The Mental Health Crisis in Healthcare: Addressing Insurance Barriers
Posted by Improving Lives Counseling Services, Inc. | Mental Health
High costs, limited access, health disparities, quality issues, fragmentation, public health challenges, mental health crises, and political gridlock are just some of the reasons critics disparage America’s health insurance industry. While some argue these challenges stem from the system’s unique structure, others are advocating for adopting models similar to Europe’s universal healthcare system and others simply want Medicare for all.
Though the history of the U.S. healthcare system dates back to the Franklin Health Assurance Company of Massachusetts, founded in 1850, and Baylor University Hospital’s initiative to provide healthcare to teachers for a monthly fee leading to the foundation of Blue Cross health insurance plans, progress toward a justifiable healthcare system has been stagnant. This ongoing stagnation has left Americans divided over the industry’s distinctive structure, and its future.
The first health insurance company to cover mental health care was the Federal Employees Health Benefits Program in 1961, but others were slow to follow. Many carriers in the industry view mental health care as expensive and are reluctant to cover services they perceive as high-cost with a low return on investment — a disheartening perspective on the needs of mentally ill Americans.
Improving Lives Counseling Services’ diverse team of trained, licensed counselors, therapists, and clinicians accept Medicare, Medicaid (SoonerCare), private insurance plans, and clients covered under the Affordable Care Act. In addition, we believe the uncovered and /or uninsured deserve quality mental health care. Their mental health and well-being is just as much a priority as that of the fully insured. We provide compassionate care and support to all who walk through our doors.
PURPOSE OF HEALTH INSURANCE
The purpose of health insurance includes promoting health, ensuring access to healthcare for individuals and families, and providing financial protection against extraordinary healthcare costs. Health insurance shields individuals from financially burdensome medical expenses caused by diseases, disorders, illnesses, accidents, and disabilities. In addition, health insurance companies (carriers), are a mechanism for financing or prepaying a variety of healthcare services, including standard immunizations, cancer screenings, well visits, and preventive care for women and children. Some prepay diabetes and HIV screening, lab, x-rays, and annual physicals.
Although many individuals with health insurance file claims each year, healthcare spending and health insurance payouts are concentrated among a small group of patients who incur high costs due to serious conditions. Statics show, “ten percent of the population accounts for 70 percent of health care expenditures.
Due to continued medical research, scientific and technological advances in medicine, telemedicine, an aging population, increase in chronic conditions, healthcare inflation, and expansion of health care coverage, the cost of medical healthcare insurance continues to rise.
DENIAL OF COVERAGE
Doctors examine patients, provide diagnoses, recommend procedures or medications, and submit them to health insurance carriers, which can approve or deny coverage. A denial of coverage occurs when the insurance company refuses to pay for a medical service, treatment, or medication ordered by the healthcare provider. Such denials can be a source of frustration and may negatively impact on the patient’s physical health and mental well-being.
Why Coverage is Denied
Denials can happen for various reasons; typically based on the policy and terms of the patient’s health plan. In the healthcare industry, insurers often prioritize their interpretation of necessity, cost, and return on investment over the physician’s assessment and the patient’s needs. The most common complaint from patients is the lack of communication from their insurance carrier including a clear explanation or justification for the denial. Other reasons for denial can include:
- A service, treatment, or medication is not medically necessary based on its policies.
- Certain treatments, medications, or procedures require prior authorization.
- The healthcare provider is not part of the insurance company’s network.
- Policies often have coverage limits, such as a maximum number of visits for certain therapies or caps on the amount reimbursed for specific treatments.
- Treatments or conditions may not be covered due to specific exclusions in the policy, such as experimental or cosmetic procedures.
- Policies may exclude coverage for conditions diagnosed before the insurance policy took effect, especially in non-ACA-compliant plans.
- Treatments deemed experimental or not yet proven effective.
Denial – Mental Health Effect
The Epilepsy Foundation reported some parents of children with seizures, despite having insurance, were informed that visits to specialists or necessary medications were not covered. When parents are unable to pay for their child’s care, and the insurance they pay for monthly refuses to cover essential treatments, they often experience frustration, anxiety, and hopelessness, which can lead to chronic stress and depression. They feel their child’s needs are not being met and their well-being is not prioritized. Children are also affected by their parents’ frustration. Witnessing the stress and anxiety of parents battling insurance denials, and the uncertainty surrounding access to necessary treatment, can take a significant toll on the child’s physical health and mental well-being.
