A Reflection on America's Healthcare System and What It Means For The Mentally Ill
Three months. I had to wait three months to see a specialist in Michigan, and I was told that I was lucky to get in during that time-frame. I was told in the spring that my specialist wouldn’t be back until September due to maternity leave, with no other physician replacing her. As I waited, I endured intense pain and had no answers. This is just a snippet of what the healthcare system in America looks like for patients seeking help for a mental health condition.
This blog will provide an overview of what the American healthcare system can be like for those with mental illness and will reflect on upcoming changes that will hopefully help to improve the situation going forward.
Two years later I was diagnosed with Vestibular Migraines (VM), alongside my diagnoses of anxiety and depression. I had been bounced around from so many medications that my body was shutting down. I was constantly nauseous, dizzy, and anxious. I felt controlled by my depression, making the smallest task difficult. My diagnosis had changed three times and my doctors were not communicating with each other. The process was debilitating and dramatically impacted both my mental and physical health.
I am not alone.
Even prior to COVID-19, the prevalence of mental illness in the United States was increasing, with a reported 19% of adults experiencing a mental illness. In June 2020 alone, during the pandemic, up to 40.1% of adults reported a behavioural condition such as anxiety or depression. As a social worker, I see the struggles of my clients suffering with mental illness, desperately trying to get better while the system works against them.
The U.S. vs The U.K.
In other countries, particularly the U.K., healthcare is managed very differently. The accessibility is much easier and less strenuous than its U.S. counterparts. In the United States, there is no national healthcare system or universal healthcare model. Here are some of the other major differences:
Americans must purchase their insurance through their employer or through the “marketplace”, which serves as a hub for available insurance carriers for them. It goes by age and income.
Americans are charged more money if they go out of the insurance carriers’ ‘network’. Within the insurance companies’ ‘network’, they have contracted physicians, where the typical cost of a visit alone is $20-$40. If a patient needs to see an out-of-network physician, in some cases this is unpaid for by the insurance company and becomes entirely the patient’s responsibility, resulting in hundreds of dollars at the patients’ expense.
The U.K. requires patients go through their general practitioners (GPs) for mental health referrals, whereas in the U.S. patients can freely go to a mental health clinician without a referral . A referral must be provided by their Primary Care Doctor first, then the patient can schedule an appointment.
These differences play largely into how the overall idea of mental health is perceived and addressed in different countries. For instance, the United States often treats each bodily system individually in isolation, where in the U.K., the common belief is that it should be treated holistically and collectively.
Specifically to mental health, 6 in 10 Americans try at some point to get treatment for a psychiatric illness, but the market cannot meet the demand. Insurance is often a barrier here. As mental health services are typically reimbursed by the patients’ insurance at a lower rate, it often leaves healthcare providers being pickier about who they choose to see.
Medicaid and Medicare are both federally funded insurance programs, however, they do have certain eligibility criteria, such as income level or age. These programs cover 1/3 of the U.S. population. This can be problematic for people since some health care providers will deny insurances such as Medicaid because of the aforementioned low reimbursement rates and others are so busy they refuse new patients altogether.
Prescription medications for psychiatric conditions can be expensive and come with a variety of obstacles. Many controlled substance medications can only be obtained by a face-to-face visit with your physician, typically every 30 days. With Doctors being overbooked, this often creates a barrier for patients, who find their physician does not have the availability needed for these repeat prescriptions, meaning some patients are left without their medication for a period of time.
Medication costs vary widely according to insurance plan and type of medication. One of the strategies often used by physicians to overcome this financial barrier is to replace the brand-name medication with its generic version. For instance, with antidepressants, Paroxetine is then $40 for a month supply, versus its name-brand counterpart, Paxil, at $233. Despite this, the costs of psychiatric medications and the need for frequent visits (which also cost money) are still often too high leading to many patients going without medications which, in some cases, can lead to hospitalisation.
Approximately 5.1 million adults in America are uninsured, which is about 10.8% nationally. There are a few insurance options available, however, for a large number of Americans, many of these options are unaffordable.
This can be critical for mental health. If the person does not have insurance, they will not be covered and must pay the cost of care at a much higher rate. Often times, this is required at the time of the visit, meaning patients are denied the care that they need, simply because they cannot afford it.
To combat not having insurance. The Affordable Care Act created the Marketplace, which is a hub to find plans if you are not offered them in other ways. However, many report that this also costs several hundred dollars per month, despite being the only option for some Americans. Even with insurance, the nation is struggling with medical debt, with approximately 16.2% still owing for medical costs.
Lack of Transparency
The cost of care in the United States is often unknown to patients at the time they receive the treatment, as each insurance carrier offers different healthcare service coverage. This results in many Americans neglecting their mental health by not seeking professional help when they need it most. As a result, much needed healthcare services such as mental health assessments, medication reviews, and general or specific therapy are missed. A psychological assessment can be rather expensive, and while some insurances cover therapy, others do not.
But there is hope on the horizon.
On October 29th 2021, a new rule was established that requires MOST private insurers to make their rates publicly available. It remains to be seen how this will play out, as it is proposed that this information will come through three ‘data files’, which will pull information from out-of-network costs, in-network costs, and prescription drugs (including rebates or discounts). The insurers are set to begin posting prices in 2022.
Health Reform & What’s Expected
Under President Joe Biden, there are plans to lower costs in the marketplace, lower drug costs, and expand the health plans through his American Rescue Plan.
The American Rescue Plan makes subsidies more widely available for those who may not have qualified for certain insurance prior. The income cap, has been eliminated for the next few years, allowing more American’s to apply for assistance, whereas before these were strictly regulated based on income guidelines according to state. These calculations are completed by the household’s income and varies by state.
Additionally, in 2021 a qualifying life event, such as marriage, divorce, or change of employment, is no longer necessary to change your medical plan or obtain insurance, as it has been historically, outside of the annual renewal date. While all have access to the healthcare plans available nationally, this will allow individuals to have more freedom in choosing employer-based plans at any point.
The ability to have more affordable insurance and medications can be lifesaving for those suffering from severe mental health illnesses, such as depression or schizophrenia. It would allow them to see clinicians more often and obtain the prescriptions they may need at lower costs. Additionally, those who make less money would be able to qualify for insurance, opening new opportunities for getting the care they need.
These give us hope that mental healthcare will be taken more seriously and become more widely accessible.
While we are making great strides, America still has a lot to work to do.