Why Is It So Hard to Find Quality Mental Health Care in the U.S.?
Humans have been notoriously bad at talking about and caring for our mental health. We’ve feared mental illness, disorders, and neurodiversity. We’ve locked people in institutions with archaic policies.
Today, we humans have made some significant progress in our understanding and acceptance of mental health care. And although we’ve gotten better at talking about it, and even caring for mental health, there’s a big problem: people can’t access the care they need.
Since the start of the pandemic, there has been a huge spike in adults reporting symptoms of anxiety and depression.
From January to December of 2019, a monthly average of 7.4% - 8.6% of U.S. adults reported symptoms of anxiety. In the same time span in 2021, 28% - 37% of adults reported symptoms of anxiety.
Similarly, on average 5.9% - 7.5% of U.S. adults reported symptoms of depression in 2019, while 20% - 31% of adults reported symptoms of depression in 2021.
Encouraging each other to talk about our mental health and seek care is all great, but when people do seek mental health care, they encounter a system unable to provide it.
The problem accelerated – during the pandemic 65% of psychologists had no capacity for new patients, per the American Psychological Association.
Currently, over half of the people who need mental health care in the United States don’t receive treatment. When people experience a mental health crisis many have nowhere to go for care, and they wind up in the Emergency Room.
Since the pandemic began, Emergency Rooms have been overloaded with patients waiting, sometimes months in the ER, for mental health care.
Clearly, there is a problem with how our mental health care system is set up, so...
Let’s take a look at mental health care in the United States of America.
For years we kept people in institutions that practiced archaic forms of “treatment” [torture]. We eventually shut these institutions down with the understanding that care for mental health would take place at outpatient community mental health centers – which would have been a great idea, had we funded them properly. But we didn’t.
This creates a problem where people who need mental health care don’t have access until they’re in a crisis – and even then, they may have to wait days or even months before they get the care they need.
What this all shows is: that the main problem facing mental health care in the U.S. is a lack of mental health care workers – from psychiatrists and psychologists to social workers. And the problem gets even worse in rural areas.
When people have no access to the healthy coping mechanisms taught through therapy, they may adopt unhealthy ways of coping, exacerbating the mental health crisis.
Adults in rural America have higher rates of use of tobacco and methamphetamines. And the shortages aren’t just disproportionately worse by geography.
If you are looking for a provider of color you may have difficulties given capacity shortages, as white people make up nearly 85% of the U.S. psychological workforce. Therefore, some patients may have trouble finding a provider they can relate to.
This massive gap between supply and demand, patients needing providers, has proven very attractive to Silicon Valley.
There are over 10k apps geared towards mental health care that you can currently download on your smartphone or smart devices – from Calm and Headspace to apps like Woebot (? Chat with a mental health AI robot, but I don’t recommend it).
Most of these apps are harmless, sometimes helpful, tools to add to your mental health care routine, but none can replace therapy.
However, it’s not just apps springing up to fill this gap in supply and demand – Podcasts, TikTok influencers, and entrepreneurs are jumping in too.
Talkspace, done., BetterHelp, Cerebral – all these services claim to connect you to a therapist or medication. And nothing is inherently wrong with the idea of a service that connects people to mental health care, virtual or not. Teletherapy care is an excellent tool to fill the gap in mental health care access. But the reality of these services is deeply underwhelming and sometimes downright evil.
In May 2022, Cerebral was subpoenaed by federal prosecutors under suspicion of overprescribing certain controlled substances, like Adderall. In an article published in Bloomberg Business in March of this year, former Cerebral staffers claimed that the company’s then-Chief Medical Officer, and now-CEO, said “95% of people who see a Cerebral nurse should get a prescription.”
Cerebral claims it never pushes pills and has services set up to deal with mental health emergencies like suicide ideation, but even if Cerebral and all these other apps and services were perfect in every way, they still wouldn’t solve the current underlying issue.
Silicon Valley can create as many apps and services as they want, but they still can’t suddenly hire more mental health care providers if not enough exists.
Unfortunately, the system not only prevents patients from accessing it but prevents providers from entering the mental health care workforce. And a lot of this problem comes down to how we pay for therapy.
Therapy is expensive. The typical fee for one session with a licensed clinical social worker is between $120 - $180 and as much as $300+ for a single session with a psychologist.
We currently have laws that are supposed to make mental health care affordable and accessible.
In 2008 we got the Mental Health Parity Law, which basically says big insurance has to cover mental health care at the same level as all other care. Then in 2010, the Affordable Care Act extended that parity to individual and some small group plans. That all sounds great, but the reality is horrid.
Try finding a mental health provider who takes your insurance, much less a provider for children who is in-network.
Network Provider lists from insurance companies, that should be up to date with current providers, are often full of providers no longer accepting new patients or no longer in-network, wrong numbers, and dead ends. Lists like these from insurance companies are so notorious that they’ve become known as “ghost lists.”
In 2015 a team of researchers examined the availability of psychiatrists listed on an in-network provider list supplied by Blue Cross Blue Shield. Of the 360 psychiatrists the researchers attempted to contact, only 40% of all calls were answered, and 16% of calls were the wrong number – including numbers that connected researchers to a McDonald’s restaurant, a boutique shop, and a jewelry store.
