In 55 percent of U.S. counties, there are no practicing social workers, psychologists, or psychiatrists. All of those counties are rural. And with health-care reform dominating headlines, many in those rural communities are worried about the implications of Congress’ American Health Care Act (AHCA) and the Better Care Reconciliation Act (BCRA) for their long-term survival and ability to manage a mental health crisis.
Tools that help rural communities address mental health needs, including regional clinics and telemedicine, are at severe risk from Medicaid cuts and other policy changes. Telemental health in particular is an opportunity to change the rural health-care landscape, and its loss would be a blow.
The rates of mental health conditions in urban and rural communities are relatively comparable. But the access to treatment for those conditions is quite different. In the rural United States, suicide rates are nearly twice as high, with rural areas having a higher rate of untreated mental health conditions, including depression. Many mental health conditions are exacerbated by stressors like unemployment, poor access to health care, and poverty—all of which are more common in the rural United States. Farm-related stressors, including unstable income and fear of losing crops, are a uniquely rural problem that contributes to depression and substance abuse in some communities.
Rural patients also face a constellation of compounding problems that may limit their access to insurance coverage for these conditions. Many work for small businesses or for themselves, which cuts them out of employer insurance requirements and forces them onto the private market. Poverty has others turning to Medicaid, and in states where it is available, the Medicaid expansion for coverage; about one in four nonelderly adults in rural communities use Medicaid. Others end up on Medicare, either because they are elderly or they qualify for Social Security Disability Insurance.
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And even with health coverage in hand, there’s no guarantee that said coverage will meet patient needs, especially in the realm of mental health. Diagnosing mental health conditions isn’t as simple as taking a blood test or performing an imaging study. It requires a professional evaluation that can sometimes come down to complex judgment calls on the basis of what’s in the Diagnostic and Statistical Manual (DSM), the “bible” of mental health conditions. That comes at a cost—before the Affordable Care Act (ACA) and the advent of state mental health parity laws, insurers historically denied coverage for many mental health needs. Even now, insurers can decide that patients do not demonstrate “medical necessity.” Furthermore, many mental health providers refuse to take insurance due to past difficulties getting reimbursed for services. Travel distance can also be a serious obstacle for people who lack transportation or the ability to take time off. Social acceptance of mental health conditions is another issue: In small towns, privacy can be at a premium.
These are all reasons why telemedicine would be such a boon to rural communities. While telemedicine cannot solve rural health disparities overnight, it can increase access to care. Whether by phone, videoconference, or other means, patients can meet with health-care providers from a local clinic, or even from their own homes, depending on the state and their access to technology. It’s cost-effective and confidential, and it allows people to work closely with a provider as they adjust medications or pursue outpatient therapy. Providers can call in prescriptions, request lab work if necessary, and refer patients to other providers and facilities if it appears warranted.
Telemedicine isn’t just useful for mental health. It’s also used for activities like managing chronic illness, offering birth control consults, providing abortion care in states that haven’t legally restricted the service, handling minor urgent care issues, following up with patients after hospitalization or surgery, answering pediatric queries after hours, and home health care.
A growing number of private insurers are offering coverage for telemedicine, with requirements to do so in 34 states. But Medicaid may be one of the biggest and most important players in the field: It covers telemedicine in 48 states and Washington, D.C. Even so, each state’s telemental health reimbursement under Medicaid is slightly different, and in fact, some states have policies limiting reimbursement to rural residents only—despite shortages of care providers in some urban communities. Currently, there is no federal requirement for Medicaid to cover telemedicine. Medicare has its own coverage requirements, including, again, geographically restricted eligibility that only extends coverage to those outside metropolitan areas.
Ateev Mehrotra, lead author on a paper exploring the growth of telemedicine in the rural United States among Medicare recipients—including disabled people under age 65 who qualify for Medicare because of the nature of their disabilities—told Rewire that the practice is on the rise, but not evenly distributed. There are significant geographic disparities at work when it comes to telemedicine adoption, thanks to differences in telemedicine parity laws and regulations supporting telemental health in various states. Telemedicine requires infrastructure: It starts with a referral from a health-care provider, and the rules surrounding practice vary from state to state. With regard to mental health specifically, he says, “You have to be attached to a community mental health provider who connects you.”
“If there are no providers,” as in many rural counties, he continued, “you have no access. This is being used as an adjunct treatment.” He says it doesn’t have to be that way, and connecting primary care providers—as opposed to mental health specialists—with telemental health resources could expand access to care in struggling communities. Primary care providers, he says, may currently lack relationships with telemental health providers, making it difficult to refer patients. Some may not understand the full scope of services available via remote consultations.
Unfortunately, the potential for expanding telemental health faces danger from Washington. The AHCA and the BCRA would make a number of important changes to health-care policy in the United States, but two in particular could be devastating for communities building up fledgling telemental health programs.
For those on private health insurance purchased as individuals or employee plans, the first issue is the elimination of the “essential health benefits,” services insurers are required to cover. Under the law, states could apply for waivers to define those benefits on their own, potentially striking things like maternity coverage, preventive care, pediatric services, and mental health. If insurers are no longer required to pay for mental health services or are allowed to be more selective about what they choose to cover, telemental health may well be among the services dropped in states where it’s possible to do so.
Medicaid patients face something far worse: A rollback of the ACA’s Medicaid expansion, which allowed states to opt into additional Medicaid funding for people making up to 133 percent of the poverty level. According to the Congressional Budget Office (CBO), 22 million Americans stand to lose their coverage, many under the expansion. In addition, both the AHCA and BCRA would convert the program, which has been effective for more than 50 years, to a block grant format, in which states get a lump of money based on population and need to cover Medicaid annually.
Block granting is the worst nightmare of many Medicaid fans, though Republicans say it makes the program more flexible by giving states greater autonomy over decisions like who to cover, what to cover, and whether there should be requirements for coverage—like a threatened work requirement for Medicaid patients. In the short term, states could opt to drop or severely cut mental health services, and as a frequently late addition, telemental health could be one of the first things out the door.
Converting to a block granting program may save the federal government billions, but it will cost individual states in the long term, especially those that are already poor and struggling. Once they’ve used up that lump sum, it’s gone—and while the size of the grant will increase slightly each year, it’s tied to the consumer price index, not increases in the cost of medical care. As the cost of providing health care rises, states will likely slash Medicaid to compensate.
In addition to harming individual patients, this could have a devastating effect on entities that rely on Medicaid reimbursement to stay open, especially in rural communities. Without this revenue, facilities would be forced to drastically cut services or close altogether. This could create challenges for both in-person care and telemental health programs—with no provider to visit, patients cannot get a referral, and in states where they need to visit a health clinic for a session, they would have nowhere to go.
After decades of fighting for mental health parity across the United States, advocates are facing the risk that their work may be about to evaporate, a possibility that will hit rural communities hardest because they’re already the most vulnerable. Moreover, poverty linked to health-care disparities may also increase, again putting rural communities in the crosshairs. That high suicide rate could get worse, as could complications of untreated or poorly managed mental illness. These are costs that don’t end up in CBO analyses.