LETTER TO THE SENATE FINANCE COMMITTEE

Submission in response to the mental health issues RFI

November 15, 2021

Dear Chairman Wyden and Ranking Member Crapo,

Thank you for the opportunity to submit information to inform legislative proposals aimed at improving access to mental health care and substance use disorder services. We applaud the committee’s bipartisan work to examine behavioral health care needs and assess the factors contributing to gaps in care. The Alliance is a broad-based coalition comprised of businesses, patient advocates, employer organizations, unions, health care companies, consumer groups, and other stakeholders that support employer-provided health coverage. We look forward to working collaboratively with you to develop data-driven policy proposals to enhance access to behavioral health care services for all Americans.


Employer Focus on Addressing Mental Health Needs During the Pandemic

As you are well aware, the COVID-19 pandemic and the resulting economic recession exacerbated the mental health and substance use crisis while creating new, unique barriers to access. During the pandemic, about 4 in 10 adults in the U.S. reported symptoms of anxiety or depressive disorder, up from one in ten adults who reported these symptoms from January to June 2019.[1] In the face of this challenge, employers pivoted to provide new and expanded mental and behavioral health resources for their employees. Despite economic uncertainty, 68% of large employers added or expanded benefits or resources to meet employee needs in response to the pandemic.[2]

Already an area of acute focus, employers doubled down on mental health and emotional well-being to meet employee needs. In an informal survey of large employers, 85% said supporting and/or expanding access to mental health care for employees was a top priority for their organization.[3] In another survey conducted a year into the pandemic, 50% of employers reported that employees were taking greater advantage of company mental health resources.[4] This includes expanded access to virtual care and on-demand telemental health; enriched EAP benefits to help employees manage their wellness; newly eliminated copayments for mental health encounters; and added voluntary and supplemental benefits aimed at addressing overall wellbeing (e.g. financial wellness, caregiving supports, enhanced leave, sleep management, and more).

According to the Business Group on Health’s (Business Group) 2022 Large Employers’ Health Care Strategy and Plan Design Survey, large employer’s mental health offerings will include the following for the 2022 plan year[5]:

  • Online resources (97%)

  • Manager training to help recognize mental health issues and how to direct employees to appropriate services (74%)

  • Anti-stigma campaign (70%)

  • Flexible work schedule that encourages employees to seek care during regular business hours (48%)

  • Work with your plan to expand mental health networks (47%)

  • Peer/employee training to help recognize mental health issues and how to direct peers to appropriate service (40%)

  • Offer a mental health navigation program (31%)


A true silver lining of the pandemic has been the significant investments made in virtual and mental health offerings, many of which will become permanent. These include expanded telehealth or virtual health offerings (76%), better access to virtual health (68%) and new mental health benefits (62%).


According to a Morning Consult National Tracking Poll conducted by the Alliance to Fight for Health Care, seven in ten insured adults (71%) feel it is important that they are able to access telehealth services under their current health care plan and 89% rated their or their family member’s previous telehealth visit(s) as good or excellent. A fifth of insured American adults have personally had a telehealth appointment for their mental health care and nearly two-thirds are willing to receive mental health care virtually through a telehealth system.[6]


When it comes to mental health treatment, employers are also enhancing access through reduced out-of-pocket costs for employees. For 2022, 75% of large employers are offering access to lower- or no-cost mental health support through their telemental health provider and 33% are offering lower cost counseling services at the worksite – bringing services directly to employees wherever they are.


In addition to the Business Group’s survey, detailed stories of employer actions to provide new and expanded mental and behavioral health resources for their employees are also available in the American Benefits Council report, Silver Linings Pandemic Playbook.


We urge federal policymakers to do their part to encourage and support these initiatives. To do this, our overarching policy objectives include:

  • Expand and diversify the behavioral health workforce through federal programs that recruit diverse students into primary care and behavioral health professions and financially support their training.

  • Enhance flexibilities for the provision of primary and behavioral health care to meet increased demand, improve access, and mitigate workforce shortages through enhanced telehealth, cross-state licensing, and low- or no-cost care before the deductible.

  • Support care models that integrate primary and behavioral health care and incentivize providers to address patients’ holistic needs, including mechanisms that incentivize provider uptake, such as behavioral-health specific metrics, including metrics encouraging timely access to care, as well as other financial incentives.

  • Provide additional clarity to employers in response to mental health parity compliance so plans and employers can work with the Department of Labor  to find the right solution to ensure adequate access to critical mental and behavioral health services for all 177 million Americans with employer-provided coverage. 