On the off chance that patients do connect to mental health care, insurance companies use outdated, subjective policies to deny treatment. In some cases, insurance companies will approve a form of mental health treatment only to intervene midway through treatment and revoke their approval.
Imagine an insurance company refusing treatment midway through any other medical treatment, like surgery or chemotherapy, because they claim it is no longer medically necessary.
This struggle doesn’t only exist between patients and insurers; debate over coverage between insurers and mental health providers can get incredibly adversarial. As a matter of fact, a reviewer for Anthem Health, now Elevance Health Insurance, at one point had an average denial rate of 92%.
An Excerpt from a 60 Minutes interview with Scott Pelley and Dr. Paul Keith, Former medical director at Anthem. Watch the interview.
Dr. Paul Keith: I cannot, offhand, think of a situation where a decision was made to discharge a patient from a hospital and some terrible consequence occurred soon thereafter. I'm sure it happens, but--
Scott Pelley: We found quite a few.
Dr. Paul Keith: I'd have to look at them to see. There's one that occurs to me that I was involved with where the child left the hospital with his parents, escaped from his parents, drove cross country to another state, and days later, committed suicide. Keeping that individual in the hospital longer is not likely to have made any difference.
Scott Pelley: I would have to imagine that the parents would say, "If you'd kept him in the hospital, he wouldn't have been in another state killing himself."
Now, we may have parity laws that aim to make mental health affordable, but the insurers work hard to get around parity in care. Once more, the agencies responsible for upholding parity laws do very little to enforce these rules.
Health and Human Services, the Department of Treasury, and the Department of Labor are all public departments responsible for upholding mental health parity laws – but these departments rarely penalize insurers.
As a matter of fact, the Department of Labor closed just 74 parity cases in 2021, finding violations in only 12, according to the Washington Post.
Since 2017, state departments, including all 51 states, have enforced parity laws through fines just 13 times.
Private insurers are not the only source of the problem.
Community mental health clinics are suffering too due to insufficient reimbursement rates through public insurance like Medicare and Medicaid.
Essentially, from top to bottom we underpay mental health providers, limit the path to provider-ship, and prevent access for patients.
For example, patients are five times more likely to have to use out-of-network providers for mental health care than other medical services. And once a patient does connect to care, insurers can sometimes take 90+ days to pay providers, and the amounts paid/reimbursed to mental health providers are often so low that it deters other mental health providers from accepting insurance.
Soon, the only people who will be able to afford mental health care will be those who can afford to pay out-of-pocket.
This is not a sustainable system. Therapists are in a no-win situation: they can refuse insurance and ultimately turn away patients who need care, or they can accept insurers' reimbursements and get woefully underpaid/reimbursed.
It’s important to note that some out-of-network therapists can make a lot of money if they’re based in the right location, with enough clients who can afford the treatment. However, those who can’t afford the out-of-pocket costs are stuck with whoever insurers provide from their “ghost list” of in-network providers.
Basically, if you can’t afford out-of-pocket costs, you’re stuck with whoever insurers are willing to pay.
The battle between insurers, and providers/patients, creates an atmosphere where psychiatry as a profession suffers. Psychiatry consistently ranks as one of the lowest-paying jobs among all medical specialties.
Counselors and social workers with master’s degrees earn approximately 33-45% less than other health care professionals with comparable education.
And as bad as our current mental health care system is now, it’s only getting worse.
A February 2022 study titled, “Outpatient Mental Health Access and Workforce Crisis Issue Brief” from the Association for Behavioral Healthcare said, “for every 10 clinicians entering the mental health workforce, 13 clinicians leave.”
At that rate, eventually, we won’t have a mental health workforce, only apps.
The cost of leaving mental health untreated is massive, for individuals and the community. Untreated mental health is a big driver of homelessness and forces people into contact with the criminal justice system.
Correctional facilities have actually become the largest providers of mental health care in the United States. Basically, we went from institutionalizing people with mental health difficulties to imprisoning them.
So how do we fix it?
My argument: single-payer health care. But it’s kind of like we’ve put that option up high on a shelf and we can’t seem to reach it anymore…
However, we could also begin to 1. recruit and educate more mental health workers and 2. Make sure insurers cover mental health care properly.
On the first point, and to the Biden Administrations' credit, $100 billion in mandatory funding over 10 years aims to alleviate some of the current mental health crises in the U.S.. $700 million of that money will go towards programs like training, scholarships, and loan repayments for those entering the mental health workforce.
On the second point, California recently passed Senate bill No. 855 which basically says insurers must base medical necessity determinations on current, generally accepted standards of mental health care – instead of just making it up as they go.
In the past, our problem was stigma, fear, and silence. Today, we ask for help, but when we do reach out we are increasingly frustrated with the lack of access to care.
Respect for mental health means respect for mental health care. Part of the process of ending the stigma is setting up a system that adequately cares for mental health and makes care accessible to all.
If we’re going to be a country that recognizes and champions mental health care then we need to support the people that provide mental health care.
It may be hard, but it’s more than necessary.