By former U.S. Rep. Patrick J. Kennedy
There are often two main roadblocks when it comes to the average American getting help for a mental health or addiction challenge. The first is stigma, which, thankfully, we are making great strides as a nation in overcoming. The second is access to care, which is often misunderstood and underprioritized by our elected leaders, hence historic rates of overdoses and suicides that were sweeping the nation long before COVID-19 drastically changed life as we know it.
You see, behind the headlines about celebrity struggles and the mental health awareness campaigns is a very complicated system of policy, payers, and professional affiliations. One that ultimately determines how easy or how difficult it will be for you or a loved one to get help, by dictating which mental health and addiction treatment providers your health insurance will cover. No coverage means high out-of-pocket costs—something that a majority of Americans simply can’t afford.
By potentially unleashing a new wave of mental health and substance use disorders in the U.S., COVID-19 has thrown a major wrench into the mental health care system, which was already in great need of repair. We have a serious shortage of mental health and addiction treatment providers across the country, and, in many cases, we are operating under shortsighted policies that actually hinder access to care.
So, what can we do to address these issues head on? In addition to providing emergency relief to essential mental health and addiction treatment providers who are struggling to survive during the pandemic and increasing mental health funding to expand services, our government should take a closer look at the practices of the largest payer of all mental health services: the Centers for Medicare & Medicaid Services (CMS).
Congress must end antiquated and restrictive practices such as the IMD exclusion within Medicaid, which limits the availability of critically needed crisis beds. Additionally, Congress must make urgent changes to Medicare, which serves 60 million of our nation’s seniors and people with disabilities. Medicare is not subject to the Federal Parity Law, which requires insurers to cover treatment for mental health and substance use disorders no more restrictively than treatment for illnesses of the body, such as diabetes and cancer. Without parity protections, blatantly discriminatory practices within Medicare will continue, including the 190-day lifetime inpatient psychiatric limit. No other illnesses are subject to these harmful restrictions.
Congress must also end unnecessary Medicare restrictions on accessing an essential group of mental health and addiction treatment providers for much-needed services: clinical psychologists. Clinical psychologists must have a doctoral degree (PhD, PsyD, or EdD) in psychology and hold a state license in order to participate in Medicare. They are qualified to independently perform psychological and neuropsychological testing, provide treatment—such as psychotherapy—for mental health and substance use disorders, and deliver psychological services that help patients manage physical health conditions.
Title XVIII of the Social Security Act, which governs Medicare, uses “physician” as a key term throughout. Providers included under this term are allowed to practice independently in accordance with their scope of practice. Currently, clinical psychologists are not included in the Title XVIII definition of “physicians,” but psychiatrists, who hold a medical degree and are able to prescribe medications, are.
Because of this omission, clinical psychologists face unnecessary roadblocks. For example, they are not eligible for Medicare’s 10% bonus payment for services provided in health professional shortage areas, thus removing an important mechanism to improve access to mental health services in rural and underserved areas for Medicare beneficiaries. Clinical psychologists are also excluded from federal support to help with the adoption of electronic health records, which is critical to integrating care.
Expanding the definition of “physician” to include clinical psychologists would expand access to care—for one of our most vulnerable populations—at a time when they need it most.
Make no mistake: this push for this action is not about prescribing privileges for clinical psychologists. Psychiatrists, not psychologists, can and should continue to prescribe medications for mental health and substance use disorders.
Indeed, the definition of “physician” in Medicare already encompasses other non-medical professions, including dentists, podiatrists, optometrists, and chiropractors. Additionally, clinical psychologists currently fall under the definition of “physician” in other parts of the U.S. Code, including the Federal Workers Compensation Act , and do not face restrictions with other federal payors, such as TRICARE, the VA, or even Medicare Advantage. So why the disparity in traditional Medicare?
At the heart of this matter is access to care. Especially as overdose rates increase across the nation, we need all hands on deck when it comes to treating mental health and addiction. I urge Congress to pass H.R. 884/S. 2772, the Medicare Mental Health Access Act, which will right this wrong and expand the definition of “physician” to include clinical psychologists. Now, more than ever, lives are at risk, especially those of isolated seniors.
Making this change is one small step that can and should be combined with other important workforce-enhancing measures such as dramatically expanding the number of Medicare-supported residency slots to increase the number of psychiatrists—given the projected shortage of 18,000 to 21,000 psychiatrists by 2030—and passing H.R. 945 / S. 286 to allow marriage and family therapists to bill Medicare.
It’s time to unite in our dedication to mental health as essential health, and truly walk the walk for policies we know can make a difference.
