Mental Health Insurance: Unaffordable For Many

Mental health issues affect a large number of people, with nearly 1 in 5 Americans suffering from some form of mental illness. However, accessing mental health services can be challenging due to financial barriers. In the US, the cost of mental health treatment can be prohibitively expensive, even more so than physical health costs. This is a significant issue as it prevents people from receiving the care they need. According to a survey, over half of the respondents cited cost as a reason for not seeking treatment for mood disorders. Financial barriers to mental health care are not limited to the uninsured; even those with private insurance can face high out-of-pocket costs. This is due to the low reimbursement rates for mental health providers, resulting in a majority of therapists and psychiatrists being out-of-network for many insurance plans. As a result, people with mental illnesses often have to seek out-of-network care, incurring high costs.

The cost of mental health services

Insurance Coverage

People with mental health issues are less likely to have health insurance than those without. In the US, around 37% of working-age adults with severe mental illness were uninsured for at least part of the year, compared to about 28% of those without. Even with insurance, people with mental health issues may face high out-of-pocket costs, with around 14% of working-age patients with mental disorders having out-of-pocket expenditures exceeding 20% of family income annually.

Cost of Treatment

The cost of mental health treatment and services reached $225 billion in 2019 in the US, a 52% increase since 2009. This includes spending on therapy, prescription medications, and stays in psychiatric or substance abuse rehabilitation facilities. An hour-long therapy session can range from $65 to $250 for those without insurance, and a patient with major depression can spend an average of $10,836 a year on health costs.

Access to Care

Access to mental health care is improving but remains an issue, particularly in rural areas. Many providers operate outside the health insurance system, so patients have to pay out-of-network rates, which can be very expensive. Only about 56% of psychiatrists accept commercial insurance, and those seeking mental health care are over five times more likely to seek out-of-network care. As a result, many people with mental health issues do not receive treatment, with approximately 56% of American adults with a mental illness not receiving treatment.

Alternative Options

There are some alternative options for those who cannot afford mental health care. These include:

• Seeking in-network care first, or turning to Federally Qualified Health Centers, which are community-based and government-funded.
• Contacting local training institutes, which may provide free sessions for up to two years.
• Reaching out to university hospitals, which often offer low-fee sliding-scale psychotherapy.
• Contacting state or local community health departments, which may offer counseling based on need and financial situation.
• Trying alternative remedies such as acupuncture, massage, dietary changes, or nutritional supplements.
• Seeking treatment through a primary care provider, who can help manage symptoms with medications and regular check-ups.

Lack of insurance coverage

The high cost of mental health services is a significant barrier to accessing care for people with mental health issues. While the 2008 Mental Health Parity and Addiction Equity Act barred health insurers from making coverage for mental health more restrictive than for physical ailments, there are still many loopholes, insurance complexities, and out-of-pocket costs that hinder access to affordable care.

People with mental illness are less likely to have health insurance than those without mental health issues. In the US, 37% of working-age adults with severe mental illness were uninsured for at least part of the year, compared to about 28% of people without severe mental illness. Even with insurance, high copays and deductibles, limited provider options, referral requirements, restricted visit numbers, and spotty prescription coverage can create barriers to care.

The percentage of people forgoing mental health treatment due to cost may be increasing. In 2018, about 5.8% of American adults believed they had an unmet need for mental health services during the previous year, up from 4.7% in 2015. Cost was the most commonly cited reason for not receiving needed services in 2018, mentioned by 39% of people. This figure is lower than in 2008, when 45% of people cited cost as a barrier, but other obstacles to care have increased since then.

In the US, Medicaid is the largest single payer for mental health services, and it offers some protection against financial barriers to care for low-income adults and disabled people. However, Medicaid has limitations, such as a 190-day lifetime limit on psychiatric inpatient care, and it covers only about 23% of psychiatrists in the country.

The Affordable Care Act has expanded parity provisions and specified that mental health and substance abuse services are essential health benefits. It is estimated that, if fully implemented, the act could provide coverage for around 3.7 million adults with severe mental illness. However, the state Medicaid expansions are optional, and as of 2013, 24 states had decided not to implement them.

Strategies for Improving Access to Mental Health Care

To improve access to mental health care for those without insurance or with inadequate coverage, several strategies can be considered:

• Contacting local training institutes, psychoanalytic training institutes, or university hospitals, which may offer free or low-cost therapy provided by interns or residents.
• Seeking treatment from mental health practitioners in training, who often offer discounted rates to accumulate the required number of hours for licensing.
• Visiting sliding-scale clinics, which offer treatment based on a sliding-scale fee system adjusted according to need, with fees as low as $10 or $20.
• Contacting state or local health departments, which may provide counseling based on need and financial situation.
• Exploring alternative remedies such as acupuncture, massage, dietary changes, or nutritional supplements like magnesium, which have shown some promise in alleviating mental health symptoms.
• Consulting primary care providers, who can treat mild to moderate mental health symptoms and may be able to help manage symptoms with medications and regular check-ups.

