As millions of Americans gain health coverage through the Affordable Care Act’s Medicaid expansion, experts say their higher rates of mental health and substance abuse disorders will be difficult to treat due to a lack of counselors and behavioral therapists who accept Medicaid patients.
In the District of Columbia and the 25 states where the expansion is under way, nearly 1.2 million uninsured adults newly eligible for coverage will have substance abuse problems, according to federal estimates, and more than 1.2 million are projected to have some sort of mental illness. An estimated 550,000 of those will have serious mental disorders that impair their everyday functioning.
As these patients seek treatment for any number of problems, a shortage of caregivers – from physicians to dentists – will pose a major challenge for Medicaid, the federal-state health program for poor people and those with disabilities. The lack of providers may be most acute in the area of mental health services.
The Medicaid expansion extends coverage to adults who earn up to 138 percent of the federal poverty level. Those with behavioral problems will be treated at community mental health agencies and health centers that serve low-income patients. This new expansion population will strain the limited resources of these facilities, many of which already have staff shortages and waiting lists for behavioral treatment.
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Further complicating the problem: Most mental health therapists in private practice won’t treat Medicaid patients because of the program’s low reimbursement rates.
And now that the health care law has made mental health treatment a mandatory, or “essential,” benefit for millions of people with private coverage, the demand for therapists and counselors will increase, making it even harder for Medicaid’s community-based providers to recruit and retain behavioral health professionals.
“As more people are insured, more people are also going to be seeking services,” said Rusty Selix, the executive director of the California Council of Community Mental Health Agencies. “Our biggest concern is more competition for a limited number of professionals and the cost pressures that’s going to create. We’re going to have to pay more to retain people. It’s supply and demand.”
Already, the demand far outstrips the supply.
Nearly 91 million Americans live in federally designated mental-health-professional shortage areas, where there’s only one psychiatrist for at least every 30,000 residents. That’s compared with only 59.4 million who live in primary-medical-health-professional shortage areas and 46.7 million who reside in dental-health-professional shortage areas.
Fifty-five percent of U.S. counties – all of them rural – have no psychiatrists, psychologists or social workers, according to the U.S. Department of Health and Human Services.
Filling the needed positions nationally would take 1,846 psychiatrists and 5,931 other professionals, federal estimates show.
“That’s a critical problem. And the Medicaid expansion will make that even worse,” said Susan Mandel, the CEO of Pacific Clinics, the largest community mental health agency in Southern California.
Joel Miller, the executive director and CEO of the American Mental Health Counselors Association, said he was expecting to see “pretty significant increases” of 20 to 25 percent in the numbers of psychologists, mental health counselors, social workers, and marriage and family therapists over the next five years, based on student enrollment trends.
“I’m very much an optimist,” he said. “But sure, if you look at the current capacity, there are holes. There are gaps in inner cities and in rural areas.”
Most of the expansion enrollees will be single, childless adults, a group that Medicaid traditionally has declined to cover. Among this group, military veterans, the homeless and former jail inmates are expected to have higher rates of mental illness.
For many, the Medicaid expansion will provide their first opportunity for health coverage as adults. After living for years with untreated or undiagnosed disorders, their pent-up demand for care might trigger a run on Medicaid services.
“I think we’re going to see a pretty good uptick, an increase, right off the bat,” Miller said. “Based on what we’ve looked at in states that have increased coverage for people who were uninsured with a behavioral health condition, we expect there’ll be a pretty significant increase right from the get-go.”
When Oregon’s Medicaid program began accepting childless adults in 1994, for example, the new enrollees logged three times as many mental health and substance abuse treatment visits as the program’s low-income parents.
At Yakima Neighborhood Health Services, a community mental health agency in Yakima, Wash., 40 to 50 percent of the several hundred homeless Medicaid-expansion clients who’ve enrolled since October have had some sort of mental illness, said Rhonda Hauff, the agency’s chief operating officer.