Below are specific policy suggestions in response to the committee’s priority areas:

Strengthening the workforce


According to the Health Resources & Services Administration (HRSA), over 130 million Americans live in Health Professional Shortage Areas (HPSAs) for mental health care, requiring an additional 6,586 providers needed to plug the gap.[7] Strengthening the mental health workforce should be a top priority – without providers, there is no access. In addition to the sheer shortage, the workforce is not reflective of the population it serves. In 2015, 86 percent of psychologists in the U.S. workforce were white, 5 percent were Asian, 5 percent were Hispanic, 4 percent were black/African-American and 1 percent were multiracial or from other racial/ethnic groups. This is less diverse than the U.S. population as a whole, which is 62 percent white and 38 percent racial/ethnic minority.[8] This should be a key focus of the workforce discussion, as studies find that patients who shared the same racial or ethnic background as their physician had higher patient satisfaction and that race concordance may enhance the quality of care provided. [9]

The Alliance supports workforce development and training programs that aim to increase the supply of behavioral health professionals and improve the distribution of a quality behavioral health workforce, such as the Behavioral Health Workforce Education and Training (BHWET) Program and Graduate Psychology Education Program, as well as those specifically focused on increasing the diversity of the workforce to ensure providers reflect the communities they serve. This includes the Minority Fellowship Program (MFP), which aims to reduce health disparities and improve behavioral health care outcomes for racial and ethnic populations.

We also support the Dr. Lorna Breen Health Care Provider Protection Act (H.R. 1667/S. 610) aimed at bolstering access to mental and behavioral health care for health care providers, removing stigma and addressing other barriers to help reduce burnout and improve the mental health and resiliency of our workforce.

Additionally, the Alliance supports flexibilities that enable mental health care providers to see more patients amid shortages and other access issues, specifically through enhanced telehealth options and licensing flexibilities. This includes legislation that allows mental health providers licensed in one state to treat—either in person or via telehealth—patients in any other state.


Increasing integration, coordination, and access to care

The Alliance raises to your attention the importance of integrated primary care and behavioral health care. While many providers continue to operate in silos, employers are pushing the system towards mental health integration through various innovative models and provider incentives. Evidence shows that integration – and positive outcomes such as reduced costs in downstream utilization – is most likely to succeed when alternative payment models incentivize providers to address patients’ holistic needs.[10] Examples of this include employers working with providers in capitated primary care arrangements such as Direct Primary Care, which encourages providers to treat the whole person and often includes “warm handoffs” in which primary care physicians refer patients to behavioral health programs by means of a personal introduction. Other models are driven by the inclusion of mental health-specific metrics (e.g. depression screenings) in primary care and coordinated care models, such as employer-run Accountable Care Organizations (ACOs).

In addition to the notable access and downstream cost management benefits, people with chronic physical conditions are also more likely to suffer from mental health problems. Research suggests that people who have depression and other medical illness tend to have more severe symptoms of both illnesses and that a collaborative care approach can improve overall health.[11] Because of this critical link, the Alliance supports legislation such as the Chronic Disease Management Act (H.R. 3563/S. 1424), which allows greater flexibility to offer pre-deductible coverage for chronic disease prevention.

The Alliance supports advancing legislation and continued funding of programs across all payers and communities that address this critical integration, as well as payment models and quality metrics that incentivize individual providers to participate. This includes programs that provide grants to encourage primary and behavioral health integration, such as those as part of the SAMHSA-HRSA Center for Integrated Health Solutions.

Ensuring parity between behavioral and physical health care

As described above, employers are enhancing access and removing barriers to mental health care in the face of increased employee demand and new pandemic-driven constraints to access. In addition, they are engaging actively in anti-stigma and education campaigns to encourage uptake and access to those enhanced benefits, with promising results. However, even when providers are in-network, other important barriers exist such as long wait times and finding the appropriate mental health specialist to address particular concerns. One large analysis that looked at U.S. graduate students — a population in which diagnosable depression and anxiety are believed to affect between 50 and 75 percent — found average wait times for care of more than 10 weeks.[12] Anecdotally, employers have also found that even when employees get paired with a mental health care provider, they are not always specialized or even experienced in the area of need.

Employers believe strongly in the value of mental health coverage for their employees and have made great efforts to comply with the requirements in the Mental Health Parity and Addiction Equity Act (MHPAEA). However, due to the subjective nature of those requirements and the lack of sufficiently clear guidance, we urge policymakers to avoid creating additional monetary penalties. Instead, compliance efforts should focus on providing additional clarity, including regarding the requirements recently adopted in the Consolidated Appropriations Act, 2021 (CAA). We hope to work together to find the right solution to ensure adequate access to critical mental and behavioral health services for all 177 million Americans with employer-provided coverage.  


Furthering the use of telehealth

Not surprisingly, telehealth, mental health, emotional well-being and health and lifestyle coaching are the most prevalent virtual services offered by employers. The growth in virtual care is something that employers have prioritized for the past several years, and the pandemic fueled adoption. According to the Business Group survey cited above, easing access to telehealth and virtual care, along with accelerating the number of these services offered, were the two top strategies put into place by employers in response to the pandemic. In fact, three in four employers reduced or waived cost sharing to basic telehealth services during the pandemic in an effort to address barriers to accessing care at a time when most individuals were unable to visit their provider in a traditional office environment.


