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More Americans receive treatment for and pay less out of pocket than they did two decades ago, according to a recent analysis.

Depression is a pervasive disorder: 17.3 million American adults experience at least one depressive episode each year. The condition therefore creates a substantial economic burden for both the individual and the health-care system. A few key policies—most notably the Affordable Care Act and Medicaid expansion—seem to have relieved the burden for patients and broadened access to treatment. However, 14 states have not expanded Medicaid, potentially missing an opportunity to treat those suffering from mental illness.

“States that haven’t expanded Medicaid could look at these estimates and think: There’s a way to expand treatment of mental health conditions like depression,” says Julie Donohue, a professor of health policy at the University of Pittsburgh, who was not involved with the research.

The Affordable Care Act strengthened behavioral health coverage by expanding the Mental Health Parity and Addiction Equity Act—which mandated that insurance companies cover mental health and substance use disorders on par with medical and surgical needs. The ACA also required individual and small-group plans to cover mental health care as one of 10 essential services, and it offered states the opportunity to expand Medicaid coverage to more of their residents.

To understand how the law influenced depression treatment, researchers at Emory University analyzed the health-care data of more than 86,000 people from 1998, 2007, and 2015. The treatment rate for depression rose from 2.36 percent to 3.47 percent of the total population over the 17 years—representing a relative increase of 47 percent. The shift may appear small at first, but adding one person per every 100—in a country of 330 million—translates to roughly 3 million more people receiving care.

The increase in treatment from 1998 to 2007 was likely due to the wave of drug discovery from which SSRIs emerged. The bump from 2007 to 2015 is likely attributable to the Affordable Care Act and Medicaid expansion, says Jason Hockenberry, the lead author of the study.

The percentage of spending on depression care that was paid out of pocket dipped from 32 percent in 1998 to 29 percent in 2007. Then it dropped to 20 percent in 2015. “That’s a massive change,” Donohue says. “The proportion of expenditures for depression treatment covered by self-payment went down by 31 percent, which suggests that part of the increase in the treated prevalence of depression is driven by the Medicaid expansion.”

Even though more people were treated for depression by 2015, spending increased more slowly for depression than for health care overall. One reason is that became less expensive. “Early blockbuster drugs that were developed and widely prescribed are now off patent and there’s generic ,” Hockenberry says.

Another notable trend was the difference between and . The use of medications held steady from 1998 to 2015. But therapy use declined after 1998 and then climbed back up after 2007. The reason for the fall is unclear, Hockenberry says, but the rise may be due to expanded insurance coverage, since the cost of repeated therapy visits can be prohibitive without insurance.

The current treatment rate, 3.47 percent, is still below the rate of depression, which falls somewhere between 4 percent and 12 percent. At least four barriers contribute to the discrepancy, Donohue says. First, 28 million Americans remain uninsured, so cost is still a problem. Second, primary care offices don’t consistently screen for depression. Third, stigma still deters many from seeking help. A fourth, longer-term hurdle is that there has yet to be another wave of drug discovery to herald innovative, effective, and cheap new drugs.

Despite these challenges, analyzing the consequences of new laws offers policymakers the information they need to provide mental health care to as many Americans as possible. “In 2007, the uninsured population was this large mass of people,” Hockenberry says. “Because of Medicaid expansion, more of them are now getting covered and treated.”

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