TO: LEGISLATORS BELONGING TO THE MENTAL HEALTH INITIATIVE COMMITTEE
FROM: DIAMOND MARIE BRELAND
SUBJECT: BUIDLING BRIDGES TO ACCESSIBLE MENTAL HEALTH CARE
CC: DR. NANDAN KUMAR JHA
SEPTEMBER 8, 2018
Introduction
The inaccessibility to Mental Health has become problematic in the United States. Each year, millions of Americans with mental illness struggle to find care. Nearly half of the 60 million adults and children living with mental health conditions in the United States go without any treatment. People who do seek treatment must navigate a fragmented and costly system full of obstacles. Many people cannot access mental health care when they most need it. Despite the passage of federal mental health and addictions parity law in 2008, significant barriers exist in obtaining mental health treatment and support. Barriers include high rates of denials of care by insurers, high out-of-pocket costs for mental health care, difficulties accessing psychiatric medications and problems finding psychiatrists and other mental health providers in health insurance networks. In 2016, NAMI, the National Alliance on Mental Illness, conducted its third nationwide survey to explore the relationship between health coverage and access to mental health care. The study found that people with mental illness continue to experience significant barriers to finding affordable, accessible mental health care. These barriers exist whether the person is covered by private insurance or by a public plan such as Medicaid.
Specific Challenges
1. Difficulty finding a new provider
In the United States, getting psychiatric care has been harder than it should be, patients around the country have challenges booking appointments for outpatient care (Linehan, 2018). Besides, the mental health patients face significant hurdles concerning the provision of the inpatient psychiatric care. Various reasons can be attributed to this difficulties:
a. Current Providers are overwhelmed
The number of the psychiatric patients in the United States are limited. With the limited supply of the psychiatric therapists and more people are obtaining insurance coverage under the Affordable care act. A large number of the psychiatric doctors are not taking new patients as they are already overwhelmed with the current number of people with a mental health condition, and this makes it harder for the new patients to obtain care from the doctors. According to Dr Renee Binder, the immediate past president of the American Psychiatry Association, there is a shortage in the number of psychiatrists, and the number gets to be more limited when it comes to those that deal with child and geriatric psychiatry. Per the American Medical Association, the numbers of the children and adult psychiatrist only increased by 12 per cent since the year 1995 to 2013, that is from 43,640 to 49,079. The number lags far behind the 45 per cent increase in the total number of physicians as well as the general population growth in the United States.
Despite the efforts by the Mental Health and Addiction Equity Act that was enacted in the year 2008 to ensure that the mental health services got covered in level with the medical and the surgical health insurance benefits. Psychiatric experts articulate that the coverage of mental health in the United States still lags, and this compels a large number of the mental health patients to pay out of pocket for the psychiatric services or even forgo the coverage. A large number of psychiatrists, on the other hand, don’t accept the private insurance or even the Medicare, while others have decided to opt out of insurance plans or networks, as they cite what they perceive as the unfavorable reimbursement levels.
b. Not enough providers to meet demand
The demand for the mental health services is on the rise nationally, and this can be attributed to the rising number of mental health patients both adults and children and the limited number of the psychiatric health providers such as the psychologists, psychiatrists, counsellors as well as therapists in the United States. As a result, the comprehensive mental health legislation is gaining momentum in Congress for the first time in many years. According to Thomas Insel, the director of the National Institute of Mental Health, More than half of the United States counties have no mental health professionals and therefore do not have any access to the mental health services.
According to statistics, nearly one out of five individuals in a population of about 43 million people had a diagnosable mental health condition within the past year. To almost 10 million individuals, the situation was more pressing to affect their ability to carry out their daily activities. Millions of adolescent struggle with a debilitating mental disorder making the demand for the mental health services to rise in a significant proportion. A majority of the people as well have become eligible for coverage of mental health following the 2010 Affordable Care Act. Despite the high number that is eligible for coverage, finding professionals to deliver the much needed mental health care has increasingly proven to be tough.
c. Providers are not located in areas of high need
According to a research conducted by Merritt Hawkins a physician search firm, among the list of 20 most in-demand medical specialist, psychiatry trailed only the primary care doctors in the list. According to the Patient Advocacy group Mental Health in America, the states with the lowest access as well as the highest rates of mental illnesses are in the south and west, with the rural areas experiencing the highest deficits. The lack of psychiatrists, as well as the other mental health providers, are part of the overall shortage of the physicians in the United States. A study conducted by the Association of American Medical Colleges indicated that the nation would be faced with a deficit of between 46,000 and 90,000 doctors within a decade. Besides the shortage in supply of the primary care health providers, the largest deficit will be among the specialists caring for the elderly and to whom the psychiatrists are included. Thus an implication that the demand of the mental health providers will be on the rise, but on the contrary the demand will not be met due to the shortage of specialists.
d. Providers are not responding to inquires
The mental health professionals are already overworked as they are understaffed. Besides, the demand for the mental health care has been on the rise, a fact that can be based on the significant increase on the number of people who are eligible for mental health services under the Affordable care act. With the demand for the psychiatrists and other mental health providers being very high, it is unfortunate that there is not enough number of the mental health care providers to cater for a large number of people with the condition. Due to the high demand and understaffing of the mental health professionals, a large number of queries often go unattended as it is impossible for the limited workforce to cater for the high demand appropriately. On the other hand, the mental health services as earlier observed are not provided in all the regions that they are needed especially in the rural areas where people have limited access to the mental health specialist (Jansen et al. 2017). In these regions, it is rare for the mental health professionals to be deployed and therefore any queries relating to mental health services and care remain unanswered.
