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Despite efforts to close gap, parity in mental health care remains elusive – Center for Public Integrity

Reading Time: 9 minutes

In recent years, mental health care has become a mainstream issue.

President Biden proposed an expansion of services nationwide. Lawmakers and celebrities speak openly about their struggles. States are providing incentives to expand the behavioral health workforce. Companies are recognizing the need for mental health leave. Telehealth care is rapidly expanding.

But countless surveys have found people assume they cannot receive mental health treatment or have to pay hefty costs for care. They aren’t wrong.

Approximately 1 in every 5 people has a mental health condition, and more than half, received no treatment at all last. These statistics do not represent a sudden shift but a deep-seated problem rooted in many decades of history. 

After documented abuses forced closures of mental health institutions across the country in the mid-1900s, community-based services became the norm. But pervasive stigma and underinvestment by the government limited the resources necessary to support widespread need. 

Some lawmakers and advocates, including former First Lady Rosalynn Carter, believed better, more equitable insurance coverage for mental health services could improve access and lessen the stigma. In 1996, the first federal parity legislation passed, requiring that certain insurance providers offer mental health care benefits on par with those for medical or surgical care. Legislation adopted in 2008 and the Affordable Care Act of 2010 expanded the reach of the 1996 law to more people and providers.

But the system remains inequitable. Even with federal mandates and state laws on the books, violations by insurance providers and state agencies occur regularly. People are denied coverage, capped on visits or required to pay higher costs for mental health versus medical care. Unaware of their rights, people go without services — with potentially disastrous impacts.

“If you think about food insecurity, if you think about housing insecurity, if you think about the underinsured and unemployment, poverty, all of those things are clearly linked in studies to mental health outcomes,” Dr. Enrique Neblett, Jr., a professor of health behavior and health education at University of Michigan told Naseem Miller from the Journalist’s Resource

To unearth mental health care disparities, the Carter Center, along with the Center for Public Integrity, launched the first newsroom cohort of the Mental Health Parity Collaborative in 2022. In the last two years, 32 news outlets in nine states have collectively published more than 70 stories that have won awards, resulted in legal and public action, and shed light on solutions.

Systemic failures harm mental health care

As rates of mental health conditions have risen in recent years, treatment options have become increasingly hard to find, especially for specific disorders or needs. Providers report backlogged caseloads, and patients face months-long wait times — if they can find services at all.

A recent report showed that patients were 10 times more likely to go out of their insurance network to see a psychologist versus a medical or surgical provider, typically paying a high cost for that care.

In Texas, regularly ranked at the bottom in the U.S. for mental health access, 251 of the 254 counties in the state are “wholly or partially designated by the federal government as ‘mental health professional shortage areas,’” Stephen Simpson from The Texas Tribune reported

“When it comes down to meeting a psychiatrist or meeting a therapist or any kind of provider, it’s, ‘Come back tomorrow, or we will give you a call next week,’ and that phone call never comes,” parent Elizabeth Ramirez told Simpson about trying to find services for her child.

Elizabeth Ramirez, mother to three children, sits at home. She looks to her left. She wears a gray top, a necklace and brown tortoise shell glasses. Her dark hair is pulled up.
Elizabeth Ramirez, mother to three children, sits at home in El Paso. After her eldest child experienced a mental health crisis, Ramirez navigated through the confusing and under-resourced Texas mental health system in search for professional help. (Emily Kinskey for The Texas Tribune)

Those seeking care also face “a widespread problem with inaccurate provider directories known as ‘ghost networks,’” Leigh Paterson of KUNC in Colorado found. “This is when an insured person pulls up a list of in-network therapists but then is unable to connect with them over phone or email.” 

Even when counselors and therapists are available, many will not take insurance due to low reimbursement rates. “Reimbursements have to cover not only the actual time spent in therapy, but also the costs of doing business, such as rent and time spent on documentation and billing,” explained Chicago Tribune’s Lisa Schencker. “In some cases, therapists can make twice as much by billing patients directly, without taking insurance.”

“It’s truly the Wild West because insurance companies make the rules, make the changes, and don’t really think about the ramifications,” Jennifer Froemel, a counselor in Illinois, told Schencker.

Children left out

For families with children in need, community care deficits have pushed many into dire circumstances, especially as rates of depression, anxiety and thoughts of suicide have risen.

