William Davis knows how hard it is for his wife to hear he wanted to stick a shotgun in his mouth. Right now, he has no one else to tell.
“There’s days where you’ve got to tell somebody what’s going on in your head just to get it out of your head,” said the 50-year-old from Columbia, Tenn.
Davis was already prone to suicidal thoughts as someone with bipolar disorder. Then he got the coronavirus in April 2020. Lingering effects have left him with anxiety and a depression he calls “pretty damn awful.”
He used to rely on physical strength to do custom renovations on homes and restaurants. Simple tasks exhaust him now. He can no longer work full-time as a craftsman.
“This isn’t just my livelihood,” he said. “It’s who I am.”
Dealing with Covid-19’s physical after-effects are challenging enough, but the virus is also taking a toll on the mental health of survivors with lingering symptoms, who call themselves long haulers. A research study reported in The Lancet Psychiatry journal found a third of Covid-19 survivors were diagnosed with a neurological or psychiatric condition in the six months after being infected; 17.4% had an anxiety disorder.
Survivors with physical conditions like heart or lung problems are often able to find in-network specialists with minimum hassle, particularly if their primary care doctor is part of a large health network. Uninsured people can seek treatment for immediate health issues at community clinics or emergency rooms.
With mental health, however, it’s often a struggle to get help at all.
Even if survivors like Davis are able to push past the stigma that’s long caused people to shy away from mental health treatment, finding a provider that’s covered by insurance and still accepting new patients can seem insurmountable.
Health experts say it illustrates how the U.S. health-care system is ill-equipped to meet the growing demand for mental health treatment.
“You might have an insurance card, but actually finding a provider in-network is extraordinarily hard even for people with quote-unquote good insurance,” said Jennifer Snow, director of public policy at the National Alliance on Mental Illness.
Podcast: Bloomberg Law reporter Lydia Wheeler discusses long haulers’ dire mental health situation.
The Affordable Care Act requires individual- and small-group health insurance plans to cover mental health and substance use treatment, though employers with over 50 employees aren’t required to offer that benefit.
If they do, federal law requires mental health coverage to be comparable to coverage of physical health care. Still, the act says nothing about reimbursement rates, and some providers won’t take insurance because the rates are too low, Snow said.
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Most large plans have some mental health coverage, ”but even with the increased coverage we still find actually getting care is a problem for many people,” Snow said. “Many times people are forced to get care out-of-network, which can make care unaffordable.”
A behavioral health office visit is more than five times more likely to be out-of-network than a primary care appointment, according to a 2019 report commissioned by the Mental Health Treatment and Research Institute LLC, a not-for-profit subsidiary of the Bowman Family Foundation.
Olga Alferez has been trying to find a therapist that’s not only covered by her My Health LA plan, but one that will work around her schedule. The mother of three from South Central Los Angeles became a widow a month into the pandemic, when her husband died alone of a heart attack in the hospital waiting for tests. Alferez is now the sole earner for her family. She says she’s exhausted, a byproduct of Covid-19 that’s been compounded by grief.
“I find myself on the phone a lot of times for hours and then I get told they don’t accept my insurance,” she said, speaking in Spanish through a translator at a community clinic where she now goes.
My Health LA is for county adults 26 and older who are uninsured and don’t qualify for comprehensive public health insurance, the LA County Department of Health Services said in a statement.
Some of the more than 200 community clinics where participants receive primary care offer mental health treatment on site, “or refer participants to the LA County Department of Mental Health, where services depend on the individual and the need,” the department said.
Meiram Bendat, an attorney who sues insurers for denying mental health claims, said insurance networks often don’t cover enough mental health providers. It’s largely because health insurers market cheaper plans with narrower networks that purport to be ACA compliant, he said.
The founder and president of Psych Appeal has already filed lawsuits challenging denials of coverage for mental health treatment during the Covid-19 pandemic.
He has yet to see any suits brought by long haulers, but those may be coming. When they do, they could follow the same pattern of the pre-pandemic litigation—either the patient gets mired in an administrative appeals process and gives up or goes to court where the insurer often settles before trial.
“Generally speaking, before you get to court, you have to exhaust appeals internally with the insurance company, and that process is private unless regulators audit the insurer,” Bendat said.
But just doing the work to find a provider on an insurance network list can be overwhelming for people who are depressed and struggling with physical symptoms of Covid-19, said Elena Fernandez, chief program officer at St. John’s Well Child & Family Center, in the South Los Angeles and Compton areas.
If someone just gives up and forgoes treatment without alerting their insurance company that they can’t find an in-network provider, there wouldn’t be a denial to appeal and no case to bring, Bendat said.