2. Out of Pocket Costs are too high making it unaffordable
The cost of obtaining therapy for the people with a mental health condition has proven to be too high with the patients being forced to pay around 200 dollars a session (Follette & Cummings, 2016). Mental illness being mental illnesses being a critical condition that demands immediate care to avoid harm such as suicide and to which has affected a large proportion of people around the United States and besides there are insurance covers to cater for the treatments, should not cost the patient too much. On the contrary, the cost of seeking mental health services has proven to be too costly keeping in mind that the mental health professionals do not accept the insurance services citing the reimbursement problems from the government. Due to this, the patients are required to pay for the services from their own pockets of which it is too costly taking up to 16 per cent of individuals’ income. The demand for the mental health services is on the rise, but the number of mental health providers has been limited over time increasing at a prolonged rate, and this has resulted to the high cost of getting psychiatric services. It is not worthy for a single therapy to cost more than 200 dollars as very few individuals can afford to take into consideration that a significant number of individuals live just below the poverty line and this makes it harder for them to pay the amount.
Spotty coverage for the prescription drugs can be another reason as to why the treatment of mental illnesses could be termed as being too much expensive. After therapy, a patient is advised to purchase certain medications that aid them through recovery and therefore these are essential drugs. Unfortunately, these drugs are too expensive and require good money to buy them, proving to be costly for a majority of the patients. Some of the conditions that require to see a psychiatrist are not diseases, but the policy or notion for the coverage that requires a diagnosis before one can pursue a mental health treatment may prove to be not only time-consuming but as well expensive. The reason is that an individual has to seek a physician before being attended by a mental provider.
3. Lack of inpatient mental health care facilities
There is a severe shortage of the inpatient care for the individuals suffering mental illnesses, and this has amounted to a public health crisis (Strauss, 2017). The reason behind is that the number of individuals who are struggling with a range of psychiatric problems is still on the rise. According to Dominic Sisti, the disappearance of the long-term care facilities as well as the psychiatric beds has escalated over the past decade, as a result of deinstitutionalization of the people with a mental health condition in the 1950s and 60s. A report by the Treatment Advocacy Center, a nonprofit organization of the year 2012 found that the number of psychiatric beds had decreased by 14 per cent from the year 2005 to 2010 (Fakhoury & Priebe, 2002). The organization works in the elimination of treatment barriers for the individuals with mental illnesses. In 2010, there were 50,509 state psychiatric beds and the reduction meant that there was only 14 bed available per 100,000 individuals. Dominic continues to state that a majority of the individuals relying on intensive psychiatry care find themselves homeless or more while others in prison. Much of the mental health care for the individuals have now shifted from hospital-based to the correctional facilities.
4. The stigma surrounding mental health treatment
Any person who had previous experience with mental illness can attest that despite the advances in the field of psychiatry and psychology as well, there has been a great deal of the role of stigma inhibiting a person from seeking medical attention. The mental health field has made tremendous progress, but despite all this, the issue of stigma has continued to be a reality. There are two types of stigma that includes the social stigma that involves the prejudiced attitudes that other people in the society have concerning mental illness. Self-perceived stigma is another type of stigma that involves an internalized stigma to which a person with the mental condition tends to suffer from. Both kinds of stigma are real and affect the individual in various ways.
A review of the studies regarding the public stigma of mental illnesses indicates that it is still widespread, despite the public being more aware of the nature of the various conditions related to mental health (Katz, 2014). While some people accept the medical or the genetic nature of the mental states and treatment, a significant number still possess the negative view towards those with the mental condition. The perceived stigma leads to an internalized shame of having the mental illness, and it has been found that the internalized stigma leads to poorer treatment outcomes leading to stigma being the primary challenge that hinders the treatment of mental illness due to relapse.
Future Challenges
If the inaccessibility to mental health services isn’t resolved, this can lead to complicating and detrimental challenges in other sectors of society.
