With rates of suicide and opioid deaths rising in the past decade and children's mental health declared a national emergency, the United States faces an unprecedented mental health crisis. But access to mental health care for a significant portion of Americans — including some of the most vulnerable populations — is extremely limited, according to a new government report released Wednesday.
The report, from the Department of Health and Human Services' Office of Inspector General, finds that Medicare and Medicaid have a dire shortage of mental health care providers.
The report looked at 20 counties with people on Medicaid, traditional Medicare and Medicare Advantage plans, which together serve more than 130 million enrollees — more than 40% of the U.S. population, says Meridith Seife, the deputy regional inspector general and the lead author of the report.
Medicaid serves people on low incomes, and Medicare is mainly for people 65 years or older and those who are younger with chronic disabilities.
The report found fewer than five active mental health care providers for every 1,000 enrollees. On average, Medicare Advantage has 4.7 providers per 1,000 enrollees, whereas traditional Medicare has 2.9 providers and Medicaid has 3.1 providers for the same number of enrollees. Some counties fare even worse, with not even a single provider for every 1,000 enrollees.
"When you have so few providers available to see this many enrollees, patients start running into significant problems finding care," says Seife.
The findings are especially troubling given the level of need for mental health care in this population, she says.
"On Medicare, you have 1 in 4 Medicare enrollees who are living with a mental illness," she says. "Yet less than half of those people are receiving treatment."
Among people on Medicaid, 1 in 3 have a mental illness, and 1 in 5 have a substance use disorder. "So the need is tremendous."
The results are "scary" but "not very surprising," says Deborah Steinberg, senior health policy attorney at the nonprofit Legal Action Center. "We know that people in Medicare and Medicaid are often underserved populations, and this is especially true for mental health and substance use disorder care."
Among those individuals able to find and connect with a provider, many see their provider several times a year, according to the report. And many have to drive a long way for their appointments.
"We have roughly 1 in 4 patients that had to travel more than an hour to their appointments, and 1 in 10 had to travel more than an hour and a half each way," notes Seife. Some patients traveled two hours each way for mental health care, she says.
Mental illnesses and substance use disorders are chronic conditions that people need ongoing care for, says Steinberg. "And when they have to travel an hour, more than an hour, for an appointment throughout the year, that becomes unreasonable. It becomes untenable."
"We know that behavioral health workforce shortages are widespread," says Heather Saunders, a senior research manager on the Medicaid team at KFF, the health policy research organization. "This is across all payers, all populations, with about half of the U.S. population living in a workforce shortage."
But as the report found, that's not the whole story for Medicare and Medicaid. Only about a third of mental health care providers in the counties studied see Medicare and Medicaid patients. That means a majority of the workforce doesn't participate in these programs.
This has been well documented in Medicaid, notes Saunders. "Only a fraction" of providers in provider directories see Medicaid patients, she says. "And when they do see Medicaid patients, they often only see a few."
Lower reimbursement rates and a high administrative burden prevent more providers from participating in Medicaid and Medicare, the report notes.
"In the Medicare program, they set a physician fee rate," explains Steinberg. "Then for certain providers, which includes clinical social workers, mental health counselors and marriage and family therapists, they get reimbursed at 75% of that rate."
Medicaid reimbursements for psychiatric services are even lower when compared with Medicare, says Ellen Weber, senior vice president for health initiatives at the Legal Action Center.
"They're baking in those discriminatory standards when they are setting those rates," says Steinberg.
The new report recommends that the Centers for Medicare & Medicaid Services (CMS) take steps to increase payments to providers and lower administrative requirements. In a statement, CMS said it has responded to those recommendations within the report.
According to research by Saunders and her colleagues at KFF, many states have already started to take action on these fronts to improve participation in Medicaid.
Several have upped their payments to mental health providers. "But the scale of those increases ranged widely across states," says Saunders, "with some states limiting the increase to one provider type or one type of service, but other states having rate increases that were more across the board."
Some states have also tried to simplify and streamline paperwork, she adds. "Making it less complex, making it easier to understand," says Saunders.
But it's too soon to know whether those efforts have made a significant impact on improving access to providers.
CMS has also taken steps to address provider shortages, says Steinberg.
"CMS has tried to increase some of the reimbursement rates without actually fixing that structural problem," says Steinberg. "Trying to add a little bit here and there, but it's not enough, especially when they're only adding a percent to the total rate. It's a really small increase."
The agency has also started covering treatments and providers it didn't use to cover before.
"In 2020, Medicare started covering opioid treatment programs, which is where a lot of folks can go to get medications for their substance use disorder," says Steinberg.
And starting this year, Medicare also covers "mental health counselors, which includes addiction counselors, as well as marriage and family therapists," she adds.
While noteworthy and important, a lot more needs to be done, says Steinberg. "For example, in the substance use disorder space, a lot of addiction counselors do not have a master's degree. And that's one of their requirements to be a counselor in the Medicare program right now."
Removing those stringent requirements and adding other kinds of providers, like peer support specialists, is key to improving access. And the cost of not accessing care is high, she adds.
"Over the past two decades, [in] the older adult population, the number of overdose deaths has increased fourfold — quadrupled," says Steinberg. "So this is affecting people. It is causing deaths. It is causing people to go to the hospital. It increases [health care] costs."
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