For millions of people who are covered by Medicaid, mental health services were already challenging to access before the COVID-19 pandemic hit. Now those resources have become even more limited.
Across the board, the past year and a half of the COVID-19 pandemic has negatively impacted people’s mental health, creating a great need for support during a difficult, fraught time.
Dovetailing with this great overarching demand for mental health support comes the bleak reality that some of the most vulnerable in our society might not always have the greatest access to mental health services to begin with.
In June, the Kaiser Family Foundation (KFF) revealed that during this same period when our mental health needs increased, Medicaid enrollment exponentially rose. The foundation reported Medicaid enrollment scaled from 71.3 million in February 2020, just as the pandemic started in the United States, to 80.5 million in January.
Our nation’s mental health resources are historically underfunded and strained to begin with. Add on top of that the realities of shortages in mental health care providers and barriers to accessing mental health care for many on Medicaid — especially people of color.
The system is also buckling under the weight of deficiencies in infrastructure and support for its practitioners, and then there’s the additional challenges that have been brought on by the COVID-19 pandemic.
What’s being done to help those covered by Medicaid access the mental health services they need and to support those who are providing that needed care?
Experts say the answers to those questions are clear: We aren’t doing nearly enough.
Earlier this year, KFF reported that about 4 in 10 adults in the United States reported symptoms of depressive disorder or anxiety over the course of the pandemic.
Similarly, a July 2020 tracking poll from the foundation discovered that U.S. adults were experiencing a range of negative symptoms that indicated a downturn in mental health — from 36 percent reporting trouble sleeping to 12 percent revealing they increased the consumption of alcohol and other substances.
In short, the pandemic’s drastic, traumatic shifts to the ways we work, socialize, and ensure the health and safety of ourselves and those around us dramatically affected our mental health.
While the demand is there for mental health services right now, nationwide shortages in providers offering that kind of care underscores a large problem, especially for underserved, economically disadvantaged populations.
In just one example, many of New Hampshire’s 10 community health centers have 25 to 40 clinical staff vacancies, unable to fill needed positions, according to the New Hampshire Bulletin.
When it comes to reaching the mental health needs of their residents, “rural and frontier counties” in the United States have an average of just 1.8 and 1.5 licensed behavioral health providers, respectively, per every 1,000 Medicaid enrollees.
This compares to an average of 6.4 providers in urban counties, reports Health Affairs.
Access to care isn’t always easy for many in America. This can be due to a range of challenges such as geographic location of clinics and services, ineffective outreach, and other factors.
The number of people enrolled in Medicaid coverage has risen at the same time that poor funding, relatively low compensation, and job burnout are leaving a lot of providers strained during a very difficult time.
“Mental health care is a chronically underfunded sector of the healthcare system,” explained Dr. Amal Trivedi, MPH, professor of health services, policy and practice at Brown University School of Public Health.
“Payment rates are so much lower for mental health care than they are for other types of care especially specialty care, in general. Many mental health providers do not accept Medicaid coverage and that is often driven by the lower payment rates.”
Medicaid is a program that is often confused and conflated with Medicare in discussions about U.S. health coverage.
For reference, Medicare is meant to offer medical insurance coverage to people who are age 65 and older. Medicaid, on the other hand, offers health coverage to individuals and families with low incomes.
For most adults under 65, eligibility for a Medicaid program is having an income that is lower than 133 percent of the federal poverty line, according to the government’s official Medicaid website.
The Children’s Health Insurance Program (CHIP) extends coverage to children.
For 2021, this would stand at $12,880 for a single person and ranges from $17,400 up to $44,660 for families of 2 to 8, respectively, according to Healthcare.gov.
The 2010 Affordable Care Act, so-called “Obamacare,” made it possible for states to cover virtually all lower-income people under 65.
While it has become a political lightning rod ,expanding Medicaid eligibility to more people has been shown to improve health outcomes and save lives, according to recent research.
Currently, 39 states, as well as Washington, D.C., have adopted some form of Medicaid expansion to cover more of their populations, according to KFF.
Trivedi told Healthline that it’s hard to paint too broad a brush when discussing issues with mental health services for Medicaid enrollees nationwide, given that experiences differ state by state.
