Health Care Disparities Among U.S. Women of Reproductive Age by Level of Psychological Distress

Abstract

Background:

Reproductive-age women have a high rate of contact with the health care system for reproductive health care. Yet, beyond pregnancy, little is known about psychological distress and unmet health care needs among these women. We examined reasons for delayed medical care and types of foregone care by level of psychological distress.

Materials and Methods:

We used a nationally representative sample of U.S. women aged 18–49, from the 2015–2016 National Health Interview Survey. Using the K6 screening tool for nonspecific psychological distress, we examined differences in reasons for delayed care and types of care foregone due to cost by level of psychological distress (none, moderate psychological distress [MPD], and severe psychological distress [SPD]).

Results:

Overall, 20% of U.S. women aged 18–49 had MPD (16%) or SPD (4%), equating to nearly 13 million women of reproductive age living with psychological distress. Women with SPD or MPD are more likely to have delayed and foregone care. Notably, women with SPD have higher odds of needing but not receiving mental health care (adjusted odds ratios [AOR] = 12.4, 95% confidence interval [CI] 8.4–18.4), specialist care (AOR = 3.6, 95% CI 2.6–5.1), and follow-up care (AOR = 3.5, 95% CI 2.4–5.1) due to cost than women with no psychological distress. Cost is the greatest barrier to timely medical care for women with MPD and SPD.

Conclusions:

Women of reproductive age with psychological distress face considerable structural and cost-related barriers to accessing health care, which may be exacerbated by their psychological state. Despite recent policy advances such as the Affordable Care Act, additional efforts by policymakers and providers are crucial to address the needs of this population.

Introduction

In the United States, women are twice as likely as men to have past-year depression and anxiety, as well as having a higher lifetime prevalence of mood or anxiety disorders.^1
–3 Rates of psychiatric disorders are high among women of reproductive age,⁴ regardless of pregnancy or postpartum status.⁵ Although previous research has addressed mental health issues in the peripartum period, less is known about psychological distress among women of reproductive age independent of childbearing. Nearly two-thirds of women diagnosed with mental illness are parents of minor children,⁶ with adverse consequences for child health and development throughout the lifespan.^7,8 Reproductive-age women without children may also have mental health issues that can negatively affect physical health and increase the risk of unhealthy coping behaviors, which in turn can lead to difficulties with relationships, loss in productivity, and overall compromised quality of life.

Despite increased treatment-seeking for major depression and other psychiatric disorders, many people continue to experience unmet needs for mental and physical health services, with concern about cost as the most frequently cited barrier to seeking care.^9,10 Unmet mental health care needs in the general U.S. population grew between 1997 and 2010, with the disparity between the insured and uninsured widening.¹¹ However, little is known about the intersection between women's mental health and use of health care beyond the peripartum period. While reproductive-age women have a high rate of contact with the health care system for reproductive health care, use of primary and mental health care is much lower.^12,13

Recognizing growing levels of unmet health care needs, U.S. policymakers enacted the Affordable Care Act (ACA) in 2010. The law included reforms for private insurance plans and created state-based marketplaces where individuals may purchase health insurance, supported by income-based subsidies. The ACA also supported states in expanding Medicaid programs, such that individuals who previously did not qualify for Medicaid coverage—for example, childless adults with no disability—would be eligible. In response to gaps in mental health care coverage, policymakers passed the Mental Health Parity and Addiction Equity Act (MHPAEA) in 2008. The MHPAEA makes treatment for those with mental health or substance use disorders more accessible by requiring insurers to provide benefit levels for mental health and substance use disorders that are comparable to those for other medical conditions. The ACA builds on the MHPAEA by including mental health care as 1 of 10 essential benefits that insurance plans are required to cover. These policy reforms have led to higher rates of health insurance enrollment, increased access to reproductive health care among women, and lower out-of-pocket spending on mental health care.^14,15 While use of general health care services such as clinic visits and inpatient stays did not change significantly post-ACA, those in Medicaid expansion states became less likely to report concerns over paying medical bills and inability to afford needed follow-up care. Use of mental health care services also increased after the implementation of the ACA, especially among young adults.^16,17 However, few studies have examined health care access among reproductive-age women with psychological distress, a population particularly vulnerable to poverty and poor health. This study aims to address this gap.

