Center for American Progress: 'Mental Health Care Was Severely Inequitable, Then Came Coronavirus Crisis'

WASHINGTON, Sept. 29 -- The Center for American Progress issued the following report entitled "Mental Health Care Was Severely Inequitable, Then Came the Coronavirus Crisis" by Azza Altiraifi, research and advocacy manager for the Disability Justice Initiative and Nicole Rapfogel, research assistant for health policy.

Here are the excerpts:

Introduction and summary

People with mental health disabilities, like other historically oppressed communities, are experiencing compounded harms due to the COVID-19 pandemic. This is because sanism - oppression that has systematically disadvantaged people perceived or determined to be mentally ill--pervades public policy and life in the United States./1

People with mental health disabilities face disproportionately high rates of poverty, /2 housing and employment discrimination,/3 and criminalization./4

The economic and social upheaval caused by the coronavirus outbreak has merely exacerbated these disparities for those who were disabled prior to the crisis, while also exposing scores more people to individual and communal trauma, loss, and uncertainty.

As the coronavirus crisis continues to wreak havoc on communities, the need for accessible, culturally affirming mental health support services has never been more acute. However, even before the pandemic, the U.S. mental health care system was already failing to meet people's needs. In particular, for people of color and people with marginalized gender identities, the system too often operates in oppressive ways.5 The psychiatric establishment, whose leadership is overwhelmingly white and male,6 has historically denied communities facing various forms of oppression any control over their mental health care. Today, treatment is often cost-prohibitive, scarce, and coercive.

This report lays out the existing barriers to accessing affordable and affirming mental health services and considers the impact of COVID-19 on an already strained and inequitable mental health system. It also recommends that local, state, and federal governments take the following actions:

* Provide an immediate increase in funding to Medicaid providers and in-need communities.

* Increase funding for peer support and community-based services.

* Address the social determinants of mental health.

* Commit to permanently funding these policies.

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Recommendations

In order to sufficiently meet people's needs, it is essential that all funding and reforms put in place during this pandemic remain in place after the emergency declaration expires. Responses to trauma are often delayed, and it is likely that individuals' psychiatric symptoms will continue long after the initial spread of the coronavirus is contained. As such, funding to adapt to the current situation, as well as long-term, sustained efforts to offer supports and access to services, will be needed in order to properly address pandemic-related psychological and emotional distress.

Expand access to health care coverage

There are several important, immediate steps that can be taken to expand health care coverage. Amid rampant job loss,/53 risk of infection and hospitalization,54 and increased need for mental health services,/55 universal health coverage has never been more important. However, the current administration in the White House is committed to undermining health insurance coverage through its attacks on the Affordable Care Act (ACA) and Medicaid, making this approach unattainable for the time being./56

As an intermediate step, federal and state governments can and should make every effort to offer affordable coverage to the uninsured within the existing ACA and Medicaid infrastructure.

Under the ACA, people who face certain life events--such as the loss of employer-sponsored health insurance, moving, marriage, or the birth or adoption of a child--qualify for a special enrollment period (SEP), during which they can sign up for marketplace coverage outside of the yearly open enrollment period./57

Twelve states that operate their own state-facilitated marketplaces have opened a COVID-19-specific SEP that allows currently uninsured individuals to obtain individual market coverage, regardless of whether they qualify for a traditional SEP./58

According to estimates by health care analyst Charles Gaba, in the eight states that have opened COVID-19 SEPs and are reporting data, at least 240,000 people already have enrolled in coverage using this pathway./59

The Trump administration, however, has refused to implement an SEP for the federally facilitated marketplace in response to the COVID-19 pandemic. Gaba estimates that approximately 920,000 people nationally would enroll in ACA coverage if the federal government opened a national COVID-19 SEP./60

Allowing more people to enroll in coverage would not only alleviate some of the financial concerns associated with fears of getting sick contributing to individuals' psychological distress, it would also allow more people to access mental health services.