Families increasingly rely on K-12 schools to provide care, Vanessa McCray from The Atlanta Journal-Constitution reported, but their services can be threadbare. Georgia had 6,390 students for each school psychologist, and 5,272 students for each school social worker. Outside of schools, psychiatrists that prescribe medication were even scarcer. The state had an estimated eight psychiatrists per 100,000 children, McCray found.

Colleges, too, reflect similar disparities, especially for students of color, reporting by Lisa Kurian Philip from WBEZ in Chicago showed. 

At University of Illinois Chicago, “24 providers, including several temporary trainees … serve more than 22,000 undergraduate and 7,000 graduate students. Faculty and staff say there are waitlists just to get an intake session,” Philip wrote. She found untrained faculty were trying to fill in the holes.

Isabelle Dizon inside UIC’s architecture and design school, where she is a junior studying graphic design. Dizon said her parents are Filipino and don’t really believe in mental health issues. She worried they would look down on her for seeking therapy, so she tried to get help on her own through her campus counseling center. (Lisa Kurian Philip/WBEZ)

For children with higher needs, families have resorted to desperate measures. 

Kayla Branch of The Frontier reported that Oklahoma families were relying on emergency rooms to treat their children or sending them out-of-state for residential treatment because they couldn’t find care at home. “In the 2023 fiscal year, Oklahoma spent over $5 million to send 49 kids out of state for treatment” due to care deficits in the state, Branch wrote. 

Other distressed families have even relinquished custody of their children because they couldn’t afford to pay for needed services, Christine Herman reported for Public Integrity.

“I have a life threateningly ill child,” parent Lisa Norris told Herman, who was recognized with a national award for mental health coverage. “If this were cancer, if this was a genetic syndrome, if this was a traumatic injury … I would never ever, in any place, be told, ‘Well, the only way you can do that is to turn over custody of your kiddo.’”

Vulnerable populations face higher barriers to care

Inequality in mental health care is especially acute among vulnerable populations, including low-income residents, communities of color and people living in rural areas. 

Multiple federal studies have found that people of color with mental health conditions receive less care and poorer quality care. In some states, pharmacies have denied prescriptions for substance use treatment for marginalized populations. Legislation in Arizona and elsewhere has made it harder for immigrants to access treatment. Additionally, Texas and other states have passed regulations restricting the care transgender populations receive.

The Arizona Center for Investigative Reporting found the state’s Medicaid agency failed to prevent and effectively respond to a multi-billion-dollar fraud scheme among behavioral health providers that disproportionately affected Indigenous communities. Though the state cracked down on the fraudulent providers, their response left many people in need without critical replacement care for life-threatening conditions.

Rural communities in particular often face a heightened shortage of mental health professionals and are less able to receive telehealth treatment due to limited broadband. 

“[Health care providers] are reluctant to set up practice in an area where families must travel long distances to access their services, which they may not be able to afford,” University of Georgia student reporters Sydney Rainwater and Navya Shukla found.

Stigma, too, can impact the uptake of services even when they are available.

In Georgia’s agriculture community, “people may not be willing to park their truck in front of the mental health center in town,” Dr. Anna Scheyett, dean and professor at the UGA School of Social Work, told Georgia Public Broadcasting’s Riley Bunch. Bunch reported on the high rates of farmer suicides and Georgia’s efforts to provide services to a population reluctant to admit they need help.

A Native American man with a blue headband, holds feathers for part of a traditional healing ceremony. He stands in a wooden hogan.
Wayne Wilson stands in a hogan at the Native American Baha’i Institute in Houck, Arizona. He holds eagle feathers that he uses in traditional healing ceremonies. (Laura Bargfeld/Cronkite News)

Language and cultural barriers influence treatment access too. 

Laura Bargfeld and Natalie Skowlund from Cronkite News at Arizona State University reported on the difficulties of getting providers to pay for traditional healing practices for Indigenous populations in Arizona. Also for Cronkite News, Deanna Pistono found that stigma and language barriers mean that fewer people of Asian and Pacific Island heritage seek care. 

“In more senior generations, we do see stigma as a huge barrier to entry of care. A lot of people (feel) like if I go to a therapist, to a psychologist, it represents some weakness on my part. Like I can’t figure things out on my own or I can’t get my stuff together,” psychologist Euodia Moffitt-Chua told Pistono.

Crisis conditions

State investments to expand behavioral health services can easily hit roadblocks, with legislation failing to pass or roll out effectively due to partisanship and systemic inefficiencies

Individuals who need more substantial behavioral care often struggle in vain to find help, especially if they are on Medicaid or uninsured, Lisa Halverstadt of Voice of San Diego found.   

