The COVID-19 public health emergency declaration expires in less than a month. When it does, it will have far-reaching effects, and one of the biggest is little known: it could begin to undo the expansion of access to mental health care for millions of Americans.
Before the pandemic, more than 95% of outpatient mental health services were in person in the United States. Today, that number has dropped about 50 percent for conditions such as depression and anxiety. The others are meeting with their vendors through a video portal or over the phone, but they may not be able to do so in the coming weeks.
THE temporary closure of mental health treatment programs during the pandemic – to prevent the spread of the disease – forced people to seek treatment virtually. Many patients seem to have appreciated the change. A national survey by the American Psychiatric Association found that nearly half of millennials and Gen-Zers, two age groups that heavily use mental health services, now prefer telehealth to in-person care.
Additionally, many new people have sought mental health treatment during the pandemic. Among Americans aged 18 to 44, approximately 6 million more people received such care in 2021 compared to 2019. There is no doubt that this was largely due to increased needs: the pandemic has fueled anxiety and depression at previously undocumented levels. But, bolstered by an expanded telehealth infrastructure, the supply has also increased.
These benefits of telehealth may soon disappear. Consider, for example, a Medicare provision authorized during the pandemic that allows providers to be reimbursed for audio-only telehealth visits. This policy offered individuals, primarily the elderly, a way to obtain care over the telephone, especially in areas where broadband Internet access was limited. During the pandemic, this policy was a no-brainer: virtual care has mitigated the risk of COVID-19 for older adults. This policy was extended by the law of consolidated credits but is due to expire at the end of next year, even as it continues to reduce barriers to care for the elderly.
In many states, Medicaid reimbursement for audio-only telehealth expires alongside the public health emergency. Medicaid is the lfirst american insurer people with serious mental illnesses, such as schizophrenia and bipolar disorder. Because serious mental illnesses compromise job stability, people with these conditions are less likely to afford or use smartphone and internet. Audio-only telehealth helped solve this problem.
State pay parity mandates, which require private insurers to provide equal reimbursement for telehealth services and in-person care, are also due to expire in many communities. With healthcare providers suddenly being paid less for virtual visits, will they continue to offer telehealth services at the same volume? Basic economic theory suggests the answer is no.
Other expiring policies may reduce the flexibilities associated with telehealth. The US Department of Health and Human Services has given providers the option to use video chat platforms such as FaceTime, Skype and Zoom, if HIPAA-compliant products were not available. Similarly, in-person examination requirements for writing certain prescriptions have been lifted by Drug Enforcement A(DEA) during the health emergency period. This has allowed millions of patients to receive prescriptions via telehealth for conditions such as anxiety disorders and ADHD. Both of these flexibilities had trade-offs: for example, the potential for privacy breaches and inappropriate prescribing. Nonetheless, stopping them could have a chilling effect on telehealth.
Research on the benefits of telehealth, including for mental health care, is nuanced. Because COVID-19 was unexpected, we primarily designed observational studies as the pandemic unfolded. These mainly measure feasibility, acceptability and adherence to treatment rather than patient outcomes such as remission of symptoms. And telehealth may prove more beneficial for some mental disorders than for others, or for adults than for children. Nevertheless, new high-quality studies are emerging every week. A full review, published in Januarysynthesized evidence before and throughout the pandemic, concluding that telehealth and in-person mental health assessments and clinical outcomes are comparable.
If telehealth policies began to unravel, the timing of a rollback in mental health care would be deeply concerning. The lack of affordable and accessible mental health care in the United States underlies catastrophic levels teen suicide ratecrawling homelessness in major citiesAnd dead of despair associated with an ongoing opioid epidemic.
Mental health care is one of the few areas where politicians have consistently worked across the aisle, and progress has been made in recent months. For example, the DEA is currently considering permanent extension of the prescription of drugs through telehealth. Blue and red states, ranging from Massachusetts to Texas, have adopted policies to promote the long-term use of telehealth. However, many other states are catching up and time is running out.
Ryan K. McBain is a policy researcher at the nonprofit, nonpartisan RAND Corporation and an assistant professor at Harvard Medical School. He focuses on the design and evaluation of health policies and programs intended to reach vulnerable populations, including those struggling with mental health issues, homelessness and poverty.
This part has been updated.
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