If a family member or close friend came to you and confided that they needed professional help for what appeared to be depression or another mental health problem, would you know where to point them? Even for people with a solid health insurance plan, finding an affordable, in-network, nearby and available mental health provider can be a challenge. What would you tell someone who has no insurance and cannot afford to pay hundreds of dollars out-ofpocket for each appointment or prescription drug? For many Americans, that is the reality.
One in five American adults suffers from a diagnosable mental illness in a given year. Whether it’s diagnosed or undiagnosed, whether it’s depression, schizophrenia, bipolar disorder, anxiety or substance abuse, we probably all know someone who has a mental illness and needs support. The trouble is that mental healthcare is not financed or delivered as much as physical healthcare relative to demand: in other words, people who need an MRI will usually get one, but the same cannot be said for people who need ongoing counseling for depression or another condition.
Why are mental health services given second-class status in our healthcare system? One reason is that mental illness is considered tougher to diagnose and treat than physical illness. Insurers want to see demonstrable improvements in health status from a given procedure or drug, but results of mental health treatment are almost always subjective and self-reported by the patient. Consider the difference between years of psychotherapy and antidepressants next to a three-hour spine procedure that (when successful) can stop debilitating back pain in its tracks.
There is also a social reason for the difference in how physical and mental health are viewed and treated. Whereas physical illness often shows outward symptoms and is considered something that happens to people, mental illness can be less obvious and is harder for people to empathize with. Therefore, people with mental illnesses can feel stigmatized and less willing to reach out for social and professional support.
Mental health advocates cheered with the passage of the Mental Health Parity and Addiction Equity Act in 2008, which mandated that all health plans could not impose more restrictions, such as co-payment or visit limits, on mental health services than on physical health services. Despite being law, however, insurance companies have not yet brought full parity to mental health services. In April, the National Alliance on Mental Health released a survey of 3,000 adults across 84 health plans in 15 states with the following results:
- Consumers and family members report serious problems with finding mental health providers in their health plans
- Insurers are denying authorization for mental health care at higher levels than they are for other types of medical care
- There appear to be significant barriers to accessing psychiatric medications in health insurance plans
- Even when covered, the out-of-pocket costs of medications may pose a barrier to participating in care
- Out of pocket costs may present a greater barrier to inpatient and outpatient mental health care than inpatient or outpatient medical specialty care
- When selecting health plans in State Marketplaces, consumers and family members generally do not have access to information needed to make informed decisions
While it can take some time for insurers to change policies, six years from the effective date of a major law seems like more than enough time. Insurance companies and government payors are remarkably quick to approve the latest treatments and technology for complex physical illnesses, so why does the same priority not extend to an area of healthcare that is rapidly emerging into the public consciousness as a real crisis? Even as progress has been made with that landmark legislation and the inclusion of mental health and substance use disorder services as “essential benefits” for Affordable Care Act exchanges, it will be important to continuously ensure that patients truly enjoy equal access to mental and physical health services.
At the same time, the national conversation is ramping up. Due to recent mass shootings, mental health is now a hot-button issue in Congress and in state legislatures across the nation. The logic, which some consider to be flawed, is that more funding and attention on mental health care will stop people with mental illnesses from committing violent crimes. Prominent voices, including Republican presidential candidate Chris Christie, have proposed making it easier for families and doctors to involuntarily commit patients to the hospital if there is a concern that patients might turn violent. The American public agrees with him: according to a 2013 Gallup poll, 48 percent believe that the mental health system’s failure is “a great deal to blame” for mass shootings.
Critics of that approach say that the vast majority of people with mental illnesses are never going to commit violent crimes. They point out that having a conversation about mental health only in the wake of a mass shooting is misguided and distracts from the core issue. German Lopez wrote for Vox in early October that such an approach “misses the nuance of the issue.” He spoke to a professor at Vanderbilt, Jonathan Metzl, who argues that “mental illness is often a scapegoat that lets policymakers and the public ignore bigger, more complicated contributors to gun violence.”
While national-level policy debates are important, thousands and perhaps millions of patients are having trouble accessing needed mental health services right now. If you, a family member or friend are having trouble navigating the system, resources and information available through MentalHealth.gov or the National Alliance on Mental Illness might be able to help.
NOTE: The views expressed here are those of the author and do not necessarily represent or reflect the views of Healthcare, Inc. and HealthCare.com.
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