Social, economic, and health-related factors contribute to the use of health care. Thus, our theoretical framework draws on an updated version of Andersen's Behavioral Model of Healthcare Utilization.^18,19 This model is often used to explain use of health services and has been applied to both physical and mental health care.^20,21 The model posits that use of health services is a function of the predisposition to use services, factors which enable or hinder use, and the need for health care. Predisposing factors represent demographic characteristics that increase the likelihood of individuals needing health services (traditionally, age, and gender). They also include social structure characteristics that determine individuals' ability to cope with health conditions, assess their own need for health services, and navigate the health care system (traditionally, race/ethnicity, educational attainment, and employment). Enabling factors are resources that facilitate the use of health services, which include both the availability of services and the means to obtain those services. Traditional variables representing enabling factors include income or poverty status, health insurance, and having a usual source of care (USOC). Finally, need factors represent perceived need for health services and have traditionally been represented by measures of self-reported health status, limitations in activity due to health-related factors, and specific health conditions. Factors such as limitations in activity, in particular, may limit the accessibility of health services when individuals are unable to make appointments or find adequate transportation to service providers.

We examine unmet health care needs post-MHPAEA and -ACA, among women of reproductive age, by level of psychological distress. We use a measure of nonspecific psychological distress, which quantifies symptoms that occur with many serious mental disorders, but are not specific to any one disorder.^22,23 The aims of our study are as follows: (1) to examine the reasons for and magnitude of delayed care by level of psychological distress and (2) to examine the magnitude of types of foregone care due to cost by level of psychological distress.

Materials and Methods

Data source and target population

Data were from a nationally representative sample of reproductive-age women (18 to 49), who participated in the 2015 and 2016 National Health Interview Surveys (NHIS). The NHIS is an annual household survey of the health and health care of the U.S. noninstitutionalized, civilian population.²⁴ The sample is drawn so that the data analyzed using the sampling weights are representative of the U.S. population.²⁵ Our analytic sample included reproductive-age women who had complete data for all covariates (n = 16,333 unweighted; 95% of total). There were no significant differences in sociodemographic characteristics (with the exception of marital status), health status, uninsurance, or reasons for delayed care between those included and excluded. Those with psychological distress or having a USOC were more likely to be included, and those with forgone medical, follow-up, and specialist care were less likely to be included. We used publicly available, de-identified data from the National Center for Health Statistics.

Measures

Mental health

Mental health was defined using the K6, a measure of nonspecific psychological distress. Developed for use in the NHIS,²³ the K6 comprised six questions asking how often respondents experienced symptoms of psychological distress in the past 30 days (i.e., felt sad, nervous, hopeless, restless, worthless, or that everything was an effort). The sum of the responses yields an overall K6 score ranging from 0 to 24, with higher scores indicating greater severity of psychological distress.^26,27 We used cut-points 0–5 for no psychological distress, 6–12 for moderate psychological distress (MPD), and 13–24 for severe psychological distress (SPD), which have been identified as the optimal K6 cut-points.^26,28 The K6 is a good predictor of mood disorders such as depression and anxiety and is a useful population screen, as it does not require a doctor visit, captures mild and severe symptoms, and specifies timing of distress.^29
–31

Health care outcomes

We consider two types of health care outcomes: delayed care and foregone care. Delayed care consists of indicators representing reasons for delayed care in the past year: cost, unable to get appointment, limited office hours, unable to get through on phone, or transportation issues. Foregone care consists of variables indicating types of care needed but not received due to cost: medical, dental, mental health, prescription medication, eyeglasses, medical specialist, or follow-up care. Specifically, the series of questions ask “During the past 12 months, was there any time when you needed _____ but didn't get it because you couldn't afford it?”