The most common problems are depression, anxiety and post-traumatic stress disorders, along with more serious problems such as bipolar disorder and schizophrenia, Hauff said, adding that a fourth full-time behavioral specialist was needed.
Medicaid providers are likely to face similar pressure in Minnesota, where an estimated 30 percent of uninsured, expansion-eligible adults suffer from some form of mental illness and 19 percent have serious mental illnesses, according to federal estimates.
In Delaware, Ohio, West Virginia and Vermont, roughly 1 in 4 uninsured expansion-eligible adults have mental illnesses, federal data shows. Those states – along with Iowa, Rhode Island, Kentucky and Oregon – have double-digit rates of serious mental illness among that group.
“When the new enrollees get coverage, there’s a real opportunity to engage them in treatment, but there needs to be capacity in the system to do so. And that, I would say, is one of the challenges,” said Allison Hamblin, the vice president for strategic planning at the Center for Health Care Strategies, a nonprofit resource center.
Finding psychiatrists is one of the toughest problems faced by Mandel, of Pacific Clinics. The number of practicing psychiatrists in the U.S. declined by 2 percent from 2000 to 2010, according to the Association of American Medical Colleges, even as the population increased by nearly 10 percent. Retirements by an aging workforce are a big part of the problem. Nearly 57 percent of U.S. psychiatrists are 55 or older, the group reported in 2012.
Recruiting younger ones is hard, Mandel said, because most newly trained psychiatrists don’t want to relocate.
“When people go to medical school and go into their residency, they tend to put down roots in that community,” she said. “They marry. They have kids. So if you don’t have a medical school with a department of psychiatry in your neighborhood, it’s very hard to recruit people.”
Not everyone, however, is fretting about the situation. Matt Salo, the executive director of the National Association of Medicaid Directors, said the new expansion patients weren’t likely to arrive en masse but probably would seek treatment gradually, making them easier to accommodate.
“And we really don’t know who’s going to come in,” Salo said. “It’s hard to quantify people who haven’t shown up yet.”
The real problem may not be a lack of providers but a lack of funding, said Jennifer Mathis, the director of programs at the Bazelon Center for Mental Health Law, a national nonprofit advocacy group in Washington. From 2009 to 2012, states cut a collective $4.4 billion from their mental health budgets, according to the National Association of State Mental Health Program Directors.
Since the federal government will pay all the medical costs for Medicaid-expansion patients in 2014, 2015 and 2016, states have an incentive to offer greater mental health benefits, Mathis said.
“It remains to be seen whether there’s an actual shortage of providers,” she added. “I don’t think we have data to suggest one way or the other, really.”
In California, Selix said his organization was working to loosen licensing regulations for counselors so a broader segment of people could be hired.
“There’s a lot of people that have valuable experience but they don’t have mental health licenses, and we want to be able to use them for services as much as possible,” Selix said.
As an example, he cited “peer support” counseling, led by instructors who are recovering from their own mental health struggles.
“Using people who have been through that to help others navigate through it reduces the amount of licensed clinician time we need,” Selix said. “Plus it’s less expensive, so we’re trying to expand that.”
Efforts nationwide to place counselors, social workers and others with behavioral health credentials in clinics and other safety-net facilities will help provide greater access to counseling in primary care settings.
In Kentucky, where more than 14 percent of uninsured expansion-eligible adults are estimated to have substance abuse problems, the new Medicaid benefit presents their best hope for recovery – if the providers are available.
"We know that there’s a significant number of people that need substance abuse services who’ve not had a way before to pay for it,” said Tony Zipple, the CEO of Seven Counties Services Inc., which treats mentally ill Medicaid patients in the Louisville area. “Whether that becomes a problem for us depends on how many people come in, for what services and over what period of time.
“I may eat my words and we may be surprised tomorrow, but I really do think this will happen in an incremental enough way that we’ll be able to handle it reasonably well. But only time will tell.”