KALAMAZOO, MI — It’s estimated that about 20% of Michigan adults experience a diagnosable mental-health condition in a given year.
Yet more than half will go untreated.
A major barrier?
Cost, experts say.
Mental-health therapy can result in hundreds or thousands of dollars in out-of-pocket expenses, even for people with insurance, depending on deductibles and co-pays. That issue can be compounded by insurance plans with limited in-network options for mental-health providers.
Affordability is the No. 1 deterrent to seeking mental-health treatment, more than stigma or people not knowing where or how to obtain services, according to a 2018 federal survey of 5,000 Americans.
The good news: Access to affordable mental-health care has improved in recent years.
One reason is the Healthy Michigan program, the Medicaid expansion created under the Affordable Care Act that has cut the number of uninsured Michiganders in half.
Another are reforms resulting from the COVID pandemic, such as the huge growth of telehealth services, expansion of school-based counseling programs and the pressure for employers to improve benefits related to behavioral health.
A third factor and the newest change, which has major implications for Kalamazoo and St. Joseph counties: Their community mental health agencies are part of a federal/state pilot project to greatly expand publicly subsidized mental-health services.
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Services provided by these new Certified Community Behavioral Health Clinics are available to all residents regardless of age, as long as they have a diagnosed mental-health condition. Fees are based on income and insurance coverage, using a sliding scale discount program.
Michigan joined the federal CCBHC program last fall in 14 counties, which means that expansion is just getting underway. (Additional Michigan counties also have CCBHCs that were created in recent years and funded outside of the federal project.)
“It’s a game-changer,” said Jeff Patton, head of Integrated Services of Kalamazoo, or ISK, which is Kalamazoo County’s community mental health agency.
“There are individuals not receiving mental-health services, including services for substance abuse disorders, who really need access,” Patton said. “This has opened us up, made us much broader, so that we will be able to do that.
“This is a major, major change for us.”
Service expansion
Michigan created the community mental health system in 1998 to provide publicly funded behavioral health services. However, the focus has been on residents with severe mental illness, substance abuse or developmental disabilities, Patton noted.
The new funding -- which comes from 2014 federal legislation co-sponsored by U.S. Sen. Debbie Stabenow, D-Michigan -- allows CMH agencies to also serve those with mild and moderate mental-health conditions.
What that means in numbers: Integrated Services of Kalamazoo has had about 8,000 clients annually in recent years. With the pilot project in place, Patton expects that to increase to 9,000 this year and could well double to 16,000 in three years.
“It will grow exponentially,” he said.
The new services include 24-hour crisis intervention; screening and diagnosis; outpatient therapy and substance-abuse services; coordination with physical care; targeted case management; follow-up services after a psychiatric in-patient stay; family support services, and enhanced programs for veterans.
For now, the target audience for the Certified Community Behavioral Health Clinic are people who are uninsured or on Medicaid. While the latter already can obtain mental-health services at minimal cost, reimbursement rates for providers are low enough that private therapists typically limit the number of Medicaid patients they take, Patton said. The new clinic should make it much easier for Medicaid patients with mild or moderate conditions to find a counselor.
People with insurance also can use the new program, and it’s especially advantageous for those with high deductibles and co-pays who feel they can’t afford the out-of-pocket costs associated with mental-health treatment, since the sliding fee scale offers additional subsidies on top of insurance.
Stabenow has said that the federal initiative is designed to close the gap between physical and behavioral health services.
Although Michigan didn’t receive funding for the initiative until last year, a number of other states opened certified community behavioral health clinics in 2017, and have reported positive results.
“The CCBHC demonstration increased access to care, largely due to increased availability of same-day appointments and concerted efforts to conduct outreach to underserved groups,” a 2021 federal report said.
Among the seven states with available data, the total number of individuals receiving behavioral health care increased and the clinics “substantially” reduced wait times for services.
Those benefits have translated into societal benefits. Communities with CCBHCs have seen 63% fewer emergency department visits for a behavioral health crisis, a 41% decrease in homelessness, and 60% less time in jails, according to the U.S. Department of Health and Human Services.
Other reforms
The CCBHC initiative is not the only positive development in recent years in regards to affordable mental-health care.
The Healthy Michigan program launched in 2014 currently insures 765,000 Michiganders age 19 to 64, about 13% of Michigan adults in that age group. To qualify, people must have an income under 138% of the federal poverty guidelines, or about $18,750 for a single person or $27,750 for a family of four.
This Medicaid expansion program covers mental-health outpatient and inpatient services, including counseling and medication, with very low co-pays. For instance, the co-pay for an office visit is $2 to $4. It also will pay for transportation to and from therapy appointments.
For people with private insurance, the ACA requires those policies to cover mental health services at the same level as physical health services in terms of co-pays and deductibles.