And for many attorneys, these cases aren’t worth the time for the amount of money at stake. The federal law that governs private employer health plans doesn’t allow for punitive damages, so people who are denied coverage can only recover what they paid out of pocket and maybe their attorneys fees, Bendat said.
Even if a therapist is in-network, insurers have to deem the treatment medically necessary before they’ll cover it. Those determinations have been a source of litigation.
A recent ruling, however, could make it harder for insurers to deny claims.
A federal judge in California ordered United Behavioral Health in November to reprocess 67,000 claims for outpatient and residential mental health, and substance use disorder treatment it denied using pervasively flawed medical necessity criteria from 2011 to 2017.
United Behavioral Health has appealed the ruling to the U.S. Court of Appeals for the Ninth Circuit.
“This long-running case is focused on guidelines we stopped using years ago and the plaintiffs in that case never offered any evidence showing that the challenged guidelines ever caused any plan member to be wrongfully denied benefits,” Maria Gordon Shydlo, a spokeswoman for UnitedHealthcare, said in a statement. “Beyond that, the case does not reflect the work we are doing today to meet the needs of the people we serve.”
United Behavioral Health, which operates as Optum Behavioral Health within United Health Group, said the Covid-19 crisis has highlighted the need for behavioral health.
“Over the past four to five years we’ve grown our network by about 50%, so now we have more than 240,000 mental health providers,” a UHC spokesperson said.
Alferez, a St. John’s patient, decided she needed to talk to someone after she was diagnosed with Covid-19 on Feb. 1, so she booked an appointment with a therapist that’s out of her My Health LA plan network. It costs $100 per visit out-of-pocket for Alferez, who has a job packaging fish.
“It’s been very, very difficult,” she said. “There are times where I don’t want to get up because I’m depressed. I’m sad. I don’t have the energy. My body just doesn’t give me the strength.”
St. John’s, in South Los Angeles and the Compton area, is a free and low-cost community health care clinic that’s been offering long-term Covid-19 care.
Though the clinic provides mental health treatment to patients who don’t have insurance, it also gets five to seven clients a week who are insured but can’t find a provider in their network, Fernandez said. Many of them are long haulers.
Some, she said, are insured but can’t find a provider with appointments readily available.
“With mental health, you can’t wait three months for an appointment,” she said. “Mental health is usually about the now. I am distressed now. I need help now.”
During the pandemic, the Centers for Medicare & Medicaid Services and the Department of Health and Human Services relaxed rules for telehealth and agreed to reimburse online appointments at the same rate as in-person care. Most insurers followed suit. But mental health advocates wonder if the changes will last once the public health emergency subsides.
“There’s lots of concern that after Covid, they are going to pay for telehealth at a lower rate, which will have an impact,” said Stephen Gillaspy, senior director of health care and healthcare finance at the American Psychological Association.
UnitedHealthcare has been providing free access to online therapy through UnitedHealth Group’s Sanvello Health Inc., but that benefit may change, the company spokesperson said.
Even with telehealth, advocates say federal legislation is needed to expand access to mental health treatment and make it more affordable.
After the district court ruled against United Behavioral Health, California passed a law that requires commercial insurers to provide coverage for all mental health conditions and substance use disorder treatment that’s medically necessary. If patients can’t find a provider in-network that’s either in their area or able to offer a timely appointment, the plan has to pay for out-of-network care at no additional cost to the patient.
The law also requires insurers to cover treatment throughout the full continuum of care and follow a uniform statewide definition of medical necessity, among other things.
But even if providers are available, finding the right therapist to meet a patient’s needs can still be challenging. Gillaspy said. Insurers clump providers together in lists without sorting their specializations, making it hard for Covid-19 survivors to find the right option to treat post-traumatic stress disorder (PTSD), anxiety, and depression.
Davis got insurance through his wife’s work in February and has started calling the providers listed in his Blue Cross and Blue Shield of Texas network. He’s had a hard time finding a psychotherapist that’s accepting new patients.
“So many people are just packed, “ he said.
Blue Cross and Blue Shield of Texas said it doesn’t comment on individual situations but advised members to reach out to the company directly if they’re having trouble accessing care.
“The onset of the COVID-19 pandemic challenged all aspects of the healthcare system, including available behavioral health specialists,” Dr. Leslie Weisberg, market chief medical officer, said in a statement. “BCBSTX continues to provide expanded telehealth coverage for members needing to see behavioral health specialists.”
Davis got on a waiting list last week for a therapist at Vanderbilt University Medical Center. He’s considering seeing a therapist online in the interim. He’s also working to get a referral from his primary care doctor to be seen by Vanderbilt’s Adult Post-Acute Covid Clinic, which is focused on caring for long haulers. The clinic coordinates care across different specialties, including behavioral health, according to its website.
“I really hope this clinic is what I’m looking for and that they take my insurance,” Davis said.
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