that. That helped show these really are outcome changes in the short term as well as the long term, but outcome changes that affect lawmakers and the state and communities in that biennium cycle.

[J.B. WOGAN]

Okay, I have a couple more questions. This one is for the group: Where do you think we're headed with respect to extending health insurance coverage for postpartum birthing people? Do you think more states will be extending postpartum Medicaid coverage and which ones?

[LAURIE ZEPHYRIN]

This is Laurie. I think we're heading in a positive direction. I think the case has been made in terms of how important this is. I think with COVID, the American Rescue Plan Act providing the initial sort of – some of that funding support, at least for the first few years, first five years – is a helpful incentive. I am optimistic that more states will take it on, particularly with some of the administrative flexibilities – like being able to use SPAs instead of 1115 waivers.

I'm hoping that more states will extend it for the full year. I think there's a lot of advantage to that. I do hope that there will be continued work to provide matching and support for more than five years so that states are able to incorporate this into their budget priorities. I think currently, as we've seen, the last data that I looked at was at I think the end of March. Like 28 states have taken some action towards Medicaid postpartum coverage extension and concluding 15 that are going to end that.

That might change by the time you post this broadcast, but that have enacted state legislation permitting them to move forward. Some have used Section 1115 waivers. Some are using state plan amendments. So I think this is a really exciting time.

The other interesting piece is earlier last year, we funded some work which showed that over 700,000 additional birthing people would gain coverage through expanded Medicaid postpartum coverage. So that's a lot of people being covered, and I think there's a huge opportunity to affect some of the outcomes we're seeing around just broadly maternal mortality and morbidity.

[J.B. WOGAN]

Kara?

[KARA ZIVIN]

I am optimistic but also hesitant to make prognostications, especially in an election year, at the state and federal level on what will happen. I think we might argue that if you were designing the U.S. Health Care System from scratch, it might not look the way it does in that it involves a lot of incremental changes over time. But I think that there has been a groundswell of attention to this topic, particularly around the really horrendous information about maternal morbidity and mortality more broadly in the U.S. compared to other developed countries and the vast disparities.

I think trying to remind people that it's not just an issue for women or for kids; it's all of society. It's a multigenerational issue. It's a public health, it's a human rights issue. So I feel like from the perspective where we sit, trying to provide credible, non-partisan, evidence-based data to support elected officials and other stakeholders is what we're trying to do with this work and are really fortunate to have had interested partners trying to find different ways to do that.

Honestly, of all the research I've been and evaluation studies involved in, in my career, this has been the one – you've heard from two different individuals on this podcast but elsewhere where people have come to us and said, "Hey, we saw you did this over here. Can we tweak it this way for our purposes over here?" That continues to happen whether it's state governments, whether it's foundations, women's organizations. So that's been really gratifying and encouraging as well.

[J.B. WOGAN]

Adriana, even within Texas after this legislation passed, that's not the end of the story. What needs to happen next? What are the next battles to be fought on this topic, on this issue?

[ADRIANA KOHLER]

Yeah, I hope it's just the beginning. I remember sitting in a committee hearing room this time last year and telling lawmakers a handful of states had extended Medicaid postpartum, and now it's over half the states. That is just an avalanche of action in such a short amount of time. From my point of view here in Texas, it is just amazing to see other states in the South – Louisiana, Georgia, Florida, Alabama, Kentucky – they've all passed or adopted some way of extending postpartum coverage.

Georgia went from 6 months postpartum – they've now recently passed -- they've extended it to 12 months postpartum. So I'm thinking Texas should be the next one up, and we should move to 12 months postpartum.

[J.B. WOGAN]

Okay, so you're priming a little competition there among Southern states. I see that. I see you.

All right, so last question – I'll wrap up with this. As states debate extending postpartum Medicaid coverage, where do you think new evidence could help decision-makers? Are there aspects of the problem of untreated mental health conditions that require more research or better data, and are there policy solutions that require more research or better data that should be subject to rigorous evaluation?

[KARA ZIVIN]

Well, if you ask a researcher if they should do more research, they will always say that you should do more research. But I think one of the things we've been focusing so much on in some of these studies or evaluations is looking at the cost of untreated illness. I think it's a fair question of what does it cost to treat and which different types of treatment, which can include everything from therapies to medications to newer inpatient treatments.

