The Affordable Care Act and Mental Health Care

One thing is for certain about ACA: It didn’t fix mental health care in the United States. Far from it. While it did add some people to insurance programmes that offered more mental health options, the copays for mental health services are still quite high (even on platinum plans) and the costs for services like hospitalisation are extremely high as well. Thus, people with mental health conditions may be dissuaded from seeking treatment by the cost, or may be unable to follow recommended treatment plans because of the associated expense. Moreover, social stigmas still create barriers to treatment: People can’t talk openly about it in the workplace and among friends for fear of being shut out, for example, some patients may not be able to disclose for fear of losing their jobs, and other barriers stand in the way of truly free and clear mental health access.

Sane people are fond of telling us that we just need to go fix ourselves, and that if we worked harder and committed to getting care, it would be there for us. Of course, we’re told to be quiet when we talk about mental health issues, and we’re informed that the comfort of the sane always trumps our need for social supports and treatment. This creates a strange double standard where we are at one stroke told to get treatment, and at another told to not discuss it or reach out for help when it comes to getting it, which is a terrible double bind to be caught in, especially in a community where support is sometimes a critical component of getting help.

There’s another barrier, though, that has actually ironically been created by ACA itself.

It’s always been challenging to get a mental health appointment. Historically, patients often needed to go through hoops of demonstrating insurance or ability to pay, getting referrals, going through social workers, and finally being given opportunities to sit down with a psychiatrist for an intake interview and a discussion about their needs. Patients could wait days or even weeks for appointments unless they were experiencing mental health crises, in which case they might be rushed into care if they could demonstrate a clear  need, but followup treatment was sometimes difficult, and so, too, was access to stable treatment.

One would think that with the removal of cost barriers, it would be easier to get mental health care. That’s not actually the case, though — as discussed above, mental health services are still expensive, but more importantly, psychiatric facilities are being swamped by new ACA patients taking advantage of their benefits to get service. The same thing is happening across the medical field as patients who haven’t been to the doctor in years use their insurance to finally get care, sometimes for complex and poorly-managed conditions that they couldn’t afford to get treated for in the past.

For doctors, this comes with mixed feelings. Obviously care providers are glad to see patients seeking treatment and finally getting help, and the ability to care for more patients in need is a good thing. However, an increase in patient load is a problem for care providers already struggling with extremely tight schedules and limited time. Now, they’re just expected to see even more patients, in the same period of time, without the ability to dedicate the care, time, and thoughtfulness they want to offer to every single patient.

This is especially problematic in the realm of mental health, where care providers need to be highly attuned to patient needs. A good intake appointment should take at least an hour, providing plenty of time to go over the patient’s history, discuss any present or ongoing issues, and develop a plan for moving forward. But it’s not just about the questions and the back and forth and the exchange of information. The psychiatric professional also needs to be paying attention to hidden cues and issues. Even the patient who wants care may be reluctant to be fully open with a new doctor, may struggle to articulate issues, may be afraid of the consequences of being fully out about an issue — for example, someone might not want to admit to a strong suicidal ideation for fear of being hospitalised and missing work or being unable to afford it.

The intake appointment is a delicate, complicated dance in which patient and care provider feel each other out to determine what’s going on, and if they’re a good fit for each other. The end result may be a referral to another provider, or the creation of a care team: Maybe the patient needs a dedicated psychiatrist as a medications manager and key support person, and a psychologist, psychotherapist, or other form of trained counselor for therapy and support services. The patient may also need a social worker to get help with qualifying for benefits that can help her afford services, get into secure housing, access food stamps, and get other social services that she’s entitled to, and would benefit from.

When patients seek mental health services, they need extremely attentive, focused, and also complicated care. It’s not as simple as slapping a prescription bottle into their hands or ordering some diagnostic tests and calling it done. Which means that for each new psychiatric patient, practitioners face a complex and demanding time investment. They, like other medical professionals, are delighted to see people seeking care and want to provide it, but they are sometimes hampered by limitations from the environment and people around them.

ACA, in its quest to get patients into the doctor’s office, hasn’t thought through the other end of the equation: Where are the doctors going to come from?

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Image: Bellevue Hospital, First Avenue, Manhattan, Jeffrey Zeldman, Flickr