U.S. Needs a Behavioral Health ‘CARES’ Act Now — Here’s What It Must Include
By Sean Joe, PhD, MSW
The global pandemic caused by COVID-19 has left millions struggling with grief in a new way. Specifically, the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has left many in America and across the globe without the opportunity to be present during the illness process, dying process, or the burial process of those dear to them. Families are experiencing shockingly abrupt realizations that this pandemic is challenging their cultural practices and coping responses to illness and death. Many are left confronting intensely troubling, very deep, and endless amounts of challenging grief. This is what Kenneth J. Doka, PhD, author of Grief Is a Journey, refers to as “disenfranchised grief”—so much loss, not culturally or publicly sanctioned or mourned (Doka, 2016).
Many Americans are also experiencing vast amounts of loss and stress, not only to death but also the loss of jobs and wages, intense physical insolation, and the inability to celebrate momentous occasions, such as graduations, holidays, anniversaries, and weddings. All while increasing news reports share stories of emergency medical service workers as well as emergency department nurses and doctors, all experiencing numerous patient deaths, unprocessed grief, insomnia, and severe frustration associated with being unable to attend to volumes of unmet need (Brooks et al., 2020). The impact is traumatic and some feel inconsolable.
Pending Behavioral Health Epidemics
Soon escalating waves of individuals in psychological crisis due to complex grief will begin confronting the fragile behavioral health systems in our states and cities, on college campuses, and in the workplace. In addition to rising alcohol or drug relapses, this increased demand will further cripple our behavioral health care systems, similarly to what COVID-related physical illness did to the physical health care system. We will have more behavioral health care demand than available supply. In 2018, the National Council of Behavioral Health reported notable gaps in the nation’s behavioral health workforce. They found that there was a demand for at least 8,000 more psychiatrists, 19,000 more psychologists (Health Resources and Services Administration [HRSA], 2018), and 47,000 more mental health social workers (HRSA, 2019). Without critical policy or capacity investments now, such as a targeted mental health CARES Act, cities, states, colleges, and businesses across the nation will be left unable to fully meet the forthcoming behavioral health care needs of the people.
Behavioral Health Care Investment Priorities
Significant investments in the behavioral health care workforce, technological infrastructure, and new treatments are needed. Some of the investment priorities needed are consistent with recommendations from the 2019 National Academies of Science Engineering and Medicine report, Integrating Social Care Into the Delivery of Health Care: Moving Upstream to Improve the Nation’s Health (NAEMS, 2019), and includes the following:
• Recommendation 1: Expand the Behavioral Health Care Workforce by asking federal agencies such as the Centers for Medicare & Medicaid Services and state legislatures, licensing boards, and professional associations to develop, expand, and standardize the scopes of practice of social workers and other professional therapists, as well as community health workers to fill the gaps in psychiatry or psychological care in many areas. Specifically, social workers, who provide the lion’s share of the behavioral care in the nation, and other professional therapists should be considered providers who are eligible for reimbursement by payers and, where applicable, trained and licensed to proscribe medication.
• Recommendation 2: Centers for Medicare & Medicaid Services should amend payer rules to enhance the behavioral health providers’ ability to more effectively coordinate mental health care with human service organizations capable of providing critical social care (e.g., income relief, food pantries, utility, rent, mortgage assistance). Medicare/Medicaid payment advisory commissions should evaluate models in which social workers and other social care workers are reimbursement-eligible providers of social care services.
• Recommendation 3: Health care organizations should take steps to expand tele-mental health care and to integrate social care into behavioral health care through infrastructure development to redesign and refine workflows, providing novel localities technological assistance and support staff with the ability to develop the redesign. These champions of the redesign can curate best practices, focus on health information technology to enhance integration, and create support systems for community partners and their infrastructure needs.
• Recommendation 4: The federal government should establish a 21st-century social care digital infrastructure on a scale similar to that described in the Health Information Technology for Economic and Clinical Health Act of 2009. Ideally it should identify and deploy policies and resources to build the internal capacity necessary for the behavioral health care system and social care organizations to interoperate and interact with each other.
• Recommendation 5: The Office of the National Coordinator for Health Information Technology should be resourced to act on the Patient Protection and Affordable Care Act of 2010 Section 1561 recommendations, including the adoption of modern, secure, interoperable digital systems and processes that will allow all partners to share the administrative and other data necessary to enable patients to seamlessly obtain and maintain the full range of available behavioral health care and social care services.
• Recommendation 6: Establish a COVID-19 pandemic essential workers behavioral health care fund that states can administer for the mental health needs of doctors, nurses, EMS, and other health care workers who have seen their colleagues and patients dying, resulting in traumatic work stress and complex grief.
• Recommendation 7: Private and public payers can consider expanding mental health care coverage for longer periods of time with minimal additional charges for individuals and families unable to absorb more cost.
A Call for Leadership and Action
Now is the time for decisive leadership and policy action, informed by the available or new behavioral health science. America might be approaching a tidal wave of despair and our behavioral health systems cannot adequately prepare without prudent federal legislative action. After all the many congressional legislative phases of economic stimulus relief, behavioral care relief is also needed. Our future depends on the decisions we make today.
— Sean Joe, PhD, MSW, is principal director of the Race and Opportunity Lab and Benjamin E. Younghal professor of social development at the George Warren Brown School of Social Work Washington University in St. Louis.
Brooks, SK, Webster, RK, Smith, LE, Woodland, L, Wessely, S, Greenberg, N, et al. (2020). The psychological impact of quarantine and how to reduce it: rapid review of the evidence. The Lancet, 395(10227), 912-920. https://doi.org/10.1016/S0140-6736(20)30460-8.
Doka, KJ. 2016. Grief is a journey: Finding your path through loss. New York: Atrai Books.
Health Resources and Services Administration. (2018). Behavioral health workforce projections, 2016-2030: Psychiatrists (adult), child and adolescent psychiatrists, 1-3. Retrieved May 1, 2020, from https://bhw.hrsa.gov/sites/default/files/bhw/health-workforce-analysis/research/projections/Behavioral-Health-Workforce-Projections.pdf.
Health Resources and Services Administration. (2019). Behavioral health workforce projections, 2016-2030: Mental health and school counselors. Retrieved May 1, 2020, from https://bhw.hrsa.gov/sites/default/files/bhw/nchwa/projections/mental-health-and-school-counselors-2018.pdf.
National Academies of Sciences, Engineering, and Medicine. (2019). Integrating social care into the delivery of health care: Moving upstream to improve the nation’s health. Washington, DC: The National Academies Press. https://doi.org/10.17226/25467.