Access to equal benefits and qualified providers remains difficult for many insured Americans, despite the Mental Health Parity and Addiction Equity Act of 2008, according to a recent health policy brief.1
Access to mental healthcare is “a question of social justice,” according to Brendan Saloner, PhD, an assistant professor at Johns Hopkins Bloomberg School of Public Health in Baltimore. “There is some evidence that the law has eliminated discriminatory practices in insurance plans,” he adds.
Stigmatization is one reason for underutilization of mental health treatment. The perception that people who disclose being treated for a mental health problem will be perceived as an outcast or dangerous persists, says Saloner. “There is a lot of rhetoric out there connecting people with mental health problems as violent, and this rhetoric is not based in reality,” he adds.
Access to mental healthcare is a multifaceted problem which remains difficult to solve. “There are some promising developments in the mix. But there are also some big challenges that have not been addressed,” Saloner says.
Only 41% of adults in the U.S. with a mental health condition received mental health services in 2014, according to the Substance Abuse and Mental Health Services Administration.2 “We have a huge evidence-based mental health access problem,” says John T. Walkup, MD, director of the Division of Child and Adolescent Psychiatry, Weill Cornell Medical College and New York-Presbyterian Hospital, both in New York City. Insufficient provider expertise and availability, stigmatization of mental health problems, and insurance barriers such as pre-authorization requirements all contribute to the problem, he says.
In the process of ensuring that mental health services are appropriate and necessary, “insurers willingly or unwillingly create access barriers,” says Walkup. “Accessing mental healthcare is difficult for people anyway. When they make it harder, it’s a problem.”
Insurers have the responsibility to pay for needed services, but the lack of evidence-based standards makes it difficult to determine what services to reimburse for, explains Walkup. Also, many mental health providers do not accept insurance coverage, due to most insurers’ low fee structure.
“Preauthorization requirements for medications and ongoing review of treatment, while perhaps necessary, becomes limiting, restrictive or disruptive to necessary care,” adds Walkup.
There is a need to ensure clinicians are consistently trained in evidence-based behavioral health practices, and to decrease the variability in the training provided by graduate programs, says Patricia A. Arean, PhD, professor of psychiatry at Seattle-based University of Washington.
“Some train very well in evidence-based practices, while others do not,” she explains. “It’s an ethical obligation of our education and licensing systems to make sure clinicians are prepared.”
Poor access to evidence-based mental healthcare “comes up a lot, but it never comes up in the ethical context. It usually comes up as a training issue,” says Walkup. Professional schools do not necessarily train to evidence-based standards, he explains, and licensing bodies do not require demonstration of capacity to implement evidence-based interventions.
“We have evidence-based standards, but we don’t consistently train people to those standards,” says Walkup. “We don’t have systems that require providers to practice consistent with the evidence base.”
There is a need to determine if people are getting the high-quality behavioral health interventions, according to Arean. “We really don’t have an oversight body that says, ‘These are the things you need to train your clinicians,’ or where a patient can get advice on what evidence-based treatments are available,” she says.
A recent report from the National Academies of Sciences, Engineering, and Medicine presents a framework to establish efficacy standards for psychosocial interventions used to treat individuals with mental disorders, including addictive disorders.3
“The report has many excellent recommendations for how to improve the quality of psychotherapy delivered in the U.S.,” says Arean. “But it will only have a positive impact if those recommendations are put into action.”
Arean points to the U.K.’s significant investment in increasing access to mental health services and training the workforce in evidence-based practices. “We don’t need to reinvent the wheel,” she says. “We know how to improve the quality of care. It’s being done in other countries.”
With behavioral health interventions, says Arean, “it’s very hard to measure what we do. We need pragmatic ways to measure quality of care.”
Bioethicists can play a role in ensuring ethical mental healthcare in the following ways, Saloner suggests:
- Ensuring their own institutions have policies in place that are inclusive of patients with mental health needs. This includes ensuring that health systems’ own insurance plans include comprehensive coverage for mental health services, and that workplaces have policies that allow individuals to seek mental health treatment without jeopardizing their employment.
- Publicly voicing ethical concerns about access to mental healthcare. “Provide a vision of what a humane, equitable, and inclusive system would look like,” he advises.
- Sharing anecdotal stories of patients who were helped by access to quality mental healthcare. “The public responds to hopeful narratives which help them to understand how particular people can benefit from mental health treatment,” says Saloner.
- Goodell S. Health policy brief: Enforcing mental health parity. Health Affairs, November 9, 2015.
- Substance Abuse and Mental Health Services Administration. Results from the 2014 national survey on drug use and health: Mental health findings. HHS Publication No. (SMA) 15-4927. Rockville, MD: 2015.
- Institute of Medicine. Psychosocial interventions for mental and substance use disorders: A framework for establishing evidence-based standards. Washington, DC: The National Academies: 2015.
- Patricia A. Arean, PhD, Professor of Psychiatry, Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle. Email: firstname.lastname@example.org.
- Brendan Saloner, PhD, Assistant Professor, Johns Hopkins Bloomberg School of Public Health, Baltimore. Phone: (410) 502-2116. Email: email@example.com.
- John T. Walkup, MD, Division of Child and Adolescent Psychiatry, Weill Cornell Medical College/New York-Presbyterian Hospital, New York City. Phone: (212) 746-1891. Fax: (212) 746-5944. Email: firstname.lastname@example.org.