Covariates

Predisposing factors (sociodemographic characteristics) included the following variables. Patterns of health care utilization are known to vary by age, which we included as a categorical variable (18–29, 30–39, and 40–49). We also included several factors known to influence individuals' ability to manage their health, recognize their need for health services, and obtain the means to access health services: race/ethnicity (non-Hispanic white, black, American Indian/Alaska Native, or Asian or Pacific Islander, and Hispanic), educational attainment (less than high school, high school diploma or general education diploma (GED), some college, and college degree), marital status (married, separated/divorced/widowed, never married, or living with partner), and employment (employed, unemployed, not working due to health or disability, and not working due to other reasons).

Enabling factors (health care access) were represented by the following variables. Poverty (at or below 100% of the Poverty Threshold, above poverty) and health insurance coverage (uninsured, private coverage, Medicaid, Medicare, or other types) are financial facilitators to accessing care. We included an indicator variable representing whether respondents had a USOC (has a USOC or no USOC), as it predicts health care utilization. We also included geographic region of U.S. residence (Northeast, Midwest, South, and West), since regional- and state-level differences in health and social policy may potentially impact health care coverage and access, as well as differences in norms for using care.

Need factors (health status) were represented by the following variables. Pregnancy status is a time when women of reproductive age are more likely to interact with the health care system. We included pregnancy status (currently pregnant, recently pregnant, or neither) to account for any increased likelihood of accessing health care due to pregnancy or postpartum status. As a global indicator of individuals' perception of their own current health status, self-reported health status (self-reported fair/poor health, good/very, or good/excellent) is a strong predictor of morbidity and mortality, and thus the need for health care. We also included functional limitations due to health reasons (limited in any way or not limited) and the presence or absence of multiple chronic conditions (two or more of diabetes, hypertension, coronary heart disease, stroke, cancer, arthritis, hepatitis, kidney disease, asthma, and chronic obstructive pulmonary disease), as both are likely to indicate a need for ongoing monitoring and care.

Analysis

First, we examined differences in sociodemographic characteristics, including all predisposing enabling, and need factors, by level of psychological distress. In addition, we examined differences in each reason for delayed care and type of foregone care, as well as the overall numbers of reasons and types, by level of psychological distress. We tested distributional differences using cross-tabulations with design-based F-tests. We further tested differences across levels of each variable using proportions with postestimation t-tests. Finally, we used logistic regression to examine differences in delayed care and foregone care by level of psychological distress, adjusted for the covariates listed above. Analyses were conducted with Stata SE version 15 and accounted for unequal probability of selection (sampling weights) and the complex sample design (stratification and clustering) of the NHIS.³²

Results

Predisposing factors: overall, one in five reproductive-age women had MPD (15.7%) or SPD (4.3%), which equates to nearly 13 million women of reproductive age living with psychological distress. Compared with women with no psychological distress, women with SPD were more likely to be older, non-Hispanic white, less educated, previously or never married, and living in poverty (Table 1). Strikingly, women with SPD had over 10 times the prevalence of being out of work due to health or disability (24.6%) compared to women with no distress (2.3%). Enabling factors: compared to women with no psychological distress, women with MPD or SPD are significantly more likely to live in poverty, less likely to report private health insurance coverage, more likely to report Medicaid or Medicare coverage, and more likely to be uninsured (Table 1). While there were significant differences in the overall distribution of geographic region of U.S. residence within the sample population, we found few significant differences in level of psychological distress across U.S. regions. Need factors: we find significant differences in need factors by level of psychological distress. Reproductive-age women with MPD and SPD are significantly more likely to report fair or poor health, functional limitations due to a health reason, or that they have more than one chronic health condition compared with women with no distress.

Table 1.