People with substance use are particularly impacted, Halverstadt reported. An estimated 94% of people with a substance use disorder did not receive any treatment in 2021.

“San Diegans with Medi-Cal insurance often wait weeks for residential addiction treatment or a detox bed. Others languish in hospital beds for weeks and even months waiting for longer-term programs such as mental health rehabilitation facilities,” wrote Halverstadt, who reported that 1,300 San Diego residents died from overdoses in 2022

Related Reading

Mental Health Parity Collaborative

Newsrooms across the country examine the lack of parity in mental health coverage and the impact that has on individuals, families and communities.

Though alcohol has killed more Coloradans than opioids, Meg Wingerter of The Denver Post found the state failed to pursue recommended strategies like reducing the locations where alcohol is sold and raising the sales tax on these purchases. Instead, they expanded access to alcohol. 

Without treatment, mental health conditions worsen and can lead to a crisis, resulting in unemployment, homelessness or incarceration. 

In 2023, city dispatchers in San Francisco received 23,000 calls about people having a crisis or attempting suicide, Madison Alvarado and Yesica Prado of the San Francisco Public Press found. In investigating the city’s response system, they learned San Francisco spends millions of tax dollars annually on a myriad of crisis services in the city. Yet while people may be held and treated for emergency care, they are often released with no long-term treatment plan, leading to a cyclical pattern.

A woman wearing a head scarf and glasses holds up her hand to show her wounded middle finger.
Nova Jaswan lost the tip of her middle finger when a cell door at Fulton County Jail closed on her hand. (Ellen Eldridge/GPB News)

In many communities, law enforcement officers are still the first to respond and typically have limited training on how to handle someone in a mental health crisis. As a result, people are often arrested and incarcerated, putting them on a pathway to possible mistreatment — or abuse. Reporters in the collaborative found local jails and prisons commonly referred to as “de facto mental health facilities” due to the high numbers of inmates with conditions. 

“State laws guiding mental health and addiction care in jails are vague, leaving it up to jail officials to decide how often to check on sick or suicidal detainees, or when to seek emergency treatment,” Whitney Bryen reported for Oklahoma Watch. “Behind bars, presumed-innocent people with mental health conditions often face neglect, abuse, or even death.”

Bryen found that “28 jail detainees died from untreated mental health or substance use conditions, accounting for more than half of the state’s 53 jail deaths” in 2022. 

Finding solutions for scarce mental health care

In response to growing need and interest, some states have moved to improve access to mental health care. Georgia and California, for example, passed measures to bolster mental health and wraparound services. Oklahoma is implementing a new jail diversion program

As states continue expanding the reach of the 988 crisis hotline, communities are also increasingly investing in co-responder teams. These pair mental health professionals with law enforcement to appropriately mitigate heated situations and reduce arrests.

a group of women and girlds stand around a table laughing
Rebecca Bartolomeo and Michelle Smith are grateful for the chance to have open conversation about mental health topics with the troop. (Trevon McWilliams/KERA)

But the key, experts say, is ensuring services are available and used before people are in an emergency. Crisis care is not only costly, but is more likely to lead to repeat interventions and less likely to reduce symptoms over time.

To prevent problems before they start, communities are leveraging opportunities to embed mental health assessments or basic check-ins into other touchpoints, including at primary care visits and even Girl Scout troop meetings. Legislation in Colorado called for schools to use simple screening tools to identify students exhibiting signs of mental health problems and connect them to appropriate services.

Other places are trying to grow the behavioral health workforce or increase the variety of available treatment options.

Schools in Fort Worth, Texas, for example, have created several mental health initiatives for students such as a trauma-informed curriculum, according to a Fort Worth Report series. In Georgia, some colleges “are trying strategies — such as peer-mentoring programs and shorter-term, goal-focused coaching — that may resonate with male students hesitant to try traditional talk therapy,” The Atlanta Journal-Constitution reported.

But with data showing higher than ever rates of mental health conditions, these efforts may not be enough. 

“I’m sorry to say…those disparities are still with us,” University of Michigan’s Neblett, Jr. told Miller. “How is access going to improve if there isn’t a concentrated, sustained structural investment in communities to improve the access to high quality care?”

To shine a light on the continued disparities and opportunities to mitigate them, we will keep reporting with a new cohort of the Mental Health Parity Collaborative launching in June 2024. Find links to these and other collaborative stories from Public Integrity. The collaborative is supported with funding from The David and Lura Lovell Foundation and the Brain & Behavior Research Foundation. 

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