Mental Health Crisis Demands Better Coverage, Worker Pay, Experts Tell House

More Americans are battling mental health issues now than before the pandemic. But solutions are in sight, even though workforce shortages and other barriers persist, expert witnesses in public health, child welfare, and the law assured members of Congress.

"There's no denying the pandemic has exacerbated the mental health crisis," said Richard Neal (D-Mass.), chair of the House Ways & Means committee, during a hearing on Wednesday.

Before COVID-19, one in 10 American adults reported an anxiety or depressive disorder, but recently those numbers have jumped to four in 10, Neal said.

Perhaps more troubling is the fact that those seeking help are waiting months for appointments and struggling to find in-network providers due to workforce shortages and insurers flouting longstanding mental health parity requirements.

"[T]he current state of our mental health system is unacceptable," the chair concluded.

In its most basic form, Rep. Mike Kelly (R-Pa.) said the problem is this: "We have more people who need help than we have people who can help them."

While he acknowledged that mental health issues impact almost every American family, he appeared frustrated with the idea that it's Congress's job to fix the problem.

Kelly wondered aloud where the idea came from "that somehow we have this magic wand that all we have to do is wave it, and we all of a sudden ... get the money to the right places at the right time and the right amount, and we encourage people to go into a business that they never thought of before," he said, referring to healthcare. "I don't know that we can get a handle on this. The volume of what we need is just not there."

Looking to the witnesses, he asked, "What is it that you think we should do?"

Deepa Avula, MPH, director of the North Carolina Department of Health & Human Services' Division on Mental Health, Developmental Disabilities, and Substance Abuse Services, said that the problem can't be fixed overnight, but reminded the congressman that there are "70-plus million Americans out there that depend on us to try to fix it."

As for incentives, she pointed to the loan repayment programs under the Health Resources and Service Administration that can help draw more workers to the field.

But Avula encouraged Congress not to "stop there," because people may just fill the positions then leave. It's also critical to pay wages commensurate with the work, she said.

She urged Congress to also look at psychologists, social workers, counselors, peer support specialists, and marriage and family therapists -- all of whom make up a large share of the mental and behavioral health workforce -- and ensure there aren't administrative barriers for them to get paid.

And because specialists alone can't fix the problem, it's important to expand "cross-training" of primary care and other healthcare providers, she said.

The Substance Abuse and Mental Health Services Administration (SAMHSA) has invested in training and technical assistance programs, but Avula suggested to "double, triple, quadruple that investment to make sure that individuals are getting trained."

It's also important to "mainstream" trainings and make sure that schools include behavioral health in the curriculum, she said. This would help eliminate stigma "on the front end" that prevents some providers from treating individuals in need, said Avula.

But workforce shortages aren't the only problem, noted Deborah Steinberg, JD, a health policy attorney at the Legal Action Center.

Unlike Medicaid and private insurance, Medicare was excluded from the 2008 Mental Health Parity and Addiction Equity Act, which requires that mental health services be reimbursed on par with physical health services.

As a result of this flaw in the framework, Americans who turn 65 in some cases lose access to treatment and services. The program covers the most intensive and least intensive options, but does not reimburse for intermediate-level services, she said.

Financial barriers, including lack of insurance coverage, are one of the main reasons Medicare beneficiaries report not getting needed treatment, Steinberg said, citing the National Survey on Drug Use and Health.

Rep. Judy Chu (D-Calif.) a psychologist, echoed these concerns: "We know that mental illness and addiction do not stop suddenly at age 65, and so neither should our health policies."

If Medicare were covered by the mental health parity law, it would be a violation for insurers not to cover the full evidence-based continuum of care, Steinberg said.

It would also be a violation of the law to limit coverage of providers and facilities that address mental health and substance use disorder issues, she added.

Additionally, Medicare Advantage plans would be required to meet "comparable network adequacy standards and practices," Steinberg said, and plans would not be able to enact "stricter utilization management practices" for mental health and substance use services.

"Perhaps most importantly, reimbursement rate-setting practices would need to be comparable for mental health and substance use disorder services," Steinberg added, "so we'd finally be paying these providers the rates they need to treat their patients."

Chu said she is working with the Legal Action Center to close these coverage gaps in the Medicare program.

She has also introduced the "PEERS in Medicare" bill to "define peer support specialists in the federal statute" and underscore that there is no law to prevent credentialed individuals with lived experience of a mental or behavioral health problem from being included in the Medicare psychiatric care collaborative.

Including peers on care teams can help providers reach more patients, Chu added.

Steinberg agreed, noting that data have found that peer support specialists reduce hospital admission rates, increase social support, and decrease substance use and depression.

"They help people engage in services..., manage physical and mental health and substance use disorder conditions, build support systems, and live self-directed lives in their communities," she said.

While most states allow Medicaid to reimburse peer support services, Steinberg noted, this is one more example of the services beneficiaries lose when they turn 65 or become eligible for Medicare.

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