Association of Medicaid Expansion With Postpartum Depression Treatment in Arkansas

Abstract

ABSTRACT Approximately 1 in 8 individuals experience postpartum depression in the United States. Among them, 17% had their care covered by Medicaid and 10% had their care covered by a commercial payer. Postpartum depression is also more common among American Indian/Alaska Native (22%), Asian/Pacific Islander (19%), and Black (18%) individuals than White individuals (11%). Adverse postpartum health outcomes include reduced maternal quality of life, greater difficulty with social and partner relationships, increased odds of unemployment, and adverse child health outcomes. Effective treatments for postpartum depression include antidepressant medications and psychotherapy. Yet, these therapies are often underused, particularly among Medicaid enrollees and Black individuals, due to systemic racism and lack of access to health care, childcare, and transportation. One solution that has been suggested includes expanding Medicaid coverage to a year postpartum. One study in Oregon found that Medicaid expansion increased screening for and treatment of postpartum depression. The aim of this study was to compare the differences in treatment for postpartum depression among individuals whose births were covered by Medicaid versus commercial payers. This was a cohort study conducted in Arkansas with a difference-in-differences regression design. Data were collected from the state’s birth certificate records and all-payer claims database. Included were all births between January and June 2013, when Medicaid postpartum coverage ended 60 days after childbirth, and between January 2014 and December 2015, after the state expanded Medicaid postpartum coverage beyond 60 days if the individual’s income was below 138% of the federal poverty level. The primary outcomes were the filling of ≥1 antidepressant prescriptions and the number of days supplied in the first 60 days (early postpartum period) and 61 days to 6 months after childbirth (later postpartum period). The secondary outcomes were psychotherapy visits and a diagnosis of depression in the 6 months after childbirth. A total of 60,990 individuals gave birth in Arkansas between 2013 and 2015. Of these births, 71.7% were covered by Medicaid and 28.3% by commercial payers. Compared with individuals with commercially paid births, individuals who had a Medicaid-covered birth were younger (mean age, 25.5 vs 29.4 years), more likely to identify as Hispanic (10.8% vs 3.0%), and less likely to have a college or higher level of education (5.1% vs 55.5%). In the later postpartum period, 4.2% of those with Medicaid coverage filled a prescription for antidepressants before the expansion of Medicaid. In 2015, with Medicaid expansion, the likelihood of filling an antidepressant prescription in the later postpartum period increased by 110% (adjusted difference-in-differences, 4.6; 95% confidence interval [CI], 2.9–6.3). Similarly, in the early postpartum period, the likelihood of individuals with Medicaid filling an antidepressant prescription increased by 28% (adjusted difference-in-differences, 1.9; 95% CI, 0.2–3.7). The percentages of individuals with commercial coverage who filled antidepressant prescriptions did not change between 2013 and 2015. Before expansion, 0.2% of individuals with Medicaid coverage and 1.3% of those with commercial coverage had psychotherapy visit in the later postpartum period. This increased by 0.8 percentage points (95% CI, 0.5–1.2) after Medicaid was expanded. No change was associated with Medicaid expansion in the early postpartum period. Before Medicaid expansion, individuals with commercial coverage who had been diagnosed with depression within the first 60 days postpartum received an average 72-day supply of antidepressants in the later postpartum period, compared with those with Medicaid coverage who received a 23-day supply (95% CI, 20.7–25.4). Medicaid expansion was associated with a 61% increase in antidepressant prescriptions filled. In conclusion, Medicaid expansion in Arkansas helped to narrow the disparity of postpartum care between individuals covered by Medicaid and those covered by commercial payers. After the expansion of Medicaid in 2014, more Medicaid enrollees filled antidepressant prescriptions, underwent psychotherapy, had greater continuity of treatment for postpartum depression, and had an increased antidepressant supply beyond the first 60 days after delivery.