The Health and Economic Recovery Omnibus Emergency Solutions (HEROES) Act, which passed the U.S. House of Representatives in mid-May but has stalled in the Senate, establishes an SEP for the ACA marketplaces./61

It is essential that this provision be included in the final package that passes Congress. In addition to establishing an SEP, policymakers must fund culturally appropriate outreach and enrollment efforts to allow people experiencing job loss to access health care coverage.

Millions of low-income Americans would not have access to coronavirus testing and treatment or mental health care services without the Medicaid program. As the Center for American Progress detailed in June, to streamline Medicaid enrollment for millions of unemployed folks who may have lost their employer-sponsored insurance, states should offer automatic enrollment into Medicaid expansion for the unemployed and receive 100 percent federal funding through the federal matching assistance percentage (FMAP)./62

Moreover, states that have not expanded Medicaid must do so to cover individuals who fall into the coverage gap. More than two million Americans currently do not qualify for traditional Medicaid in their states but also do not have high enough incomes to qualify for financial assistance on the individual market./63

In states that refuse to expand Medicaid, the federal government should offer a Medicaid option for the unemployed that mimics the state-based option./64

To further support low-income individuals, presumptive eligibility is another important provision to allow uninsured and low-income people to access care. Presumptive eligibility allows certain health care providers to enroll patients who would likely qualify for Medicaid into the program for a limited amount of time, typically no more than two months./65

Thirty-one states currently offer presumptive eligibility in certain settings, but most limit qualification to pregnant women and children; and all but eight states exclude childless adults./66

Furthermore, hospitals are one of the few entities qualified to use presumptive eligibility./67

Therefore, many uninsured people may need to seek mental health care in a hospital setting, which could risk their exposure to the coronavirus.

Based on recommendations from the Center for Law and Social Policy (CLASP), there are several steps that states can take to make presumptive eligibility more effective./68

States can expand qualified entities that are able to screen for eligibility to include "urgent-care facilities, child care facilities, youth serving agencies, testing sites, and virtual options."/69

As CLASP suggests: "Just as pregnant women are allowed one period of presumptive eligibility per pregnancy, individuals exposed to COVID-19 should be allowed one period of eligibility per COVID-19 exposure. Multiple periods are especially critical for essential workers without insurance who risk multiple exposures throughout the pandemic."/70

Lastly, presumptive eligibility should be available to all potentially Medicaid-eligible individuals.

States should encourage presumptive eligibility providers to assist their patients with submitting a full Medicaid application when using presumptive eligibility in order to gain longer-term Medicaid coverage./71

This would also allow people to keep their presumptive eligibility coverage until a decision on a full application is made. Additionally, states can apply for Section 1115 waivers to extend presumptive eligibility for a longer period./72

Provide immediate funding to key providers and in-need communities

While previous stimulus packages have included important supports for providers, clinics, and hospitals, additional funding is urgently needed to address the needs of mental health patients and providers. For instance, the Coronavirus Aid, Relief, and Economic Security (CARES) Act, passed by Congress and signed into law by the president at the end of March, allocated $250 million to certified community behavioral health centers as well as funding for state and local aid./73

Meanwhile, the Families First Coronavirus Response Act increased the share of Medicaid payments covered by the federal government--the FMAP--by 6.2 percentage points through the end of the quarter in which the public health emergency ends. And if it passes the Senate, the HEROES Act would raise the FMAP by 14 percentage points through June 30, 2021; if the public health emergency extends beyond that, the FMAP would return to its original increase of 6.2 percentage points./74

However, the definition of eligible services for the FMAP bump excludes most community mental health services./75

Furthermore, community-based behavioral health providers have received little of the CARES Act funding intended to keep providers in business./76

For these reasons, the Senate must pass the FMAP increase, and Congress as a whole must ensure that critical community mental health services are eligible for the FMAP increase, while also being mindful that federal Medicaid assistance may need to extend beyond the scope of the public health emergency as communities continue to face the repercussions of the pandemic./77