I also think the data is unfortunately thin on some population subgroups. So we would really like to be able to look at differences by all different race and ethnicity groups – rural, urban, people at different income levels, people with different gender identities and expressions. So I think it can be hard sometimes when you want to drill down even further and there's just not as much publicly-available information. Or in some states, they're just not as populous. So in that sense, that would be more useful information if we could get it.

Again, I encourage – or I'm sort of putting out my plug for the CDC to think about documenting the mental health and substance use contributions to these conditions or some other systematic way of collecting that data at a national level. So those are a few things that I would consider on my list.

[J.B. WOGAN]

Okay, and just to put a point on something that I think we've raised in different ways earlier in the conversation, but in Texas study in consultation with St. David's Foundation and Texans Care for Children, you did in fact do some of that subgroup analysis of the untreated costs for Black birthing people or Hispanic versus non-Hispanic Whites, right? You were able to do that demographic analysis that you would like to see happen more at the national level?

[KARA ZIVIN]

Yes, and also other race and ethnicity groups – Asian-American or Alaska Native or Native American or Pacific Islanders. All of these individuals have needs, and yet it's hard to get that kind of information. Remember, Texas is a really large state; so that was fortunate in one sense. But some of the other states, it would be even harder to do some of these subgroup analyses.

[J.B. WOGAN]

Laurie, where do we need more data/better evidence on this issue?

[LAURIE ZEPHYRIN]

Great question – so I think on the data side, definitely being able to have data on race, ethnicity and REAL and SOGI data so that we can better understand the impact is I think going to be really important.

I also think about like people, systems, and policy – so on the people side, like really being able to hear from people/communities on the ground in terms of how the policies are impacting them, how the postpartum extension is or isn't impacting them. We're funding some qualitative work now which can start addressing some of that across ethnicities. I think that will be really impactful to just get a sense of how are the policies impacting people and communities on the ground.

I think from a system's perspective, I always think about we're extending postpartum Medicaid; but does that mean the same thing to everyone? Like what does that model of postpartum extension look like? Does that include integrated mental health and primary health care? Does that include addressing the drivers of health? Because really, we're talking about essentially integrated primary health care that's gender-centered for the year postpartum and hopefully family-centered as well -- so I think really better understanding what that system of care looks like and ensuring that the policies and the coverage support that.

Then in terms of policies, I think it's really important to better understand the equity impact of policies. Ultimately our goal is to drive down inequities, increase quality, improve health care outcomes. So are those policies really doing that? If not, where are the opportunities for a transformation and change?

[J.B. WOGAN]

Adriana, I'll give you the final word here. Where do we need better research/better data on this issue, either the problems or solutions?

[ADRIANA KOHLER]

When it comes to pregnancy and postpartum health, when I think of it the interventions or the policy solutions may vary depending on when maternal mental health conditions arise or when the pregnancy complications come up. For a woman who suffers from maternal mental health conditions three or six months postpartum, the issue and the solution and the strategy could absolutely be coverage. She shouldn't be kicked off of her health coverage option.

But for a woman who struggles with maternal mental health during pregnancy, health coverage may not be the issue. It might be about finding a mental health provider in her local area. It might be about identifying or detecting these issues at the OB GYN. So it would be wonderful to see the data kind of broken out by time because that can help vary or help determine the policy strategy.

Also, perinatal health doesn't happen in a vacuum. It's about community conditions, about supportive environment, access to doulas – birth doulas, postpartum doulas – access to midwives, home visiting programs. There have been a lot of studies on home visiting programs and the ROI, but maybe we need more on the ROI to reduce maternal mental health conditions, early identification of these issues, and prevention of pregnancy complications. That can help show how state investments in these things – from doulas to midwives to home visiting – that can help reduce these really bad outcomes and these costs later on.

[J.B. WOGAN]

Thanks to my guests Adriana Kohler, Laurie Zephyrin, and Kara Zivin. As a reminder, we post a blog on the Mathematica website for every episode of the podcast. There, you’ll find links to the research we discuss on the episode as well as a full transcript of the episode. As always, thank you for listening to On the Evidence, the Mathematica podcast. There are a few ways you can keep up with show. Subscribe wherever you listen to podcasts. You can also follow us on Twitter. I’m at JBWogan. Mathematica is at MathematicaNow.