Denials and Patient Suicide
The connection between insurance denials and patient suicide is deeply troubling. While not all suicides can be directly linked to denied insurance claims, substantial evidence shows that financial strain, lack of access to care, and the hopelessness stemming from such denials can significantly contribute to mental health crises, including suicide.
Deny, Defend, Delay
Nationwide insureds report long wait times, an inability to talk to a real person, and difficulties communicating with automated systems. Patient’s have termed this “Deny, Defend, Delay” a strategy associated with the way organizations or companies respond to claims, disputes, and /or legal challenges.
“The connection between timely treatment and health outcomes is well-established. In health disparities research, it is widely recognized that adhering to prescribed medications, undergoing screenings, and receiving follow-up care promptly are critical for reducing inequities in health outcomes. Many in the medical community report denials by insurance carriers can lead to further complications.”
POLITICS OF HEALTH INSURANCE & HEALTHCARE
The Health Care and Financial Services Division of the United States House Committee on Oversight and Accountability has been focusing on healthcare, mental health care, healthcare affordability, and the overall objectives of health insurance providers. The Affordable Care Act (ACA) and Medicaid Expansion Program passed in 2010 provided millions of uninsured Americans with health insurance coverage, protected individuals with pre-existing conditions, and allowed children to remain on their parent’s health insurance plans to the age of 25. However, like other health insurance options, these programs have their pros and cons.
Access to Care
Each year, politicians debate over the rising cost of healthcare, healthcare insurance, and Medicare (healthcare coverage for seniors). Despite the Affordable Care Act (ACA), millions of Americans remain uninsured, often due to high premiums or the absence of Medicaid. Even among those with insurance, high out-of-pocket costs continue to impose significant financial burdens. Rural areas and underserved urban communities often lack adequate healthcare facilities and professionals, further deepening disparities in access to care. In 2002, 18 rural hospitals closed, and since 2005, 192 rural hospitals in the United States have closed.
Low-income populations face additional challenges, including prohibitive costs, limited transportation options, and systemic biases, which contribute to poorer health outcomes. Minority groups frequently experience unequal treatment within the healthcare system and have disproportionately high rates of chronic conditions. Moreover, the healthcare system tends to focus on treating illnesses rather than prioritizing prevention, exacerbating the widespread prevalence of chronic diseases.
The mental health crisis, public health issues, rising rates of obesity, diabetes, and heart disease, as well as the opioid epidemic, have further strained access to care and underscored the need for systemic reforms. In addition, the country is expected to have a shortage of over 60,000 doctors, and over 350,000 nurses in 2025 due to burnout and their aging population.
“Despite a growing need for healthcare professionals, fewer people are entering the medical field due to several factors including: high educational costs, intense training demands, increasing burnout rates, limited residency slots, a lack of exposure to healthcare careers early on, and concerns about work-life balance; all of which can deter potential medical professionals from pursuing careers in healthcare.” (AI)
Increased Healthcare Cost
As of early 2024, more than 45 million people are enrolled in the ACA, or Medicaid expansion plans. However, statistics indicate that reductions in government funding are driving up the costs of these plans and those of other healthcare insurance providers. As the cost of in-patient care, out-patient care, rehabilitation, home health care, nursing home care, long-term care and medications continues to rise, due to political and societal gridlock, very little is being done.
The U.S. spends more per capita on healthcare than any other country, yet often achieves worse health outcomes. A significant portion of healthcare spending goes toward administrative expenses due to the complex system of private insurance, public programs, and billing requirements. The cost of medications in the U.S. is among the highest globally, partly due to limited price regulations and patent protections.
SUMMARY
To date, there have been no major changes or healthcare reform, as the cost of health insurance premiums continue to rise, and healthcare insurance companies continue what many term “problematic” access to care. Industry reports in 2024 show only 17% to 30% of claims are denied, yet PBS reported one insurer denied 49% of claims in 2021; another’s denials hit an astonishing 80% in 2020. A recent study found sometimes the insurers’ denials defy not just medical standards of care but also plain old human logic. Current data shows, United Healthcare denies the most claims of any major health insurer.
Most people risk their physical health and mental well-being by accepting the denials and foregoing care. Most who pursue the health insurance carrier in an attempt to have the denial reversed, suffer anxiety, acute trauma, despondency, long-term depression, and acute stress evolving into post-traumatic stress disorder. Recently a patient turned to criminal activity in response to healthcare insurance denials. This was not the answer.
The licensed, trained, professional counselors, therapists, and clinicians of Improving Lives Counseling Services treat mental illnesses and behavior disorders triggered by healthcare insurance company denials. Let us support you with the necessary tools to control the symptoms and behaviors triggered by life’s stresses. You can cope. Call us to learn more.