Additionally, the $1 billion allocated in the CARES Act is woefully insufficient to meet the significant health needs of tribal nations during the pandemic and in its aftermath. Numerous short-term and long-term policy changes, as outlined in a recent CAP report, are needed to redress the federal government's broken treaty obligations, which have led to disproportionately high rates of COVID-19 infection and mortality in Native communities./78

Improve funding for peer support services and other community-based services

In times of crisis, peer support services are critical. Given the challenges faced by frontline health care workers, essential workers, survivors of COVID-19, the millions of people grieving loved ones, and communities--particularly Black, Latinx, and Native communities--disproportionately affected by the virus, increased access to affordable mental health services must be coupled with targeted funding for peer-to-peer supports./79

Accordingly, the Substance Abuse and Mental Health Services Administration must provide grants to peer and mental health support groups by and for people affected by the coronavirus pandemic.

Reports suggest that this pandemic has caused a surge in the number of people with lived experience seeking to complete their peer support certifications./80

Many peer-led support groups and services have transitioned to online models in order to maintain continuity of care. The CARES Act allocated $200 million to the Federal Communications Commission to disburse funds for telehealth and peer support services that fall within its purview./81

However, this funding is woefully insufficient to meet the increased demand and to support the costs of rapidly training up people who can provide tailored and culturally affirming resources to those acutely in need.

Critically, peer support specialists and community health workers are developing innovative strategies to conduct outreach to underserved populations and provide tailored support. For example, the 30 million people with eating disorders in the United States are facing new pandemic-related stressors due to elevated concerns about food scarcity and the hoarding of groceries by shoppers, coupled with a surge in media content focused on food and weight./82

Solutions such as online meal support groups can connect underserved populations with people who have a shared understanding of the unique challenges this pandemic poses.83 Adequately funding such services through operational grants that extend beyond the duration of the pandemic is crucial to ensuring continuity of care. Furthermore, increased federal funding for peer support training is essential to bolstering existing state and local peer certification programs and facilitating outreach efforts that target the most affected populations during and in the aftermath of the pandemic.

Invest in social determinants of mental health

While there clearly are protracted mental health impacts of the COVID-19 pandemic, the Trump administration's claim that lifting stay-at-home orders is necessary to curb suicide rates obscures the reality that much of this distress is due to the administration's failure to mobilize a pandemic response that meets people's basic needs./84

Until the government adequately contains the coronavirus and provides economic and social support to those affected, Americans will continue to face increasing distress and trauma./85

Psychiatric service provision and the incidence of mental health disability are shaped by the oppressive and traumatizing social conditions many people navigate daily. Racism, sanism, and other structures of oppression produce social and institutional arrangements that put some groups at risk of poorer health outcomes and premature death while allocating life-sustaining resources to others./86

Extreme social stratification and years of deliberate policy designed to unravel the social safety net have left huge swaths of the country--predominantly people of color, disabled people, and low-income people--unable to access life-sustaining resources./87

As such, without full investment in permanent housing solutions,88 expanded food assistance through the SNAP,89 and the elimination of asset limits and other cumbersome barriers to public assistance, distress will only be elevated./90

The behaviors that biomedical perspectives on psychiatry have defined as "disordered" are often the outcome of survival behaviors to cope with extreme and oppressive circumstances. Investing in the social determinants of mental health and redressing years of oppressive policy-making would ensure that the mental health interventions deployed in the wake of this crisis do not bolster the oppressive power structures that fomented such distress in the first place.91

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Conclusion

The explosive spread of the novel coronavirus underscores the importance of transforming mental health care in the United States and redressing the structural inequities baked into the psychiatric establishment and mental health policy. Even prior to the COVID-19 pandemic, people with mental health disabilities faced numerous barriers in accessing competent, affordable and culturally affirming care; this crisis has merely exacerbated these inequities.

Local, state, and federal governments must address the new challenges this crisis poses for people experiencing acute psychological distress or trauma. Their actions must be swift, comprehensive, equitable, and sustainable through the long-lasting impact of the virus.

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REPORT and ENDNOTES: https://www.americanprogress.org/issues/disability/reports/2020/09/10/490221/mental-health-care-severely-inequitable-came-coronavirus-crisis/