Characteristics of U.S. Women Aged 18–49 Years by Level of Psychological Distress, 2015–2016

	Nonspecific psychological distress			Total	p^b
	None K6 < 6	Moderate K6 = 6–12	Severe K6 ≥ 13	Total	p^b
Predisposing factors
Age group
18–29 years	36.9%	40.7%^*	39.0%	37.6%	0.001
30–39 years	32.8%	28.9%^*	25.2%^*	31.8%
40–49 years	30.3%	30.4%	35.8%^*	30.6%
Race/ethnicity
White	57.4%	60.4%^*	65.8%^*	58.3%	<0.001
Black	13.8%	14.9%	14.0%	14.0%
American Indian/Alaskan Native	0.8%	0.9%	2.1%	0.9%
Asian	7.7%	4.6%^*	2.5%^*	7.0%
Hispanic	20.2%	19.2%	15.5%^*	19.9%
Educational attainment
Less than a high school diploma	9.4%	13.3%^*	19.5%^*	10.4%	<0.001
High school diploma	20.2%	22.7%^*	27.7%^*	20.9%
Some college	20.9%	26.0%^*	28.1%	22.0%
College degree	49.6%	38.1%^*	24.7%^*	46.7%
Marital status
Married	51.8%	38.1%^*	28.2%^*	48.6%	<0.001
Separated, divorced, or widowed	8.3%	12.3%^*	19.6%^*	9.4%
Never married	29.9%	36.3%^*	39.1%^*	31.3%
Living with partner	10.1%	13.3%	13.1%	10.7%
Employment status
Employed	71.4%	64.5%^*	43.2%^*	69.1%	<0.001
Unemployed	4.4%	8.8%^*	11.3%^*	5.4%
Not working, other	21.9%	17.4%^*	21.0%	21.2%
Not working due to health or disability	2.3%	9.3%^*	24.6%^*	4.4%
Enabling factors
Poverty status
At or above 100% FPL	84.4%	76.6%	62.4%	82.3%	<0.001
Below 100% FPL	15.6%	23.4%^*	37.6%^*	17.8%
Insurance coverage^a
Uninsured	11.3%	14.7%	19.0%	12.2%	<0.001
Private	70.3%	54.8%^*	37.4%^*	66.5%
Medicaid	14.4%	23.3%^*	33.1%^*	16.6%
Medicare	0.8%	3.1%^*	6.7%^*	1.4%
Other	3.2%	4.2%	3.9%	3.4%
USOC
No usual source	13.3%	16.2%	16.6%	13.9%	0.003
Has a usual source	86.7%	83.8%^*	83.4%	86.1%
Geographic region of residence
Northeast	17.7%	15.0%^*	13.6%^*	17.1%	0.029
Midwest	21.2%	23.6%	25.4%^*	21.7%
South	36.8%	36.8%	33.0%	36.7%
West	24.3%	24.6%	28.0%	24.5%
Need factors
Pregnancy status
Not currently or recently pregnant	92.3%	92.8%	93.5%	92.5%	0.817
Recently pregnant	4.1%	4.0%	2.9%	4.0%
Currently pregnant	3.6%	3.2%	3.7%	3.5%
Self-reported Health Status
Excellent/very good/good	95.2%	83.4%^*	60.1%^*	91.8%	<0.001
Fair/poor	4.8%	16.6%^*	39.9%^*	8.2%
Any Functional Limitation
No limitation	81.8%	55.9%	31.2%	75.5%	<0.001
Limited by health in any way	18.3%	44.2%^*	68.8%^*	24.5%
Multiple chronic health conditions
Less than two chronic conditions	93.2%	82.8%	65.6%	90.3%	<0.001
Two or more chronic conditions	6.8%	17.2%^*	34.5%^*	9.7%
Unweighted sample size	12,833	2,758	742	16,333
Weighted population	51,039,054	10,037,843	2,763,186	63,840,082

Categories are not mutually exclusive.

p-Values based on cross-tabulations and design-based F-tests for differences in distributions across levels of psychological distress.

Statistically significantly different from no distress category, p < 0.05; p-values from t-test for differences in proportions.

FPL, Federal Poverty Level; USOC, usual source of care.

