Mental Health & For-Profit Insurance: A Deadly Combo

The U.S. is wrestling with a massive mental health crisis – impacting young people in particular. Half of young adults and one-third of all adults report that they always feel anxious or have often felt anxiety in the past year. One-third of respondents could not get the mental health services they needed. Why? 80% say they couldn’t afford the cost and more than 60% said that shame and stigma kept them away. The shortage of mental health providers also means that care can be very hard to find, even when we try hard to find it. Usually on the Medicare for All Podcast, we focus on the stories we think you need to know about. Today we decided to scrap the show and come up with a plan to get an hour of free therapy!*

(*Not really. None of this information is intended as medical advice.)

Our guests today are Dr. Pamela Fullerton and Lindsay Baish. 

Lindsay is a therapist and an Licensed Professional Counselor (LPC) in Illinois and a certified trauma professional – and former volunteer for the podcast.

Dr. Pamela Fullerton, Ph.D., is the founder and clinical director of Advocacy & Education Consulting, a counseling and consulting organization dedicated to ensuring social justice and advocacy through equitable access to mental health and well-being services. She is a Latina bilingual Certified Clinical Trauma Professional (CCTP), a Certified Dialectical Behavior Therapy professional (C-DBT), a Certified Clinical Anxiety Treatment Professional (CCATP), a Certified Grief Informed Professional (CGP), and a clinical supervisor and consultant specializing in working with BIPOC communities, undocumented communities, immigration and acculturation, trauma, anxiety, life transitions, and career counseling. In addition to being a professional writer and speaker, Dr. Fullerton is an adjunct instructor in the Counselor Education department at Northeastern Illinois University. She is also a volunteer contributing writer for three publications and runs a nonprofit to support Latinx youth in the Chicagoland area. Dr. Fullerton consults for two behavioral health advisory boards, Sinai Urban Health Institute (SUHI) and Illinois Unidos/Latino Policy Forum, providing advice and input to assist in promoting health equity and justice initiatives for underserved communities in Illinois.  

Show Notes

Pam tells us that counselling is a subset of psychiatry and psychology that started as a movement for career development for veterans returning from war. The profession started helping people through life transitions puts people and their lives and livelihoods at the center.

Lindsay notes that a lot of the language of mental healthcare is used interchangeably, but there are distinctions: psychologists have PhDs and can provide therapists; psychiatrists have MDs and can prescribe medications. Counselors and therapists can diagnose but not prescribe.

Congress passed the Mental Health Parity and Addiction Equity Act in 2008 to prevent insurers from providing worse coverage for mental health than they do for medical or surgical treatment. However, mental health providers are not usually treated the same as medical doctors when it comes to insurance coverage and payments.

Historically, counselors are the newest mental health clinicians on the scene and are more limited by insurers than more established clinicians like social workers or psychologists. Insurers often only reimburse for certain therapeutic models of care (Cognitive Behavioral Therapy, for example) leaving other kinds of counseling uncovered in the midst of a crisis in mental healthcare.

Pam tells us that a big part of her job is the extra work to navigate her patients’ insurance plans, Medicare and Medicaid in order to get coverage for their care. Most Americans can’t afford to pay out of pocket for mental healthcare. Counselors just got approved for Medicare reimbursement on January 1, 2024, but Pam tells us her first application was denied, as was Lindsay’s supervisor’s. Couples and family counselors were just approved for Medicare as well.

Lindsay notes that no two insurance companies pay out the same rates, so some plans are not worth taking because the payout will be late, small, and requires hours of red tape to receive. Ben calls this “rationing by inconvenience.”

Illustrating the troubling priorities of the healthcare industry related to mental health, Lindsay shares a story about the Diagnostic and Statistical Manual (DSM), the encyclopedia of mental health diagnoses. The DSM is put together by the American Psychological Association, where panels of providers create and refine criteria and definitions for diagnoses. Those panelists are required to disclose who they have received funding from including pharmaceutical companies and insurance companies. A recent study found $14 million in undisclosed industry payments to some of those panelists, representing countless conflicts of interest.

Americans have responded in a lot of different ways to the difficulty of getting mental healthcare including millions who go to TikTok for mental health advice. On the bright side, many of us have found out we aren’t alone helping to reduce the stigma of talking about mental health. Unfortunately social media has also disseminated misinformation leading to mistaken self-diagnoses. Lindsay is actually on TikTok, talking about her specialty areas and social liberation issues in psychology, because it provides a space for some people who don’t feel welcome in the traditional healthcare setting.

Since COVID, we’ve seen the rapid growth of virtual mental health services. This feels a bit like the Uber-ization or Airbnb-ification of mental health services. In theory these platforms are great for access, but many are poorly regulated and the therapists are often not held to professional standards. The FTC found that one platform, Better Help, sold patients’ data.

One of the things we always say about Medicare for All is that it would take the business out of healthcare. What would it look like if we took the business out of mental healthcare? Currently most Americans’ insurance is tied to employment, and that plan can change due to their employer’s bottom line. There’s something particularly insidious about developing a trusting therapeutic relationship with a mental health professional only to lose coverage and having to start over finding another provider who will accept the new plan. Pam dreams of a healthcare system divorced from profit, where we can do more preventative mental healthcare and collective healing, and not wait until someone is in crisis.

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