1. An increase in homelessness
According to the Substance Abuse and Mental Health Services Administration, 20 to 25% of the homeless population in the United States suffers from some form of severe mental illness (Wright, 2017). In comparison, only 6% of Americans are severely mentally ill. In the year 2006, Markowitz published data regarding 81 United States cities, the correlations between the decreasing availability of psychiatric hospital beds and the increase in crime, arrest rates and homelessness. It was reported that as the state hospital bed capacity reduced, the number of mentally ill homeless individuals increased. Besides the crimes and arrests associated with homelessness also increased. The results are consistent with a similar study conducted in Massachusetts, Ohio and New York in the late 1980s with findings that within six months, 27 to 38 per cent of patients discharged from the mental hospitals were homeless or had no known address homes.
The individuals with psychiatric disorders had been swept into the tide of homeliness that was due to macroeconomic shifts that included the loss of unskilled industrial employment, the rise on the service economy as well as the emerging shortage of low-income housing. The homeless epidemic among the people with a mental health condition was the unforeseen by-product of deinstitutionalization. People from the mental illness left the state-funded institutions to return home, nursing homes and other community-based homes. However, nearly half of the proposed community-based dwellings that were to replace the hospital facilities were never built and among those completed, ran into financial distress rendering a large number of the mental health patients homeless. It is projected in the future that the prevalence of the homeless psychiatric patients will be on the rise and this will be a massive problem in the treatment of the people with a mental health condition.
2. An increase in incarceration rates
As a result, 2 million people with mental illness are booked into jails each year. Nearly 15% of men and 30% of women booked into prisons have a severe mental health condition (Lurigi & Harris, 2016). Mental health conditions among the prisoners have consistently exceeded the rates of the disorders in the general population. Despite the court mandate for access to adequate health care in prisons, the treatment depends on the availability of resources available, and therefore the treatment for mental health conditions has been sporadic. The lack of sufficient community-based health treatment options has resulted in the drastic increase in the number of incarcerated individuals with mental illness. For example, the correctional facilities in New York Chicago and Los Angeles are currently among the most significant psychiatric facilities in the United States. The number of hospitalized individuals with severe mental illnesses decreased from 550,000 in the 1950s to 70,000 in the year 2012. On the contrary, the population in prison increased from 178,000 in the 1950s to around 5.6 million currently. The proportion of individuals with severe mental illness in the prisons increased from 0.7 per cent in the year 1880 to 21percent in 2005. The number of incarcerated individuals with psychiatric conditions is also on the rise, and the biggest problem is resulted due to homelessness.
3. An increase in avoidable emergency room visits
Mental conditions in the United States are common. Between 2007 and 2011, the rate of ED visits related to M/SUDs increased by over 15 per cent (Canady, 2017). ED visits involving M/SUDs are considered potentially avoidable—if these conditions were adequately managed through appropriate outpatient care, then ED visits should be rare (Owens et al. 2017). The rate of emergency department visit per 100,000 population related to mental and substance abuse use conditions increased between 2006 and 2013, with the highest increase being evident among the mental health disorders with 55.5 per cent being on depression, stress reactions and anxiety; 52 per cent was for psychoses or the bipolar disorders while substance use disorders accounted for 37 per cent. Between 2006 and 2013, an increase in the population rate for the emergency department visits involving the M/SUDs was more common among the lowest income communities with an increase of about 40.8 per cent substance use disorders to 79 per cent for the mental disorders such as depression, stress reactions and anxiety. The trends on the EDs that are preventable are on the rise, and therefore this possesses a significant challenge in the treatment of the mental disorders.
Implementation
Policy Analysis on the problem of mental health care being inaccessible needs to happen fast as people are falling victim to their untreated mental health illnesses. Mental health illness is a contributor to other negative events that are occurring in our country. By addressing the mental health of our citizens, we are giving people the ability to continue their pursuit of happiness in this country. Inaccessibility to Mental health in a public health crisis where the cure can be found through policy analysis. We ask that you allot funding to research the best practices to address the challenges outlined in this memo. Exploration and implementation cannot be done without support from your legislation.
Reference
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Fakhoury, W., & Priebe, S. (2002). The process of deinstitutionalization: an international overview. Current Opinion in Psychiatry, 15(2), 187-192.
Follette, W. T., & Cummings, N. A. (2016). Psychiatric Services and Medical Utilization in a Prepaid Health Plan Setting II. In Psyche’s Prophet (pp. 47-59). Routledge.
Jansen, J. M., du Preez, M., Exner, R., & Stroud, L. (2017). A guiding framework for the development of a trans-disciplinary community mental health student teaching and learning platform. South African Journal of Higher Education, 31(6), 218-242.
Katz, I. (2014). Stigma: A social psychological analysis. Psychology Press.
Linehan, M. M. (2018). Cognitive-behavioral treatment of borderline personality disorder. Guilford Publications.
Lurigio, A. J., & Harris, A. J. (2016). Inmates with serious mental illnesses. Advancing Criminology and Criminal Justice Policy, 355-69.
Strauss, A. L. (2017). Psychiatric ideologies and institutions. Routledge.
Wright, J. (2017). Address unknown: The homeless in America. Routledge.
