Policy Changes, Advocacy Are Key Components in Closing Gaps in Behavioral Health

The American Journal of Accountable Care. 2024;12(2):In Press

Behavioral health, which includes mental health disorders and substance use disorders, has been in the spotlight in numerous policy discussions as the COVID-19 pandemic shed light on mental health amid reports of worsening mental health among many Americans. A poll conducted by KFF and published in March 2023 found that both symptoms of anxiety and depression and deaths due to drug overdose increased during the pandemic.¹ This also coincided with an increased rate of suicide since 2021.¹

Although the Biden administration has announced funding opportunities for grants² and the intention to require the provision of mental health and substance use disorder care at community health centers as part of its budget,³ there are still major gaps in getting care covered while making it affordable and accessible. Experts who spoke with The American Journal of Accountable Care^® (AJAC) explained what these gaps look like and how policy and advocacy can play a part in closing them across the US.

Behavioral Health Gaps and Who They Affect

Treating individuals with mental health or substance use disorders has been difficult in the past but has become even more so after the pandemic, according to experts. Physician and therapist shortages have left behavioral health care vulnerable, even with increased use of telehealth in these areas.

“One of the biggest challenges is that most people don’t really think about the health care system until they need it, and the mental health and substance use system is even then 1 step removed,” Charles Ingoglia, MSW, CEO and president of the National Council for Mental Wellbeing (NCMW), told AJAC. “An initial barrier [to treatment] is that people, when problems emerge, really don’t understand where to go for treatment.”

Limited access to behavioral health care is one of the primary reasons individuals call the helpline run by the National Alliance on Mental Illness (NAMI), according to Jennifer Snow, MPA, the organization’s national director of government relations, policy, and advocacy. “We hear from hundreds of thousands of people, and the vast majority are calling because they cannot find a provider to treat them. They cannot get access to care and are trying to understand what resources might be available to them to…bridge that gap,” she said.

The lack of access to behavioral health care is often compounded either by patients not being able to afford the care or their insurance not covering the care. According to the American Psychological Association, the mental health parity law requires that all mental health and substance use care be covered comparably to physical health.⁴ However, not only are most patients unaware of this law, but Medicare is not subject to this law, and insurance plans for teachers and employees of state universities can opt out.⁴

“In a strange way, I would suggest that, especially if you have a mental illness, you either want to be really rich or really poor,” Ingoglia said. “Because if you’re really rich, you can pay out of pocket; if you’re really poor, you have Medicaid. And Medicaid has, in most states, the best benefit for mental health services.”

Medicare, however, does not have the same benefits as Medicaid. Ingoglia noted that most of the benefit structure of the Medicare program was established in 1965 and based on the Blue Cross Blue Shield policy of the time, which did not include mental health. This has left a noticeable gap in treatment for older adults in the US; the interventions available to them may include just outpatient therapy, limited inpatient therapy, and medication management, according to Ingoglia. Private insurance is often not better, he said, which can lead to providers not accepting commercial insurance.

A report published in April 2024 found that out-of-network care was used 3.5 times more when using a behavioral health clinician compared with surgical and medical clinicians, with the financial burden primarily falling on patients.⁵ Patients were also found to go out of network 10.6 times more often to see a psychologist compared with a medical or surgical specialist.⁵ This disparity was found across several years from 2013 to 2021.

These gaps affect not only patients but also clinicians. Snow noted that mental health providers were reimbursed approximately 23.8% less than primary care providers when providing the same services, even with parity laws in place that should make payments for behavioral health care equal to those for physical health care.

“And to me, it is illustrative then of all the downstream effects,” she said. “[It’s] why many psychiatrists don’t take insurance at all, because they’re not paid adequately. It’s why people can call around to providers for days at a time before they find someone who is accepting new patients and takes their insurance.”

Snow also noted the lack of diversity in psychologists providing behavioral health care, with approximately 84% of psychologists in the US identifying as White. Peer support workers can help to bridge the gap in diversity, but Medicaid does not reimburse for adult mental health peer support in 14 states or adult substance use peer support in 16 states.⁶

All this demonstrates the challenges in not only providing behavioral health care but also making sure patients can afford the care once they find it. To close these gaps, both experts highlighted the need for continued advocacy.

Advocacy for Policy: Goals and Challenges

Advocating for new and improved policies to update the current guidelines for behavioral health coverage is a cornerstone to addressing the state of behavioral health.

Ingoglia said that NCMW often concentrates on making sure the mental health parity law is enforced across the US on the private insurance side, as he said that full implementation of that law needs further work to be completely achieved. On the Medicare side, he said, trying to get more therapists reimbursement for services is a major goal.

“Congress finally approved licensed professional counselors and marriage and family therapists to be reimbursable in Medicare [2 years ago]. We worked on that for 25 years,” Ingoglia said. “So that was not an instant success, right? It was many, many years of advocacy that led to that.”

Ingoglia said the NCMW’s biggest success on the Medicaid side was in establishing certified community behavioral health clinics, which would provide similar treatment for mental health and substance use disorders anywhere in the country, primarily in the form of evidence-based care.

“Part of the idea behind certified community behavioral clinics is that we have a minimum standard of care available and…that there are requirements around care coordination and support and community engagement,” he said.

Snow said that NAMI is primarily focused on increasing the accessibility of behavioral health, including by advocating for the enforcement of the mental health parity law and for its renewal.

“The Biden administration recently proposed updated regulations related to the mental health parity law that would put some additional teeth into enforcement, [and] NAMI has been hugely involved in advocating for the administration to finalize those proposals,” Snow said. “[We] are now continuing that advocacy to push back on the health insurance plans, who will tell you that the sky will fall if the administration [were] to finalize these proposals.”

