As more people sign up for insurance under the Affordable Care Act, the next few months will usher in a fundamental change in mental health care. Under the ACA, insurers are for the first time required to cover mental health and substance abuse treatment as one of ten “essential benefits.” This is good news for the millions of Americans who suffer from some form of mental illness but don’t seek treatment. The question now is whether the country’s mental health infrastructure is equipped to deal with an avalanche of new patients. The answer? Probably not.
Mental health care is saddled with two problems: It’s expensive and inaccessible. A 2012 survey by the Substance Abuse and Mental Health Services Administration found that more than 18 percent of American adults suffered from some form of mental illness in the past year. Of the forty percent who sought treatment, more than one-third paid for it out-of-pocket. To put this in perspective, only about 16 percent of health care consumers overall pay for services out-of-pocket. Cost is the number-one reason why millions of Americans with mental illness forgo medical care.
Despite the high price tag, the demand for mental health care far exceeds the supply of mental health providers. This is largely due to a growing shortage of psychiatrists. According to the Association of American Medical Colleges, the number of licensed psychiatrists dropped slightly between 2005 and 2010, while the general population grew nearly five percent. An alarming 57 percent of psychiatrists are over the age of 55, with retirement on the horizon. It’s no wonder that in most parts of the country, wait times to see a psychiatrist hover in the weeks and months, not days.
Coaxing more psychiatrists out of medical schools will be no easy task. Students who want a high-paying job generally don’t turn to psychiatry; the median income for a psychiatrist is hundreds of thousands of dollars less than the salary for a surgeon or anesthesiologist. But money isn’t the only reason why med students are turning up their nose at the specialty. Beginning with Sigmund Freud, psychiatrists used to emphasize talk therapy. The rise of big pharma changed all that. Insurance companies pay twice as much for a medication consultation than for a traditional therapy session. Now, many psychiatrists spend their days scribbling cocktails of anti-depressants and anti-anxiety medicines on prescription pads during 15-minute consultations.
The Affordable Care Act tackles one element of this problem by requiring all insurance companies to cover mental health and addiction care. In the past, insurers might have wormed their way around this constraint by charging a higher co-pay for psychiatrist visits or refusing to cover them entirely. The wily architects of the ACA preempted this with a new “parity” rule; insurers must cover mental illness like any other condition, whether it’s epilepsy or cancer. This should, at least in theory, make mental health care affordable.
But the ACA is far from a panacea. The dearth of psychiatrists means that a small number of providers will face a deluge of new patients, many of whom could not have afforded insurance before. Although psychiatry is often considered to be a profession that caters to elites (Woody Allen rambling about his childhood memories in Annie Hall) people living in poverty are disproportionately likely to need psychiatric care—and the least likely to get it. Psychiatrists are overwhelmingly concentrated in urban areas, and many operate in solo practice, performing administrative tasks themselves. The stiff competition to get into a psychiatrist’s office, combined with the hassle of filing insurance paperwork, may undermine one of the ACA’s fundamental goals: bringing mental health care to low-income patients.
For example, the new parity requirement won’t make a difference if your psychiatrist doesn’t take insurance to begin with. Dr. Tara Bishop, an assistant professor of public health and medicine at Weill Cornell Medical College, surveyed psychiatrists and discovered that only 55 percent accept insurance, compared to 89 percent of other doctors. One of the reasons, Bishop speculates, may be the complexity of the reimbursement process. For a psychiatrist in a solo practice, it might not make sense to spend hours every week exchanging forms with insurance companies. The dearth of colleagues makes it easy for psychiatrists to fill their appointment calendars with patients who can pay full price.
Finding a psychiatrist who takes Medicaid is an even knottier task. Bishop found that only 43 percent of psychiatrists take Medicaid. Another study, conducted by researchers from Emory and the University of California-San Francisco, found that mental health providers are especially scarce in rural areas with large low-income, minority populations. Most psychiatrists who accept Medicaid work in outpatient clinics or community mental health facilities, but one-third of counties have no such provider. So even in the states that opt in to Medicaid expansion—giving a wider swath of people access to insurance—there won’t be anywhere near enough doctors to cope.
Janet Cummings, an assistant professor of health policy at Emory University and one of the study's co-authors, says that tele-psychiatry is one of the easiest ways to bring mental health care into rural parts of the country. Most counties, whether or not they have a psychiatrist who takes Medicaid, have a federally-funded community health clinic that could establish partnerships with hospitals in big cities. With the right equipment, patients could visit their local clinic and teleconference with a doctor miles away. The problem, Cummings says, is that most clinics don’t have the technology for these kinds of consultations—and it’s expensive. Part of the ACA’s funding is earmarked for telemedicine expansions, but it’s far from enough to address the existing need. Some insurance companies are starting to get in the game, though; last year, CareFirst BlueCross BlueShield announced that it would invest $1.5 million in telemedicine grants for behavioral health providers.
Most of these problems aren’t unique to the mental health system, which might actually make them easier to solve. Primary care physicians are also underequipped for a deluge of new patients (although there’s a much better chance they’ll take your insurance). The remedy isn’t just to entice more medical students into psychiatry and family medicine. Instead, community clinics and hospitals should make better use of their nurse practitioners and social workers to ensure, in health care reformers’ argot, that everyone is working at the “top of their license.”
For example, there’s no medical reason why psychiatrists, once they’ve decided on a particular treatment for a patient, shouldn’t delegate responsibility for refills to a nurse. This notion should make sense to anyone who’s paid a $50 for a routine visit to the psychiatrist, only to exchange small talk for ten minutes and walk out with a prescription.
This could result in a system where mental health and primary care overlap more than they currently do. “People with mental health problems often have another illness that isn’t being adequately treated,” says Chuck Ingoglia, a senior vice president at the National Council for Behavioral Health. “We want all of the staff at health clinics to pay attention to mental health conditions and symptoms but also be able to educate and engage clients about other health needs.”