He said that while the minutiae differs, there are definitely some clear “problems in accessing mental health care among Medicaid beneficiaries, just as it is throughout all the different insurance programs.”
“Some of the problems described in health policy literature involve problems with network adequacy for many of the people enrolled in Medicaid. There might not be a wide enough network of mental health providers and that can lead to problems accessing care,” he explained.
“Then, there are issues of mental health parity. There is some federal legislation to address this, but still, it is variable and uneven compliance with federal policy to ensure there is equivalent coverage for mental health services that there is for non-mental health services.”
He said that there are challenges like limits in care for mental health conditions and more stringent prior authorizations that people have to go through. This “confluence of factors” ultimately “erodes access to evidence-based, high quality mental health services.”
“Another part of this is there are large issues with substance use disorders in the Medicaid population, ” he added. “There are effective comprehensive services to deal with substance use disorders, and those are often not available to Medicaid patients, these special treatment services. These are, again, underfunded, and there are a lot of barriers to accessing these types of services.”
This combination of factors ultimately creates a brick wall of sorts, preventing people from navigating the services and care they need.
During this unprecedented time, when people are in need of mental health services the most, healthcare professionals are often feeling the weight of pressure, expectation, and lack of support.
Leslie Lennig, LCSW, is the regional manager for the Southern Region of Community Health and Counseling Services (CHCS), a nonprofit that provides home health, hospice, and mental health services to adults and children central, east, southern, and northern Maine.
Lennig, a clinical lead for CHCS, has been with the organization for more than 10 years. When reflecting on challenges the agency has faced in recent years, she said that staff shortage is one of the biggest issues.
“It’s hard to find a therapist who doesn’t have a waiting list,” Lennig told Healthline. “We are struggling with hiring and have a lot of open positions. A lot of people in entry level positions don’t make as much as unemployment right now. We are struggling to get people to enter into the work force given our entry level is not that far away from minimum wage.
“Some are choosing to go into a less stressful world of working at Walmart rather than go in and dive into working with people and trauma stories and managing intense emotions and feelings.”
Lennig said that another issue the nonprofit faces is that it isn’t situated in “the richest state in the country,” one that is very rural with areas with highly spotty, variable Internet coverage, which can be a big deterrent especially for providers who might have to go out into people’s homes and might not want to use their own personal data plans.
“They [the ranges] haven’t increased in over 30 years. If what I’m providing is therapy and what I’m getting paid per hour is the same thing I would have been paid 30 years ago, well, that was fine 30 years ago, but there’s been inflation since then,” she explained.
“If we could be reimbursed for our services at a higher rate, then we could offer more money to our staff and therefore recruit them and not have them be at a minimum wage place.”
When looking at some flaws in support for Medicaid-based behavioral health providers, Lennig said that one of the biggest issues centers on reimbursement rates with insurance companies.
“We serve the entire state of Maine and we have a ton of programs, but the reimbursement often barely — if at all — makes us cut even. We have a number of programs where we just know we are going to lose money, just as an agency. The clinical therapy unit can’t make money off that, nobody in the state of Maine can,” she added.
Mary Jones, LCMFT, LCAC, is the president and chief executive officer of the Mental Health Association of South Central Kansas, a nonprofit that has offered mental and community health services to south central Kansas since 1957.
She said that the behavioral health space “was already in a crisis prior to COVID-19,” but now gaps in coverage and support for the most vulnerable in society have only been exacerbated.
Citing the rise in substance use disorders, anxiety and depression, suicide, jobless and homeless rates during the pandemic, she said that you now have a crisis that has “stretched the system” to an extent where it’s increasingly further away from addressing the human needs it was put in place to serve.
Jones told Healthline that disruptions to in-person education has added another strain for low-income families.
Many children in these households and communities used to receive a significant amount of support through their schools, something disrupted at the height of the pandemic as families had to adhere to stay-at-home orders and schooling went remote.
“To put in perspective, many of these kids lacked even more access, disproportionately so for people of color. So you have a Medicaid population that keeps seeing increasing barriers to service,” she said.
Jones echoed Lennig in saying that the rise of telehealth platforms has also been a challenge for states like Kansas with large rural areas that don’t have broadband access or widely proliferated Wi-Fi systems.