Delayed care

Table 2 shows that half of women with SPD cited at least one reason for delaying care, compared to 15% of women with no distress. Cost is the most prevalent reason for delaying care at any level of psychological distress; however, 18.5% of women with MPD and 25.7% of women with SPD report delayed care due to cost, compared with only 9.7% of women with no distress. Table 3 shows the odds of delayed care for women with MPD and SPD compared to those with no distress even after adjusting for the stated predisposing, enabling, and need covariates. For all six reasons for delayed care, women with MPD or SPD were significantly more likely to have delayed care than women with no mental distress. The largest difference is for delayed medical care due to transportation issues, where women with MPD had 2.8 times higher odds (95% confidence interval [CI] 2.0–4.3) and women with SPD had nearly five times higher odds (95% CI 3.1–7.5) than women with no distress.

Table 2.

Percentages of U.S. Women Aged 18–49 Years Reporting Delayed or Foregone Care by Level of Psychological Distress, 2015–2016

	Nonspecific psychological distress			Total	p^b
	None K6 < 6	Moderate K6 = 6–12	Severe K6 ≥ 13	Total	p^b
Reasons for delayed care in past year^a
Cost	7.1%	18.5%^*	25.7%^*	9.7%	<0.001
Couldn't get appointment soon enough	5.3%	15.2%^*	20.6%^*	7.5%	<0.001
Wait too long in doctor's office	3.4%	8.6%^*	14.5%^*	4.7%	<0.001
Office not open when you could go	2.2%	6.7%^*	9.1%^*	3.2%	<0.001
Couldn't get through on phone	2.0%	6.2%^*	10.8%^*	3.0%	<0.001
No transportation	0.9%	4.7%^*	12.6%^*	2.0%	<0.001
Number of delayed care reasons
No delays	85.0%	63.9%^*	50.3%^*	80.2%	<0.001
One delay	11.0%	21.8%^*	27.8%^*	13.4%
Two or more delays	4.0%	14.4%^*	21.9%^*	6.4%
Needed but did not get due to cost in past year^a
Dental care	8.9%	24.7%^*	33.6%^*	12.5%	<0.001
Prescription medicine	4.5%	18.4%^*	27.9%^*	7.7%	<0.001
Eyeglasses	4.7%	16.9%^*	26.1%^*	7.6%	<0.001
Medical care	4.5%	16.1%^*	20.7%^*	7.0%	<0.001
Medical specialist	3.1%	11.9%^*	19.9%^*	5.2%	<0.001
Follow-up care	2.5%	9.2%^*	16.3%^*	4.1%	<0.001
Mental health care	1.1%	8.4%^*	18.6%^*	3.0%	<0.001
Number of types of foregone care
No foregone care	84.3%	58.9%^*	47.6%^*	78.7%	<0.001
One type of care foregone	8.7%	15.1%^*	13.4%^*	9.9%
Two or more types of care foregone	7.0%	26.0%^*	39.0%^*	11.4%

Categories are not mutually exclusive.

p-Values based on cross-tabulations and design-based F-tests for differences in distributions across levels of psychological distress.

Statistically significantly different from no distress category, p < 0.05; p-values from t-test for differences in proportions.

Table 3.

Odds Ratios of Reasons for Delayed Care for Women Aged 18–49 Years by Level of Psychological Distress (Referent: No Distress), 2015–2016

	AOR	LCI	UCI	p
Medical care delayed due to cost, past 12 months
Moderate distress	2.3	1.9	2.7	<0.001
Severe distress	2.5	1.9	3.2	0.002
Delayed care because couldn't get through by phone
Moderate distress	2.5	1.8	3.6	<0.001
Severe distress	4.0	2.7	5.7	<0.001
Delayed care because couldn't get appointment soon enough
Moderate distress	2.6	2.1	3.1	<0.001
Severe distress	3.2	2.4	4.3	<0.001
Delayed care because waited too long in doctor's office
Moderate distress	2.2	1.7	2.9	<0.001
Severe distress	3.2	2.3	4.5	<0.001
Delayed care because doctor's office not open
Moderate distress	2.4	1.9	3.1	<0.001
Severe distress	2.9	2.0	4.3	<0.001
Delayed care because lacked transportation
Moderate distress	2.8	2.0	4.1	<0.001
Severe distress	4.8	3.1	7.5	<0.001

All models adjusted for age, race/ethnicity, education, marital status, employment status, poverty, insurance type, USOC, region, pregnancy status, health status, functional limitations, and multiple chronic conditions.

