The Twin Problems of Mental Health Care: Access and Affordability
In an earlier column, I wrote about the serious impact mental health-related crisis events were having on families, calling it, “a crisis within the mental health crisis.” In this column, I return to the topic and write about the challenge of accessing and affording mental health services. There will be a few areas in health that present opportunities for bipartisan agreement in the new Congress: possibly price transparency, site-neutral payments, and pharmacy benefit managers. In his first term, President Trump signed legislation expanding community-based mental health services. Another area where some bipartisan agreement might be possible is mental health.
A good place to start would be to look at the twin problems of access and affordability, which come together with more pernicious effect in mental health than anywhere else in health care. Many people with mental health problems can’t find providers and can’t afford services or drugs they need.
The numbers are concerning across virtually every type of coverage: At least four in 10 insured adults (43%) who describe their mental health as either fair or poor say there was a time in the past year when they needed mental health services or medication but didn’t get them. Some may think this is mostly a Medicaid problem, but it’s not. This group includes more than four in 10 people with employer coverage (46%), marketplace coverage (45%), and Medicaid coverage (44%). Medicare does a little better—beneficiaries with fair or poor mental health are somewhat less likely to report forgoing needed mental health care (27%), which may have more to do with the care-seeking patterns of seniors than Medicare coverage.
Overall, this is about four times the number who report problems who say that their mental health is excellent, very good or good.
As with almost everything in health care, there are pronounced racial disparities. Among adults who report fair or poor mental health, White adults (50%) are more likely to say they received mental health services in the past three years than Black (39%) or Hispanic adults (36%).
Senators Fetterman and Smith talked earlier this year, before the election, about establishing a Senate Mental Health Commission. Also, the Senate Finance Committee released a bipartisan white paper last year that included a variety of mental health policy recommendations.
A commission would need to come to grips with the multifaceted nature of the problems people with mental health issues tell us they face. For example, 44% of insured adults who did not receive needed mental health care say they couldn’t find a provider they trust; 36% say they didn’t know how to find care; and 34% say they were afraid or embarrassed to seek care. More than four in 10 said they didn’t get needed mental health care because they couldn’t afford it (44%). Forty-two percent said they couldn’t find a provider that was easy for them to get to for an in-person visit. Just over a third of those insured adults who didn’t get mental health care say it was because their insurance wouldn’t cover it (37%). The multidimensional nature of the problem means there are lots of areas where improvements can be made. It lends itself to a package of incremental policy changes, Washington’s specialty. It also means there is no single policy intervention that will solve most of the problems.
Payers would pay for better networks and coverage if this were physical health care, say heart disease or cancer. Having interviewed hundreds of employers over the years, I know that many feel that mental health services could become a cost sink if they made their mental health coverage more generous. Some simply believe that mental health services are not sufficiently effective.
With that in mind, it was compelling to see in a recent KFF survey that half of adults (53%) who received mental health services in the past three years said they were very or extremely helpful. The numbers fell off somewhat for those most in need: 41% of those who said their mental health was fair or poor said the mental health services they received were very or extremely helpful. Still, a large share of people who felt they needed services said they were helped by them.
The policy expert in me is cautious about interpreting self-reported mental health status, which doesn’t offer much precision about what a person’s mental health problem is. Serious chronic mental illness is very different than anxiety or loneliness. An acute situational crisis is not the same as a long-term mental illness. The same goes for the self-reported efficacy of mental health services (how effective? how lasting?).
However, speaking as an employer concerned first and foremost about our employees, this level of self-reported effectiveness from people with mental health problems who took the sometimes-difficult step of seeking help when they thought it was serious enough to do so makes me hope we can make improvements in mental health coverage. There are, as always, challenges and trade-offs. Better coverage means higher premiums, and there are shortages of mental health professionals, particularly those willing to take insurance, at least at current payment rates. KFF has employees all over the country and it’s not easy for an employer to find a plan with a strong network of mental health providers, even if they are willing to pay for it. One hundred twenty-two million Americans live in an officially designated mental health shortage area.
Mental health parity has been on the books for decades. But, while it has improved coverage, prior authorization rules and limited networks for mental health mean we don’t really have parity in practice. Our KFF surveys show clearly that we certainly don’t have parity yet. The Biden administration recently issued updates to regulations that require health plans to have prior authorization rules and networks for mental health on par with physical health, though it’s uncertain what the incoming Trump administration will do with these regulations.
It’s unclear what aspects of mental health might be carved off for bipartisan action. Generally, Republicans want to dial back coverage and federal spending, which makes addressing the overall problem of mental health through more systemic improvements in access and affordability highly unlikely. But aspects of the problem—suicide prevention, support for families facing a crisis, addressing the prior authorization mess, or other pieces of the problem—may be more feasible.