The Alliance strongly believes that telemental health specifically is a vital component to enhancing access amid workforce shortages and increased demand. Telemental health can bring care to people as soon as they are willing or able to access it in addition to addressing other access issues that include barriers like child care, concerns of privacy, time and other constraints.

We support legislation such as the Telehealth Expansion Act (S. 1704), which makes permanent the flexibility for HSA-eligible plans to offer telehealth pre-deductible. Other telehealth legislation and flexibilities (as mentioned above) that enable providers to work across state lines and legislation that allows patients to receive services in their homes are critical to expanding access and bringing care to people who need it, when and where they want to access it.


We also support continued access to audio-only telehealth, along with investments in broadband and telehealth infrastructure to ensure equitable access to mental health care. Telehealth holds much promise in helping to minimize the disparities in mental health treatment between urban and rural Americans, however we must bridge the “digital divide” – the relative absence of necessary technology or capacity to use that technology in rural communities. We support proposed interventions aimed at improving access in rural areas, such as expanded community broadband availability and incentives such as increased reimbursement or enhanced investment in telehealth training and IT infrastructure.[13] In the meantime, audio-only visits are a lifeline to patients who are unable to attend visits in person or participate in telehealth visits due to lack of broadband access or necessary equipment to facilitate the visits.


Improving access to behavioral health care for children and young people

The workforce and access issues described above are even more acute when it comes to the pediatric population. According to the American Academy of Pediatrics (AAP), there are on average only 9.75 U.S. child psychiatrists per 100,000 children under age 19. The American Academy of Child and Adolescent Psychiatry (AACAP) says we need more than four times that many. The psychiatrists are disproportionately located in bigger cities; more than two-thirds of U.S. counties don’t have even a single child physiatrist. In K-12 classrooms, where children’s problems are often first identified, there is only 1 school psychologist for every 1,211 students, when the ratio should be 1 to 500. [14] And as seen with the adult population, young people’s mental health also deteriorated during the pandemic due to social isolation, exacerbated family conflict, and other issues.

The Alliance wholeheartedly supports solutions to address these most vulnerable members of our society, including programs like BHWET mentioned above that place a special focus on the knowledge and understanding of children, adolescents, and transitional-aged youth at risk for behavioral health disorders. Additionally, as many children are covered by employer-provided health care, the flexibilities discussed above to mitigate workforce shortages – provision of telemental health, licensure and site requirement flexibilities, and enabling access to low- and no-cost virtual are also critical.

Including employer-provided coverage as part of the solution can help us build on our success as we work hand-in-hand to expand access to high-quality mental and behavioral health care for all Americans.

The Alliance aims to support continued employer innovation while taking on health care costs directly by implementing policies that make health care more affordable, strengthen job-based coverage, and improve the health care system for all patients. We look forward to discussing our current set of policy proposals aimed at reducing premiums and helping consumers afford care – including vital mental health care and enhanced access to telehealth services. You can find a list of recommended policies on our website. We hope that as policymakers work to improve our health care system, they will consider measures that reduce costs and improve care for all individuals seeking and enrolling in coverage, including for those with employer-provided coverage.

Employers, health plans, unions, and others who have long served as the cornerstone of the American health care system have demonstrated success in achieving many of these laudable, critical, and shared goals. We look forward to building upon those successes, advancing our lessons learned, and coming together to fix what is broken for American patients and consumers.

Thank you again for the opportunity to comment. Please do not hesitate to contact us if we can provide further information about any of the policies outlined in this letter. 

Sincerely,


The Alliance to Fight for Health Care


[1] Kaiser Family Foundation, “The Implications of COVID-19 for Mental Health and Substance Use,” February 10, 2021.

[2] 2020 Mercer National Survey of Employer-Sponsored Health Plans

[3] Informal survey of American Benefits Council companies, October 27, 2021.

[4] Arizona State University College of Health Solutions, “Back to the Workplace: Are we there yet? Key Insights from Employers   One Year Into the Pandemic,” April 2021.

[5] Business Group on Health, “2022 Large Employers’ Health Care Strategy and Plan Design Survey,” August 2021.

[6] Morning Consult National Tracking Poll, November 1-8, 2021.

[7] HRSA, “Shortage Areas.”

[8] American Psychological Association, “How diverse if the psychology workforce?” February 2018.

[9] JAMA. “Association of Racial/Ethnic and Gender Concordance Between Patients and Physicians With Patient Experience Ratings,” November 9, 2020.

[10] Translational Behavioral Medicine, “Cost savings associated with an alternative payment model for integrating behavioral health in primary care,” 23 May 2018.

[11] NIH, “Chronic Illness and Mental Health: Recognizing and Treating Depression.”

[12] Chicago Tribune, “Mental health care appointments often come with a long wait. 3 ways to cope while help is delayed,” October 25, 2018.


[13] Health Affairs, “The Surge Of Telehealth During The Pandemic Is Exacerbating Urban-Rural Disparities In Access To Mental Health Care,” October 7, 2021.


[14] Washington Post, “Children’s mental health badly harmed by the pandemic. Therapy is hard to find,” August 14, 2021.

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