AOR, adjusted odds ratios; LCI, lower confidence interval; UCI, upper confidence interval.

Foregone care due to cost

Table 2 shows that more than half of women with SPD also had at least one type of foregone care, compared to 15% of those with no distress. Dental care is the type of care most often foregone at any level of psychological distress, and is substantially higher for those with MPD (24.7%) or SPD (33.6%) compared to those with no distress (12.5%). Among women with severe distress, prescription medicine is the second highest foregone at 28%, with medical care, mental health care, and medical specialist care all foregone by around 20%. Table 4 shows the odds of foregone care by level of psychological distress. For all seven types of care examined, women with MPD or SPD were significantly more likely to have foregone care due to cost than those with no psychological distress. Notably, women with SPD had significantly higher odds of needing but not getting mental health care (adjusted odds ratios [AOR] = 12.2, 95% CI 8.3–18.0), specialist care (AOR = 3.5, 95% CI 2.5–5.0), and follow-up care (AOR = 3.5, 95% CI 2.4–5.1). Women with MPD had between 2.5 and 6.4 times higher odds of foregone care due to cost compared with women with no distress.

Table 4.

Odds Ratios of Foregone Care Due to Cost for Women Aged 18–49 Years by Level of Psychological Distress (Referent: No Distress), 2015–2016

	AOR	LCI	UCI	p
Needed but could not afford medical care, past 12 months
Moderate distress	3.0	2.4	3.6	<0.001
Severe distress	2.7	2.0	3.6	<0.001
Needed but could not afford follow-up care, past 12 months
Moderate distress	2.7	2.1	3.4	<0.001
Severe distress	3.5	2.4	5.1	<0.001
Needed but could not afford to see a specialist, past 12 months
Moderate distress	2.9	2.3	3.7	<0.001
Severe distress	3.5	2.5	5.0	<0.001
Needed but could not afford mental health care, past 12 months
Moderate distress	6.4	4.5	9.0	<0.001
Severe distress	12.2	8.3	18.0	<0.001
Needed but could not afford prescription medicines, past 12 months
Moderate distress	3.2	2.6	3.9	<0.001
Severe distress	3.3	2.5	4.4	<0.001
Needed but could not afford dental care, past 12 months
Moderate distress	2.5	2.1	2.9	<0.001
Severe distress	2.7	2.1	3.6	<0.001
Needed but could not afford eyeglasses, past 12 months
Moderate distress	2.8	2.2	3.4	<0.001
Severe distress	3.2	2.4	4.2	<0.001

Discussion

This study fills an important gap in the literature by documenting health care disparities among reproductive-age women by level of psychological distress in the posthealth care reform period. Importantly, it is the first to document that, even in light of the MHPAEA, the ACA, and Medicaid expansions, U.S. women of reproductive age with MPD and SPD have considerable unmet health care needs compared to women with no psychological distress. Notably, half of women with SPD have delayed or foregone care in the past year, and they have significantly higher odds of reporting each reason for delaying care and each type of foregone care examined.

Our study is consistent with a small body of research in the pre-MHPAEA and -ACA period that documents high levels of unmet care needs related to mental health among reproductive-age women. Previous studies found that, among reproductive-age women, those reporting frequent mental distress were significantly less likely to have had routine checkups in the past year.^12,33 Similarly, Ko et al. reported that, among women of reproductive age with a Major Depressive Episode, 40% had unmet mental health care needs due to cost, as well as other logistic and attitudinal reasons (2012). Another study documented low rates of treatment-seeking among women of reproductive age who had lifetime clinically diagnosed mental health disorders.⁵ However, these studies only examined unmet need with respect to mental health services or medical care among those with a clinical diagnosis. While not specific to women of reproductive age, Rowan et al. reported substantially higher percentages of those with moderate and severe health problems not having accessed mental health care in the pre-ACA period (2013).