Advocacy, the experts said, comes with several challenges. The time that it takes for lawmakers to implement ideas from advocates or even renew existing laws can span decades.

“If you think about a typical session of Congress, about 2% of the bills that get introduced get passed, so it takes a long time, just in general, for things to happen,” Ingoglia said.

Both Ingoglia and Snow also said that, historically, mental health has not been a priority of the government, in terms of both policy and investment, even if some of that has changed since the pandemic. For example, Ingoglia noted that there had been no hearings on mental health in the Senate for 20 years prior to a hearing in 2007. Snow said that mental health has become a bipartisan issue, as both Democrats and Republicans tend to agree about the fundamental concept of bills or policy but are often hesitant about the amount of money that a policy or initiative would take.

“When you have something that costs a lot of money, you sometimes have members of Congress who don’t prioritize spending on that issue as much as another issue,” Snow said. “And then you have the reality that health insurance companies—spoiler alert—are better funded than the nonprofits like [NCMW] and NAMI, and they give money to political candidates.”

These realities often leave advocates working on a single issue for years before seeing notable results, which is a significant challenge to addressing the bigger issues of parity in coverage and expanding access to a variety of treatment methods.

Closing the Gaps: What More Can Be Done?

Although progress is slow, there have been some developments that benefit behavioral health. The Biden administration announced in March 2024 that it would use $39.4 million for grant funding opportunities.² These opportunities included a program that aims to reduce alcohol use in individuals aged 12 to 20 years, a program that implements new assisted outpatient treatment programs to help adults with severe mental illness, and a program that promotes integration and collaboration between primary care and behavioral health. This comes after the administration announced funding of more than $70 million in November 2023.

Ingoglia noted that, although the investment into the space is encouraging, it’s difficult to build capacity among mental health providers with grants that last only 1 to 3 years. “How do we build capacity in existing structures? Grants can enhance whatever’s happening there, but we need to really look at the core,” he said.

He also noted that sharing information between primary care and specialty mental health physicians is an important component of caring for patients, “because we want people not just to receive care, but we want people to receive effective care.”

Snow spoke about the Biden administration’s attempt to strengthen mental health parity through new regulations⁷ that would require health plans to provide adequate access to mental health services, close existing loopholes, and make clear that health plans cannot employ more restrictive medical management techniques to make it more difficult to access behavioral health compared with physical health.

The rules, which were introduced in July 2023 and could be approved later in 2024, have received praise from mental health advocates, including NAMI, with Snow commenting they would “hold insurance companies’ feet to the fire.” However, stakeholders aligned with health insurers, including AHIP and Blue Cross Blue Shield Association, have criticized the rules as written, saying that they would not lead to enhanced access to mental health services and would instead lead to higher costs.^8,9

“Fundamentally, we live in a society that delivers health care in a for-profit way, [which] creates different incentives that don’t always mean that the patient is prioritized,” Snow said.

The closing of behavioral health gaps can be a long process due to pushback from insurance companies and elected officials. However, progress can still be made in this area with persistent work, not only from advocates and nonprofits but also from constituents voicing support for proposed policy changes. Although the time to change can be long, making sure that these gaps are addressed at all is the crux of the work done by groups such as NCMW and NAMI as they press for policy and legislative changes.

Author Information: Ms Bonavitacola is an employee of MJH Life Sciences^®, parent company of the publisher of The American Journal of Accountable Care.

Editor’s Note: Ms Snow, who was interviewed for this article, is a relative of Ms Bonavitacola.

REFERENCES

1. Panchal N, Saunders H, Rudowitz R, Cox C. The implications of COVID-19 for mental health and substance use. KFF. March 20, 2023. Accessed April 17, 2024. https://www.kff.org/mental-health/issue-brief/the-implications-of-covid-19-for-mental-health-and-substance-use/

2. Biden-Harris administration announces $39.4 million in funding opportunities for grants to help advance the president’s unity agenda. News release. HHS; March 22, 2024. Accessed April 17, 2024. https://www.hhs.gov/about/news/2024/03/22/biden-harris-administration-announces-39-4-million-funding-opportunities-grants-help-advance-presidents-unity-agenda.html

3. Biden-Harris administration fiscal year 2025 budget tackles youth mental health crisis, maternity care deserts, gaps in access to primary care. News release. Health Resources & Services Administration; March 2024. Accessed April 17, 2024. https://www.hrsa.gov/about/news/press-releases/fy-2025-budget

4. Does your insurance cover mental health services? American Psychological Association. 2014. Accessed April 17, 2024. https://www.apa.org/topics/managed-care-insurance/parity-guide

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6. State mental health agency peer specialist workforce, 2022: NRI’s 2022 state profiles. NRI. December 2022. Accessed April 17, 2024. https://www.nri-inc.org/media/4dzhgyv1/peer-specialists_final.pdf

7. Fact sheet: Biden-Harris administration takes action to make it easier to access in-network mental health care. News release. The White House; July 25, 2023. Accessed April 17, 2024. https://www.whitehouse.gov/briefing-room/statements-releases/2023/07/25/fact-sheet-biden-harris-administration-takes-action-to-make-it-easier-to-access-in-network-mental-health-care/

8. Minemyer P. Payers pan Biden admin’s proposed rules on mental health parity. Fierce Healthcare. October 19, 2023. Accessed April 17, 2024. https://www.fiercehealthcare.com/payers/payers-pan-biden-admins-proposed-rules-mental-health-parity

9. Hansard S. Mental health parity rule spurs employer angst as costs grow. Bloomberg Law. February 5, 2024. Accessed April 17, 2024. https://news.bloomberglaw.com/daily-labor-report/mental-health-parity-rule-spurs-employer-angst-as-costs-grow