Fixing the Broken Mental Health System
For millions of people, mental healthcare has not been accessible for years due to a lack of mental health resources. Compounding the problem, many insurance policies do not offer coverage for mental health, limit the coverage of therapy, and/or pay a substantially lower percentage of the cost than they do for other forms of medical treatment, all of which can make seeking treatment financially unattainable for many patients and their families.
Obamacare attempts to rectify this, starting January 1, 2014, when all Americans become eligible for mental health services and addiction treatment. Under this plan, insurance companies will be required to reimburse for mental health services if the individual has an eligible policy. Moreover, they will not be able to limit visits for outpatient therapy any more than they do for other medical outpatient visits.
While the intention to offer better care to patients is admirable, there will be unintended adverse consequences to this change if it proceeds as currently planned. It is anticipated that there will be an additional strain on a system that is already at its breaking point due to a lack of mental healthcare resources in many communities.
As it stands today, there is a severe shortage of mental health care professionals and facilities, both inpatient and outpatient, in the U.S. Under Obamacare, we do not expect to see the addition of new physicians or facilities to accommodate the millions of new patients expected to seek treatment – therefore exponentially adding strain on a system already stretched to the breaking point. The result of this lack of treatment in the pre-Obamacare system is easily evidenced by the number of mentally ill patients in jails (a.k.a. “new mental asylums”) and homeless shelters – many of whom desperately need treatment for their illnesses, as opposed to being housed in jails or shelters, but never receive treatment due, in large part, to a lack of psychiatric treatment resources available in their communities. For example, there are almost three times as many mentally ill individuals in the country’s three largest jail systems (Cook County, L.A. County, and New York City) than there are inpatient psychiatric beds in these three large states. In New York City alone, mentally ill prisoners comprise 37% of the prison population, up from 24% in 2005. We also see the result of the lack of care of our country’s most mentally ill in the increase of school shootings, “suicide by cop”, and other incidents of violence by individuals who, under better circumstances, would have received the care they need.
In addition, according to a recent Wall Street Journal article, the U.S. Department of Health and Human Services reports that almost 91 million adults live in areas where shortages of mental health professionals make obtaining treatment difficult. A departmental report to Congress earlier this year reported that 55% of the nation's 3,100 counties have no practicing psychiatrists, psychologists or social workers. In 1955, there were over 300 inpatient psychiatric beds per 100,000 people in the United States. Today, according to the Treatment Advocacy Center, there are 14.1 beds per 100,000 people – the same number as in 1850, and a 95% reduction over 1955, leaving many patients and their families to fend for themselves.
The continual decline of insurance reimbursement rates and increased bureaucratic hurdles has led many providers to stop accepting insurance, which creates an even greater lack of resources – especially for those patients in lower socioeconomic communities who are not able to pay out of pocket. A study recently published in the JAMA Psychiatry found that only 55% percent of psychiatrists accept private insurance, compared to 89% of other physicians. Under Obamacare, while more patients are expected to receive coverage for mental health treatment, reimbursements for psychiatrists will decline further, and the network of providers that patients can access will be restricted, all of which will lead to a deterioration in the quality of care patients can access. The cheapest care is not usually the best care – especially in complex and complicated cases. It is unacceptable that our country is migrating towards the lowest common denominator in psychiatric care. We should strive for adequate care for our mentally ill patients, not just basic treatment.
This shortage of mental health resources is also a contributing factor to the unnecessary prescriptions of antidepressants, psychostimulants, and anxiolytics in individuals who do not meet criteria for major depression, ADHD or an anxiety disorder. It is easier and more “time efficient” for a busy clinician to write a prescription and the insurance companies to reimburse pennies for generic psychiatric medications than it is to reimburse for a thorough diagnostic evaluation by an experienced clinician and pay for therapies that may be as efficacious as medications but more time intensive.
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