While our study found striking differences in foregone mental health care among women with MPD and SPD compared to those with no distress, higher percentages of women reported care foregone due to cost for medical and specialist care, as well as for dental care, prescription medication, and eye glasses. This suggests that more women with psychological distress may be accessing needed mental health care as a result of MHPAEA and Medicaid expansions, whereas access to services not commonly included in most health plans, such as dental and vision care, remains poor.

Better access to health insurance post-ACA may have mitigated the impact of cost on delayed and foregone care to some degree. However, foregone care due to cost is a more complex issue than lacking insurance coverage. As high-deductible health plans become increasingly common, out-of-pocket costs can be prohibitive even for those who are insured.³⁴ In addition, costs include not only the direct cost of receiving services but can also accrue due to lost wages for taking time from work for medical visits, being out of work due to health and disability, or the cost of needed childcare or transportation. Given that 40% of women with SPD had two or more types of foregone care due to cost, it is also possible that they can afford only some, not all, needed care. Making sense of insurance paperwork, which might be necessary to reimburse costs, may be especially difficult to navigate for those who have psychological distress that impacts cognitive ability. With a health care system that requires patients to self-advocate for affordable services, individuals who lack time or resources to negotiate with insurers or providers may find themselves unable to afford needed care.³⁵

Differences in delayed and foregone care by level of psychological distress are significant even after adjusting for predisposing, enabling, and need factors. These differences may be associated with psychological distress itself, health care systems, or other structural barriers such as transportation and cost. Previous research has shown that adults with SPD are significantly more likely to avoid seeking medical care even when suspecting they should, due to fear of having a serious illness or thinking about dying.³⁶ Uninsurance or underinsurance may also contribute to both delayed and forgone care. Within our sample, 20% of women with SPD were uninsured, despite the ACA's aim of extending health insurance coverage to all U.S. residents. However, women with SPD were more likely than women with MPD or no psychological distress to have public health insurance coverage, which has been associated with less delayed or foregone care due to cost. One study found that, on average, ∼20% of those with moderate mental health problems and 44% of those with serious mental health problems accessed mental health care. The publicly insured had the greatest access (compared with private or no insurance), while cost barriers increased among the uninsured and privately insured who had serious mental illnesses.¹⁰ Our results indicate that, while the ACA and Medicaid expansion safety net may catch some individuals with moderate or severe distress, a significant part of this population may still be falling through the cracks.

Implications for policy and/or practice

Foregone mental health care due to cost suggests that gaps remain in mental health policy. The MHPAEA, for example, does not apply to employers with fewer than 50 employees, and it only requires parity with the general health care benefits offered by a specific plan. Individuals who are already underinsured by a health plan with limited benefits will be undercovered for mental health care as well. While reasons other than cost or lack of insurance may delay or prevent women from accessing mental health care, they are a major contributing factor and one main target of MHPAEA. Similarly, while the ACA has led to higher rates of insurance coverage, health care remains unaffordable to many due to rising premiums and deductibles. Changes in the political landscape may further lead to ACA rollbacks. Women with MPD may be at particular risk of losing access to health insurance, as their mental health conditions may not be severe enough to qualify for Medicaid coverage based on disability.

Many of the system-level, provider, and patient-related factors that contribute to health care disparities among reproductive-age women may not be adequately addressed by the MHPAEA and ACA. For example, there is a severe shortage of mental health providers, especially in rural areas. Incentives to increase the number of people entering mental health professions could address long waits for appointments, which women with psychological distress were more likely to cite as a reason for delayed care. Providers could also be made more accessible through expansions of the provider networks that are covered by health plans or accept more types of insurance, as well as by increasing or diversifying the settings where mental health care is provided (e.g., primary care clinics or community settings), which could partially address transportation, referral, and other logistical issues.

