At the Beacon Barn Therapeutic Farm in Thornton, West Virginia, a typical day for Molly McCartney involves feeding horses—and seeing patients. McCartney, a clinical social worker and therapist, opened her practice in a barn in her Appalachian community as a way to combine her passion for animals with a desire to help people. But McCartney is only one of a handful of therapists in her area—an issue that is pervasive across Appalachia, a region with limited options for individuals seeking mental health care. For patients who use Medicaid, the options narrow even further.

Mental health in Appalachia, much like physical health across the region, continues to straggle behind the rest of the country. Appalachia’s suicide rate is 17 percent higher than the national average, and Appalachian Medicare recipients reportedly experience depression at a rate 16.7 percent higher than in other regions across the country. While a few counties throughout Appalachia fare noticeably better, the rural parts of the area are suffering.

An August 2017 report by the Appalachian Regional Commission noted that, across the region, the supply of mental health-care professionals per 100,000 residents was 35 percent lower than the national average. This deficit exists in all of Appalachia, with the southern and north central sub-regions reporting nearly 50 percent fewer mental health-care professionals than national averages.

“[T]here are not enough resources for mental health services, and the ones that are available are often further away than is convenient for the client to travel,” McCartney wrote in an email to Rewire.News. She has experience counseling patients through a variety of issues—including anxiety, depression, behavioral problems, and trauma— and works specifically with foster and adoptive children and families. Since children within the foster system are insured with Medicaid, McCartney began accepting this form of insurance in order to better serve her patient population. That makes her a rarity: a mental health professional in Appalachia who accepts one of the region’s most popular forms of insurance.

Of the 25 million people who live across Appalachia, a large percentage utilize Medicaid benefits. In some counties, especially in the central part of Appalachia, Medicaid enrollees make up as much as half of the community’s total population. Medicaid is intended to function as a free insurance service for low-income individuals and families, but simply having Medicaid does not ensure access to critical mental health resources.

Gail Wade, a registered nurse and trained evaluator at Norton’s Children’s Hospital in Louisville, Kentucky, has heard a variety of complaints from Medicaid recipients in regard to the process for obtaining mental health care. While Louisville is not technically located in Appalachia, Norton’s Children’s Hospital regularly sees patients who commute from the eastern Appalachian part of the state for appointments with therapists and psychiatrists; patients sometimes travel upwards of 200 miles each way to access the specific mental health resources they need.

Norton’s accepts Medicaid, but not all health-care providers do. Medicaid has one of the lowest reimbursement rates for doctors, meaning professionals who accept this form of health insurance are not likely to turn a great profit from providing services to patients who pay with Medicaid.

With an established deficit of practitioners who accept Medicaid already, Wade said patients frequently complain about long wait times to see a mental health professional. “Families don’t like that they have to be seen several times by a therapist before seeing a psychiatrist,” Wade wrote in an email to Rewire.News. This means that patients must have multiple visits with a therapist in order to be evaluated and receive a referral to see a psychiatrist, which can mean more costs and more time.

McCartney is familiar with the reasons why other practitioners might be unwilling to accept Medicaid, citing decreased reimbursement rates, a time-consuming prior authorization process, and an increased requirement for documentation. But she recalled instances where individuals hoping for care were put on an appointment waitlist that was “sometimes months long.”

“[T]here are not enough private therapists that are willing to become Medicaid providers,” McCartney told Rewire.News. “Therefore, many of those resources are not available to Medicaid referrals, unless [patients] are willing to pay out-of-pocket, which often is not the best option for them.”

Another major obstacle that discourages individuals in Appalachia from accessing mental health care? The region’s hilly terrain. Care is too far away, and sessions typically come at a prohibitive price, with travel costs and time lost from work.

Innovative concepts such as the Health Wagon, a clinic that services residents in southwestern Virginia, deliver life-saving medicines via drone in order to avoid the transportation obstacles that arise due to the region’s limited road systems. While this delivery system works well for medicine, services such as in-person therapy and counseling don’t transfer as easily.

Lack of affordable technology can affect Appalachians’ access to care as well. In major cities such as Huntington, Pittsburgh, Atlanta, and Birmingham, internet access and speed compares to other major cities across the country. However, rural communities consistently have more limited access when compared to their urban and suburban counterparts. With 42 percent of Appalachia’s total population living in rural communities, technological barriers can deter residents from accessing mental health care online or by phone, making it difficult to make appointments online or have video calls with therapists in a different town.

In all forms of care, many Appalachian communities are underserved, but mental health-care providers in the region are more limited than other medical professionals, such as general practitioners.

Despite the structural limitations that restrict residents’ access to mental health care in rural Appalachia, providers like McCartney remain dedicated to providing affordable, accessible services to patients, including those on Medicaid. “I enjoy it very much and have found that clients respond well to the rural setting of my office,” she wrote.