“The insurance industry had to catch up to meet the needs of people,” she explained, but she stressed that in many cases those needs still aren’t being adequately met as gradually inch toward a full year of the global pandemic.
Jones said that the era of COVID-19 has shed a light on all of the lack of formal support for healthcare providers in general, much like the lack of proper personal protective equipment (PPE) and the unsustainable surge of volume of patients that have hit ICUs throughout this crisis.
While much needed attention has been paid to rectifying some of these systemic flaws that have left physical healthcare practitioners vulnerable, Jones stressed that “behavioral health providers” have remained somewhat under the radar.
Both Lennig and Jones highlighted the stress and frustrations of documentation that behavioral health professionals face. They both essentially said the same thing: Everyone enters this field with the goal of helping others, but none walk in with the fantasy of completing endless hours of exhausting paperwork.
While a primary care physician or emergency room doctor might have a nurse or a physician’s assistant complete needed paperwork, understaffed and inadequately compensated behavioral health staffers at nonprofits, clinics, and rural hospitals — often serving Medicaid-insured populations — are stretched to the limits with administrative work they might not even have the bandwidth to focus on.
Both work for organizations that have turned to Remarkable Health, a company that uses tech solutions to help behavioral health and human services professionals complete these kinds of electronic health records (EHRs).
The company recently launched Bells, an artificial intelligence (AI)-based tool for note taking.
The company’s CEO and founder Peter Flick told Healthline that it’s important that providers who serve lower income, vulnerable populations that rely on Medicaid for their healthcare needs have the tools to make their jobs easier as they face the current “tidal wave of demand.”
He highlighted the intense burnout faced by these providers and said that companies like his are hoping to fill some of the gaps in support to these behavioral health professionals — assistance that’s often not extended to them.
“For years, behavioral health has been sort of the stepchild of physical health,” said Flick, who named the Bells technology after his daughter. “It’s exciting to have product out there transforming morale of staff.”
When reflecting back on all of the challenges facing both Medicaid patients and practitioners, Trivedi said that it’s no surprise that the current pandemic has made things hard on both ends.
“We are seeing problems with what we call the ‘social determinants of health.’ So, housing instability, food insecurity, loss of jobs, all of those factors impact mental health care and mental illness, which is increasing need at the same time there’s been a lot of stress and burnout placed upon providers,” Trivedi said. “It’s an urgent problem.”
Looking to the future, Lennig said it’s difficult to imagine a “post-pandemic world” while we’re living through this crisis. That being said, she hopes as we continue to find a way to safely navigate COVID-19, its variants, and ways to gather safely that those working in the behavioral health space can return to doing the work they love the way they love it.
“Social workers get into this because we are pretty social, we like being around people. The struggle this year has been a lot of my extroverted staff miss that time getting together and meeting in person, they don’t want to stare at a screen anymore,” she said.
“If we can go into that post-pandemic world and have meetings on a regular basis, meet and have lunch together, I think morale will help in that space and we can assist further. I think it’s been hard for people to compartmentalize and do self-care when they are working out of their homes.”
Jones said that one of the bleak realities of this era is that it has shed a clarifying lens on the people who “are barely hanging on.”
“You have a whole host of people not even on Medicaid, not even eligible. I live in one of the states who have yet to adopt expansion that would get another 100,000 people or so on Medicaid,” she explained.
“What we know across the states that have not expanded Medicaid, about a third of these have behavioral health or substance use issues. So we aren’t even scratching the surface of giving the care that they need to give.”
She said that it’s important to examine just who’s being left behind.
Disproportionately, these are people of color, people of lower economic status, sexual and gender minorities, people who don’t have easy access “because we [providers] are not in their neighborhoods, we are not close to where they can access services,” she added.
Trivedi said that in the push to give everyone quality care, as the pandemic continues to ebb and flow and impact our society at large, we can’t lose sight of what needs to be done.
“We need comprehensive high quality mental health care available for everybody regardless of people’s economic circumstances, racial ethnic backgrounds, or geographic location,” he said. “We’re just far away from that ideal and we need to keep working toward it.”