Approaches to both policy and practice need to consider that women with psychological distress may be the least able to navigate the health care system or advocate for themselves. Reproductive health care providers, whom women of reproductive age favor for annual examinations and preventive care, may be ill-equipped to address serious mental health issues. Easier means of referral and mental health care navigators could ease the burden on reproductive and primary care providers while increasing the likelihood that those with psychological distress receive proper diagnosis and care. Given women's preference for reproductive health providers and that women's mental health care needs tend to be disassociated from their reproductive health care,³⁷ reproductive health providers may consider incorporating screening for mental health problems into routine clinical evaluations.

More broadly, an expansive approach to mental health care may be needed to target barriers to care that stem from lack of transportation or education, work and family obligations, and poor access to social safety nets. Efforts to increase awareness and decrease stigma associated with mental health conditions are also needed, both within and outside the health care sphere. This includes supportive workplace policies that ensure workers with psychological distress have access to employee support programs, assistance navigating the use of disability benefits, and supervisors who make sincere efforts to provide reasonable accommodations. Taken together, these initiatives facilitate the use of needed health care through provision of compensated time and enable workers with psychological distress to remain employed and maintain their needed health care coverage.

Limitations

Findings must be considered in light of potential limitations. First, the NHIS restricts its sample to the noninstitutionalized population, so women with serious mental illness who reside in institutions, although a small population, are not represented. However, if institutionalized, these women are likely receiving needed care. Second, our psychological health measure, the K6, measures nonspecific psychological distress and may not capture all women with serious mental illness. Since the K6 is a self-report screener, it is more likely to capture women with current or recent debilitating psychological symptoms than those who report ever having a clinical diagnosis. Those with well-controlled mental disorders are also not likely to score high, but most likely have had adequate access to care for treatment. However, using the K6 allows us to identify women with psychological distress without relying on a clinical diagnosis, which women with delayed/foregone care may be less likely to have. Third, questions about foregone care are specifically about unmet needs due to cost. Women with MPD or SPD may have unmet health care needs due to other reasons. Thus, some unmet needs may have been underestimated due to the focus on cost. In addition, this question, alone, does not allow us to distinguish those who are more likely to need care, less likely to receive care due to cost, or both. It is possible that there were differences in need even without differences in ability to pay. Finally, the reference period for psychological distress is 30 days, while the reference period for delayed and foregone care is the past year. Therefore, we cannot be certain that findings on past delayed/foregone care are related to current psychological health status. However, serious mental illness is rarely intermittent. Thus, women classified with current SPD are likely to have had this state episodically before the 30-day reporting period.

Conclusions

Health equity research has documented significant disparities in health and health care by race/ethnicity, age group, socioeconomic status, and rural/urban residence. In contrast, disparities in access to and use of health care by mental health status have received little attention, despite health disparities being the metric by which we measure progress toward health equity.³⁸ As noted by a former National Institute of Mental Health Director, “this population [with serious mental illness] is rarely identified as an underserved or at-risk group in surveys of the social determinants of health.”³⁹ Our study fills an important gap in the literature by documenting health care disparities by level of psychological distress among reproductive-age women.

We find that reproductive-age women with psychological distress face considerable structural and cost-related barriers to accessing health care, which may be exacerbated by their psychological state. Even after adjusting for a number of predisposing, enabling, and need factors, women of reproductive age with MPD or SPD are more likely to delay or forego needed health care than women with no psychological distress. This supports our contention that there are serious unmet health care needs among all women of reproductive age, and that greater attention to the psychological state of all women, not just during the peripartum period, is warranted. Despite recent policy advances, additional efforts by policymakers and providers are crucial to address the health care needs of this population.

Footnotes

Acknowledgment

The authors gratefully acknowledge support from the Minnesota Population Center, University of Minnesota (P2C HD041023) funded through a grant from the Eunice Kennedy Shriver National Institute for Child Health and Human Development (NICHD).

Author Disclosure Statement

No competing financial interests exist.

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