15 Jun Shameful Inequality in Mental Health System
Bart Magee, PhD
I was pleased to be invited on the air last week on KQED’s Forum program to join a discussion about the inexcusable obstacles people encounter when trying to access mental health care (listen to the program here). As I reflected on the conversation in the studio and responded to listener concerns, I was again reminded of the vital importance of Access Institute as a resource for so many people who remain in the coverage “gap”. And our dedication to training therapists who believe in providing care to people of diverse races, classes and life circumstances continues to stand out in an environment where the people needing the most help often encounter some of the greatest obstacles to getting it. This is why I and other like-minded people founded Access Institute more than a decade ago and why we need to work harder than ever to fulfill our mission.
The impetus for the show was a series of investigative reports by KQED’s Health Reporter April Dembosky exposing the shameful ways that insurance companies continue to limit access to mental health care, leaving people frustrated, angry and at risk of harm when they should be getting essential treatment. Her reporting documents how these companies, even in the era of mental health parity, continue practices that limit coverage – everything from keeping reimbursement rates low, to limiting providers on network panels and repeatedly rejecting claims for frivolous reasons. In addition, low-cost plans, the kind that most lower-income people can afford, require thousands of dollars of out of pocket payments before mental health coverage kicks in, keeping therapy out of reach for many in need.
Another context to the program was a study published last week finding low income and minority patients are less likely to get therapy appointments, or even a call back, than middle-class and white patients. This study documents a disturbing bias in the private practice arm of the mental health system, “private” being the key word to note. In this model there is no mandate that providers serve all applicants for therapy, and it’s no secret that many of them actively screen out patients who they assess as being more difficult to treat. This kind of a system, by its nature, will discriminate against low income and non-white people. The other part of the system, the public clinic, is supposed to be there to serve everyone regardless of diagnosis, class or culture, but that “public” system, long underfunded and overburdened, can’t provide adequate care. It’s a two tiered system and a profoundly unfair one.
Enter The Affordable Care Act, which along with mental health parity laws, was designed to correct that balance and offer more people access to therapy paid for by insurance. And as Keith Humphreys, a fellow guest of the forum, pointed out, more people are getting that access, however, it remains far short of the parity goal and far short of meeting societal needs. In spite of all the research documenting the importance of mental health treatment in helping people avoid needless suffering, disability, medical problems, hospitalization, substance abuse, self-harm, and early death the insurance system continues to prioritize minimizing short-term costs over maximizing long-term health. In addition, mental health providers and patients have not been the best advocates for themselves, as one caller made clear in his point about the fact that physical therapists are often reimbursed at higher rates than doctoral level psychologists.
The final question from host Mina Kim, “What is to be done?” left all of us at somewhat of a loss, as we recognized there are no clear, easy solutions to such a deeply embedded and complex problem. We all agreed that more reporting and building public awareness of the problem is an essential first. Secondly that people- that means therapists, patients and the general public (most of whom will need mental health care at some point in their lives) need to advocate and agitate for change. That might mean speaking directly to insurance companies or lobbying lawmakers. Finally, large funders need to make mental health needs a greater priority, whether we are talking about insurance payments, support from the government or from philanthropic entities. More funding for programs that bridge the parity gap will go a long way toward correcting imbalances and building a more equitable mental health care system.