Surgeon General Vivek Murthy’s latest warning unearths concerning statistics about the mental health and well-being of American parents.
These findings resonated with me deeply on two levels. First, I am a parent of three school-age children. Second, I am a trained therapist and head of behavioral health at a provider organization focused on caring for the most vulnerable members of our population — Medicaid members and those dually eligible for both Medicaid and Medicare.
So, I particularly celebrated the report’s recognition of the disproportionate impact of parental stress on marginalized populations and the compounding impact of social barriers and financial inequities. The advisory recommends addressing these barriers, increasing universal screenings, and partnering with mental health resources. That’s a good start, but it’s not nearly enough for the Medicaid population.
When I sit with patients in their homes, virtually, or in the clinic, they are usually thinking: Where will I get my next meal? How will I afford the textbook my child needs for math class? How will I get my mother the prescription for her new diabetes medication?
When you take all of these critical needs into account, prioritizing their own mental health is most likely to fall off the to-do list.
The dire lack of mental health professionals is uniquely troublesome for individuals on Medicaid given the very limited number of psychiatrists who accept insurance and even fewer who accept Medicaid, which has notoriously lower reimbursement rates. Appointment availability for those lucky enough to find a provider is its own challenge. In a recent JAMA study, researchers randomly called psychiatry offices that take Medicaid in four major U.S. cities and only 17% had available appointments.
Increasing Medicaid reimbursement is too limited and piecemeal a solution. We must focus on getting creative about what mental health care looks like for the Medicaid population. Even if someone were able to make an appointment, as a therapist myself, I know that the work I do with a patient during our half-hour session is unlikely to solve their more immediate problems.
Solving the mental health challenges of low-income, marginalized families requires more than an advisory and call for a culture shift. We must offer more local, community-based support systems within and beyond the health care system.
To truly address the parental mental health crisis for the one in eight mothers who have symptoms of postpartum depression, we can consider holistic approaches that begin with and last throughout pregnancy, such as further expansion of doula services under Medicaid to include doula services during both pregnancy and postpartum.
The leading cause of pregnancy-related deaths is mental health conditions (22.7%), including suicides and overdose/poisoning related to substance use disorders. Centers for Disease Control and Prevention research also finds that over 80% of pregnancy-related deaths are determined to be preventable.
Several studies have shown that doula support is associated with lower cesarean and preterm birth rates. Doula support can also provide a vital source of compassionate, consistent support in a system that struggles to gain the trust of those on Medicaid.
Medicaid pregnancy programs should incorporate doulas, who usually form more trusted connections with the pregnant people in our community, to be a source of mental health support, identifying and escalating more serious mental health concerns to licensed specialists, helping them navigate both financial and social assistance along the way. While more research is needed to further understand the clinical significance of doula support on parent and family mental health, I have seen its value manifest in my own practice. I encourage the industry to further the literature on the role of doulas in mental health and wellbeing, particularly for vulnerable groups.
Significant progress has been made in the coverage of doulas with most states taking some action toward doula coverage. Currently, 12 out of 50 states are actively reimbursing for doula services. This is proof that change can happen — and quickly — but more implementations are needed to support pregnant individuals, new parents, as well as parents of older children on Medicaid more broadly. While some labor doulas work with patients up to two months postpartum, I’d love to see this coverage extended during the postpartum period, especially for those with higher-risk pregnancies to support parents and babies through what is both a physically and mentally challenging experience.
While labor and postpartum doulas have a unique opportunity to build connections from within the homes of patients and at their bedsides, a lack of trust in our health care system has been well-documented and is preventing further engagement. Nearly four in 10 people with Medicaid say they have been treated by a primary care doctor they did not trust.
Community health workers often serve members of the same communities in which they were raised, serving as an invaluable bridge between the health care system and the community. Like doulas, these health workers are able to build stronger bonds of trust through consistency, building personal relationships, and making it easier to access necessary resources from financial support, food/nutrition, housing, advocacy, and more. These individuals can support families well beyond pregnancy and childbirth.
However, reimbursement for community health worker services through Medicaid is limited. Currently, 24 states pay for these services through Medicaid and three others are implementing this type of covered care. Coverage of community health workers also varies widely across state Medicaid programs from what services are offered, what populations can receive these covered services, payment methods and rates, and how coverage is authorized.
The cost associated with the certification to become a community health worker can also prevent more community health workers from entering the field, limiting those who are eligible for reimbursement.
In addition to reimbursement, community health workers should be thoughtfully trained in identifying and coordinating support for members’ social, behavioral, and physical health needs. I have found that the established trust between Medicaid families and community health workers often opens more doors to conversations about mental health and overall well-being than a traditional therapy visit could.
While doulas and community health workers can serve as the “face” of the health care system for Medicaid members establishing connections that are often much more authentic to this population, other modalities of both primary and specialty cannot be discounted. The use of telehealth has been incredibly valuable for Medicaid members and increasingly common for this population. During the pandemic, states that offered it found the majority of telehealth visits were for behavioral health services and prescriptions.
Non-traditional staff like doulas and community health workers can have a sizable impact on access to virtual psychiatric care. Medicaid members are more likely to struggle with access to technology needed to conduct these visits such as smartphones and reliable WiFi connections. By forming these deep community connections, non-traditional health care workers are well-positioned to help individuals get their vitals taken from home, bring a laptop or smartphone to facilitate a virtual mental health visit, and help them pick up and refill prescriptions.
However, current debates over the pandemic-era telehealth flexibilities and the DEA’s subsequent rules about telehealth prescribing threaten access to essential substance use disorder care for the nation’s most vulnerable group. To truly act on recommendations within the surgeon general’s report, particularly for low-income groups, lawmakers should extend and make permanent both the telehealth and DEA flexibilities on prescribing for substance use disorder.
Families who rely on Medicaid need focused, specific solutions to ensure their mental health needs are met. This will require getting creative in how we provide that support, focusing first on their more urgent needs, including housing, food, and financial stability, while also providing them with support outside the traditional therapist office setting.
Ruby Mehta, LCSW, is head of behavioral health at Cityblock Health.