“That’s absolutely how it should be. (Mental illness) is a medical condition,” said Susan Davis, a therapist with Family & Children Services in Kalamazoo.
RELATED: Michigan to begin changing how it funds mental health, addiction services
The COVID-19 pandemic has forced additional reforms, as a record number of people reported symptoms of depression, anxiety and/or stress.
One response to that has been the huge growth in telemed counseling services, in which people can obtain therapy online or via the phone. That’s not only is more convenient, but can be a less expensive way to deliver services since it doesn’t require the costs associated with maintaining an office. And it’s especially helpful for people in rural areas where therapy services are limited and the patient can access a counselor in another part of the state.
Federal COVID-19 funding also has been put to use in expanding school-based mental health services, something now in place throughout most of Kalamazoo County, Davis said. That makes it more convenient for students and parents, and addresses the cost issue since the counselors are typically paid by the district, which then bills insurance if the child has it and subsidizes the rest of the cost.
The pandemic also has put pressure on employers to address mental-health benefits by publicizing or expanding therapy services available through Employee Assistance Programs or providing free mental-health screenings or assessments.
Yet another development during COVID: An increase in support groups and peer-to-peer counseling, which tend to be much less costly than an individual appointment with a therapist.
But those advances in making therapy more affordable have been offset by other issues.
“There are many more provider options now. But it hasn’t kept up with demand,” said Robert Nykamp, chief operating officer for Pine Rest Christian Mental Health Services, a nonprofit based in Grand Rapids whose service network includes southwest Michigan.
The challenges
Indeed, nobody thinks that the issues around access to affordable mental-health care have been solved.
National statistics indicate that more than 41 million American adults received mental-health treatment in 2020, primarily counseling and/or medication. That’s a record number and up from 31.5 million in 2010. Experts attribute that upward trend to decreasing stigma, community education around the importance of mental health, and various efforts to improve mental-health access and affordability.
Yet the percentage of people with mental-health symptoms who don’t obtain treatment has stayed about the same over the past decade. In Michigan, that number is estimated to be 53%.
Affordability remains a big obstacle for many, Nykamp said.
“I think the single biggest barrier to behavioral health care today is high-deductible health plans,” Nykamp said.
He pointed to his own insurance plan, which has a $4,000 per person deductible, which means he has to pay $4,000 in health-care costs out of pocket before insurance coverage kicks in. That kind of plan gives many adults pause about whether to seek counseling.
“A lot of people would say, ‘I can’t afford that,’ " Nykamp said.
Another big factor, Nykamp and Davis say, is the shortage of therapists and other mental-health providers. Even if cost isn’t an issue, people may find themselves frustrated at trying to find one a counselor taking new patients. The wait is especially long to see a psychiatrist, particularly a child psychiatrist, which is often necessary when the treatment plan includes medication.
And things may get worse before they get better in terms of the provider shortage, Nykamp said.
“I think for the next three years, all of our experts anticipate increased use of behavioral health care due to all the issues of isolation and grief and loss, etc,, related to the pandemic. Increased alcohol use due to the pandemic,” Nykamp said. “Then we’ll potentially see a leveling off. That’s my hope.
But right now, we can’t keep up with demand,” he said.
The shortage of therapists circles back to money, Nykamp added.
“You get what you pay for,” and mental-health providers tend to earn less than other professions with similar levels of education, which has discouraged people from entering the field, Nykamp said.
“When was the last time you went to your primary care office, and that primary care doctor spent 50 minutes in the room with you? That never happens,” Nykamp said. “So that’s the falsehood of parity” between mental and physical health care.
“Depression has become the second most-prevalent disease in the world, according to the World Health Organization,” he said. Nonetheless, “Priority Health (a West Michigan insurance company) last year on their total claims spent less than 3% on all behavioral health. not just depression. For the Medicaid program in Michigan, about 10% of spending is on behavioral health.”
Yet research indicates that investments in behavioral health pay off in savings in physical health-care, Nykamp said. A recent study out of University of Chicago finds that for every $1 that employers spend on mental health care for their workers, there are $4 in savings in total medical costs, increased productivity, lower absenteeism and decreased disability costs.
Nykamp says the new Certified Community Behavioral Health Clinics initiative is a big move in the right direction, and is hoping Pine Rest can soon be among the CCHBC sites in Michigan. But he and Patton agree that even that program is not a silver bullet.
Even when the program is fully implemented, “there will still be gap in service,” Patton said. “We still don’t have adequate resources to meet the needs.”
This story is part of the Mental Wellness Project, a solutions-oriented journalism initiative covering mental health issues in southwest Michigan, created by the Southwest Michigan Journalism Collaborative. SWMJC is a group of 12 regional organizations dedicated to strengthening local journalism. For more info visit swmichjournalism.com.
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