Psychiatry’s Role in Fighting Barriers to Access and Coverage

Countless times, I have witnessed an individual poised on the threshold of the hospital entrance taking deep breaths. It takes a lot for someone to seek help for a mental or addictive disorder.

The statistics tell us that the prevalence of these disorders is great. One in every five adults experienced a mental illness in the past year, with about 5% of the adult population suffering from serious mental illness, according to the Substance Abuse and Mental Health Administration (SAMHSA).1

Yet very few people in need ever get connected to treatment. Only about 4 in 10 people (39.2%) experiencing any mental illness in 2013 received any mental health service. More surprisingly, 31.2% of those experiencing serious mental illness received no mental health services at all, according to SAMHSA.2

So, when people in a crisis with a psychiatric or substance use condition take the step of seeking help, they should be able to access care for their illness, just as they would for any other disorder.

The good news is that more Americans now have more coverage for mental health and substance use disorders thanks to two major federal laws:  The Mental Health Parity and Addiction Equity Act (better known simply as the parity law) and the Affordable Care Act (ACA). The parity law eliminates treatment and financial limits in most health insurance plans. And the ACA requires that “mental health/substance use” be one of 10 “essential health benefits” in all of the plans offered on health insurance exchanges and in Medicaid plans in states that expanded the program under the law.

In addition, more young people (ages 19 to 25) are now using health services (including mental health services) following the 2010 implementation of an ACA provision that allows them to remain on their parents’ health insurance plans.3

But as those of us who work in psychiatric health systems know, there are far too often lingering barriers to both access and coverage for mental health and addiction treatment. As access to needed care still lags, lives are at risk.

Every day in communities across the country, the problem of access to care has bubbled up to make headlines. Suicide remains the second leading killer of Americans ages 15 to 34.  Drug overdoses kill more people than traffic fatalities or gun homicides and suicides. And more soldiers die of suicide than to the enemy.

But as this is happening, the number of beds available to treat the most seriously ill has dropped precipitously nationwide as state hospitals have closed. And people who need services run into statutory barriers that continue to limit their access to necessary care.

As psychiatrists — and particularly for those who serve the most severely ill — we have an important role to play in changing the environment so that access can be improved. Some of the barriers that we can help to tackle most directly are in place because of law or regulation.

In Medicaid, the “Institutions for Mental Disease” (IMD) exclusion penalizes the disabled and poor. It prevents adults (ages 21-64) from accessing short-term acute care in psychiatric hospitals with more than 16 beds. This IMD policy adds to system inefficiencies and adds to the cost of care.