Opinion | When Therapy Eludes State Boundaries

America has an urgent mental health problem and disparity in care, so why aren’t we pursuing an obvious remedy that can expand access?

Every day, evidence grows that depression, anxiety, and other mental health conditions are not being addressed as access to care falls short for millions of Americans. It’s a long-standing problem that was exacerbated and accelerated by the pandemic.

The latest data from the Census Bureau’s Household Pulse Survey found that close to 30% of adults reported suffering from symptoms of anxiety or depression. Findings from another report found that symptoms related to anxiety alone nearly doubled since the start of the pandemic.

As if the pandemic wasn’t putting enough strain on our mental health, some of our diversions and distractions are making things worse. In recent weeks, we’ve heard reports about Instagram’s toxic impact on wellness, especially for child and teen users who reported low self-esteem, eating disorders, and suicidal thoughts.

Meanwhile, as America faces an unprecedented need for mental health care, the country is suffering a shortage of psychiatrists, psychologists, behavioral therapists, and counselors. Those seeking care are ending up on months-long waiting lists — if they’re lucky.

Not only that, but some of the country’s biggest healthcare providers are under fire for historical biases favoring physical health over mental health and not recognizing how the two are wholly intertwined. Most recently, the American Psychological Association (APA) singled out healthcare giant Kaiser Permanente for such a disparity. “We have never seen such an egregious case of delayed access” to psychological services, APA said in their assessment of one of the nation’s largest not-for-profit health plan, which has 12.5 million members.

So, here we are with a dire, complex problem that actually has a simple stop-gap solution: a federal extension of a year-old emergency order allowing mental health professionals to practice telehealth over state lines.

Telehealth Highlighted Cross-State Disparity in Care

Earlier in the pandemic, when the healthcare industry made a lightning-speed pivot to virtual visits, most states and CMS temporarily waived rules requiring clinicians to be licensed in the state where their patient is located. It was a great relief for patients who lived in states with too few providers and those who had relocated in response to COVID-19. It meant they could receive care from anywhere.

Now some states are rolling back their emergency waiver. But it isn’t time for a rollback — it’s time for a permanent cross-state allowance.

Why? Because an estimated 132 million Americans, nearly 40% of the population, live in areas with a mental health professional shortage.

It makes sense that practitioners in well-staffed states, like New Jersey and Massachusetts for example, should be allowed to fill gaps in those underserved states, like Wyoming and Utah. Shouldn’t they be able to extend a hand across state lines to people who are struggling to find help at home?

A Shortage of Mental Health Care Providers

As a doctor with decades of experience as a healthcare executive and practicing psychiatrist, I can confidently tell you this disparity isn’t new and it is accelerating.

Shortly after medical school, my first job as a primary care physician was at on American Indian reservation in New Mexico. Even then, it was nearly impossible to find state-licensed therapists living within range of any of our facilities.

But my story isn’t unique — it’s the rule, not the exception.

In 2018, Merritt Hawkins, a prominent physician search firm, published a report titled “The Silent Shortage: A White Paper Examining Supply, Demand and Recruitment Trends in Psychiatry.” It concluded that the U.S. had only 60% of the psychiatrists we needed to provide “good mental health care.” Three out of five counties had no practicing psychiatrists.

If those numbers didn’t raise alarm bells in 2018, they surely should in 2021, considering the escalating need for mental health care in a pandemic. Near the start of the coronavirus crisis, a distressing 45% of adults said the pandemic was harming their mental health.

Modern Solutions to Modern Problems

This is a 21st century problem. Let’s use 21st century solutions. We live in an age when technology can play a critical supportive role for healthcare, so why not improve access?

Innovations in digital therapeutics — whether tele-mental health care, behavioral modification apps, or online meditation tools — play an increasingly important role as an adjunct to treatment. And we’ve already seen how access to mental health care through video conferencing has been a lifeline during COVID-19 for millions of people.

With the patient-to-provider gap predicted to grow, the U.S. must enact a federal provision allowing cross-state teletherapy to continue permanently. As of July, only 21 states still had emergency waivers in place. If we make that pivot permanent, we can deliver care for our most vulnerable populations.

Murray Zucker, MD, is chief medical officer at Happify Health, a tech company offering software aimed at improving mental health, physical health, and well-being.