How to fix America’s broken mental health care system
A psychiatrist works with a young patient
(Photo by Loic Venance/AFP via Getty Images)
At age 19, Ryder Dunagan stood on the Brooklyn Bridge and prepared to jump. Instead, he checked himself into a hospital.
That six-day stay may have saved his life, but it left him with a $30,000 bill. The debt followed him for years and still stains his credit report.
Like Dunagan, one in five American adults cannot afford the mental health care they need. The situation, dire before COVID-19, has grown worse as anxiety and depression have increased during the pandemic. President Joe Biden campaigned on the promise to prioritize mental health. Now the administration must move quickly to improve access to treatment.
Barriers to care
Dunagan was diagnosed with depression in his early teens. Coming out as transgender had not gone well, triggering his suicidal crisis. He was underinsured on his parents’ catastrophic health plan. The hospital debt and the vagaries of insurance coverage compounded the stress.
“Changing therapists, doctors, shifting insurance situations — just life — made it difficult to stay on a consistent regimen of mental health medications,” he said.
When he moved to Los Angeles, Dunagan found affordable insurance through Covered California, the state’s health insurance marketplace. “Now I have mental health support,” he said. “I’m able to get counseling and medication when I need it.”
His experience illustrates how costs, bureaucracy, and the insurance reimbursement structure put good, consistent mental health care beyond the reach for many people — and how government policy can make a difference.
Nearly 120 million people in the United States live in areas with mental health provider shortages. Closing the gap would require nearly 6,500 additional psychiatrists, but there were just 6,248 psychiatry trainees in 2020, not even enough to outpace retirements.
The Substance Abuse and Mental Health Services Administration projects shortages of almost all kinds of mental health and behavioral health professionals by 2025, including clinical psychologists, school psychologists, and substance abuse counselors. The shortage is especially acute for children.
Financial incentives deter many providers from accepting insurance, effectively limiting provider supply for anyone who can’t pay out-of-pocket. Insurance companies often offer less than half of what a therapist can charge in private practice, according to Rachel Needle, a licensed psychologist in Florida.
“To make a good living based on our educational level, taking insurance is challenging,” Needle said. Insurance bureaucracy makes low reimbursement rates even less palatable.
Even with health insurance, many patients struggle to stay in high-quality, culturally sensitive care because of deductibles, copayments, and coverage limits, according to Akua K. Boateng, a Philadelphia-based licensed psychotherapist serving mostly young professionals of color.
“That is probably one of the larger things that I’m dealing with my clients of color, just being able to keep them,” she said.
The mental health agenda
The Biden administration has a range of policy options to deliver on the promise of accessible, affordable mental health care:
Reimagine tele-mental health. Use of telemedicine for mental health care has spiked during the pandemic, aided by federal policies and fueled by private insurer policies. Blue Cross Blue Shield of Massachusetts, for example, reported 38,000 daily telehealth claims a day in May 2020 — up from 200 before the pandemic. Nearly half of the claims were for mental health.
Some private insurers have committed to continuing to waive consumer costs for these telehealth visits while others have ended those waivers. The new administration should require — or at least strongly encourage — insurers to continue to cover and waive consumer costs for tele-mental health care.
Telemedicine could also be instrumental in expanding access to appropriate providers through policies that allow providers to practice across state lines. Though provider licensure is governed at the state level, federal policy can encourage reciprocity and ease restrictions on intrastate practice.
“If you can’t find a Black therapist within your city or within your area, you’re just out of luck,” Boateng said. “We need to really reinvigorate (and) re-envision (telemedicine) and join arms across states in order to up the presence and representation that’s required for quality care for people of color and vulnerable populations.”
Cap consumer mental health costs. Out-of-pocket costs deter consumers from using needed services. Especially during the pandemic, policymakers should cap consumer mental health costs such as copayments and apply lower copayments to psychiatric drugs.
“If people have very high copays or things are not covered by their plan, they’re going to be less likely to seek care,” said Meena Seshamani, a surgeon who managed implementation of the Affordable Care Act (ACA) and now is vice president of clinical care transformation at MedStar Health.
Though the federal government sets overall out-of-pocket maximums through the ACA, those limits are high for most people: $8,550 for 2021. Lower, category-specific limits could make mental health care much more affordable.
Go beyond mental health parity. The Mental Health Parity and Addiction Equity Act of 2008 requires insurers to provide equivalent mental health and medical coverage, and the Affordable Care Act requires coverage of mental health benefits.
In reality, these rules have often failed to ensure equal access to mental health care. Where treatment is quantifiable — such as the number of days covered at a skilled nursing or residential treatment facility — insurers tend to strictly adhere to parity rules, explained Lisa Kantor, a Los Angeles-based health care attorney.
Kantor recommends expanding coverage beyond parity, based on California’s Senate Bill 855, which requires insurers to cover treatment for the full range of mental illness and substance use disorders identified by the American Psychiatric Association’s most recent “Diagnostic and Statistical Manual.”
Insurers must determine medical necessity based on accepted clinical standards according to industry experts, not their own internal standards. The law prohibits insurers from using arbitrary or conflicting criteria for what they will cover, and from limiting coverage for short-term or acute treatment.
Reimburse better for mental health care. Low insurance reimbursement rates keep many providers from accepting insurance. The Biden administration should raise minimum reimbursements, such as through increased Medicare rates, to reflect the expertise and value of mental health professionals.
Forgive student debt. According to Mark Kantrowitz, publisher of PrivateStudentLoans.guru, a typical social worker with a master’s degree might owe $75,000 in graduate school debt, and Ph.D. and M.D. graduates can owe into the six figures. But many mental health providers, especially those working in some nonprofit agencies or regions, can earn less in a year than they owe. Though some working in public or nonprofit agencies may qualify for public service loan forgiveness, private practice incomes, commonly over six figures, are enticing.
The new administration should expand on legislative attempts by then-Senator Kamala Harris to create a federal student loan repayment program of up to $250,000 for mental health professionals who practice in shortage areas.
Destigmatize mental illness. Destigmatization is the key to all other improvements, Boateng says.
She stresses the need for “creating an environment where there’s safety around pursuing mental health (and) there is a culture of supporting the pursuers of mental health.”
The Biden administration must make a strong statement recognizing the serious mental health toll the pandemic has taken.
Despite including mental health in the administration’s COVID-19 strategy and response plan, the President has not announced high-level appointees with mental health expertise. The COVID-19 task force, which disbanded upon Biden’s inauguration, included just one mental health nurse and, some experts argued, lacked sufficient focus on mental health. Appointing mental health experts to high-level posts is essential to addressing urgent needs and psychological and behavioral problems that will persist even after the pandemic has abated.
Improve overall economic well-being. According to Seshamani of MedStar Health, policies that hasten economic recovery can improve mental health as well.
“People need to feel valued and … like they are accomplishing something or having an impact,” she said. Improving job opportunities and job training become mental health policy levers, but should be paired with workplace protections and accommodations for people suffering from mental illness.
Improving access to mental health care isn’t the sole purview of the federal government. Private insurers can invest in access to mental health care. The provider community can encourage people to enter the health field and support them through the long years of training. But the Biden administration has the opportunity to set a new tone for mental health care in America and lead in creating a system that works.
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