Financial barriers to receiving care

The cost of mental health treatment is a significant barrier to accessing care for people with mental health problems. Financial barriers are a major impediment to receiving needed care, and people often cite concerns about the cost of care or lack of health insurance coverage as reasons for not seeking mental health treatment.

In the United States, the cost of mental health treatment and services reached $225 billion in 2019, with spending on therapy, prescription medications, and stays in psychiatric or substance abuse rehabilitation facilities. Access to care can be prohibitively expensive, even more so than physical health costs. An hour-long traditional therapy session can range from $65 to $250 for those without insurance. A patient with major depression can spend an average of $10,836 a year on health costs, while a person with diabetes taking insulin spends around $4,800 in comparison.

Insurance coverage is also a factor in the financial barriers to mental health care. People with mental illnesses are less likely to have health insurance than those without mental health issues. Even with insurance, cost-sharing can disproportionately affect people with mental illness, who often have lower family incomes and are more likely to live in poverty. Out-of-pocket costs for mental health care can be high, with approximately 14% of working-age patients with a mental disorder having out-of-pocket expenditures that exceed 20% of family income annually.

Recent trends in the insurance market, such as a drop in employer-sponsored health insurance coverage and an increase in cost-sharing, have further exacerbated cost barriers to mental health care. Additionally, there are many medical and insurance loopholes that make it difficult for patients to access affordable care. For example, mental health and substance use treatment centers tend to be concentrated in urban areas, leaving rural parts of the country with limited access to specialized treatment options.

The impact of financial barriers to mental health care is significant. Many people with mental illnesses do not receive treatment, and even those who do may struggle to continue their treatment due to cost. This can lead to poor management of mental illness and further negative consequences.

Difficulty finding a provider

While affordability is still a top barrier to mental health care, difficulty in finding a provider is also a significant obstacle. According to a survey by the National Alliance on Mental Illness, nearly half of respondents were unsure if they were eligible to receive care or how to access services.

In the US, insurers' directories of in-network mental health providers are often inaccurate or out of date, and it's not uncommon to find providers listed who have retired, moved away, or passed away. As a result, people with mental illness are often forced to seek out-of-network care, which can be extremely expensive or even unaffordable.

The shortage of mental health professionals accepting insurance is due in part to historically low reimbursement rates for mental health providers compared to physical health providers. This has resulted in a large proportion of therapists and psychiatrists practising outside of insurance networks. In-network providers are often overworked and have long waitlists.

Additionally, mental health and substance use treatment centres and clinics tend to be concentrated in urban areas, leaving rural parts of the country with limited access to specialised treatment options. More than 112 million Americans live in areas where mental health providers are scarce, and it is predicted that the US will continue to experience a shortage of mental health professionals through 2025.

These difficulties in finding a provider contribute to the challenge of accessing affordable mental health care, impacting individuals' ability to receive timely and effective treatment.

The impact on physical health

The lack of access to mental health services due to unaffordable insurance has a significant impact on physical health. Untreated mental health issues can lead to worsening comorbidities, which are medical conditions that occur simultaneously with mental illness. This can include physical health problems such as cardiovascular disease, diabetes, or chronic pain conditions. When individuals are unable to access mental health treatment, their physical health conditions may also be left unmanaged, leading to poorer health outcomes and increased healthcare costs.

The relationship between mental and physical health is complex and bidirectional. Mental health conditions can impact physical health, and physical health conditions can contribute to or exacerbate mental health issues. For example, individuals with depression are at an increased risk for developing cardiovascular disease, and those with chronic pain conditions may experience anxiety or depression as a result of their physical pain. When mental health services are out of reach due to insurance affordability issues, the physical health of individuals is also affected.

The consequences of unaffordable mental health insurance can be seen in increased disability and unemployment rates. Mental illness that goes untreated or undertreated can lead to functional impairments, making it difficult for individuals to maintain employment. This, in turn, can lead to a loss of insurance coverage, creating a cycle of unmet mental health needs and physical health deterioration. Additionally, untreated mental illness has been linked to poorer physical health outcomes, including increased risk of fatal overdoses and poorer management of chronic physical conditions.

The impact of unaffordable mental health insurance is particularly pronounced in certain populations. For example, Black Americans face higher barriers to accessing mental health treatment and have lower rates of accessing care compared to White Americans. This disparity contributes to health inequities and worsens physical health outcomes in an already disadvantaged population. Furthermore, individuals with mood disorders, such as depression or bipolar disorder, often struggle with unemployment and lack of insurance, further exacerbating the challenges of managing their mental and physical health.

The COVID-19 pandemic has also shed light on the impact of unaffordable mental health insurance on physical health. During the pandemic, rates of depression and anxiety increased significantly, and suicidal ideation more than doubled. The inability to access mental health services due to cost concerns has likely contributed to worsening physical health for many individuals. Integrated primary care models that co-locate mental health professionals within primary care settings may help address this issue by improving access to mental health services and promoting better physical health outcomes.

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