Former First Lady, Rosalynn Carter, died last weekend at the age of 96. She was a champion of mental health awareness and treatment. Nearly five decades ago, she began her campaign to remove the stigma of mental health, put it on an equal footing with physical health and view people with mental illness as full-fledged members of society. Carter cleared a path for reform. However, there’s still a long way to go to attain her goals. Mental health isn’t prioritized in state and federal budgets or by insurance companies. To complete her mission, society will have to invest the requisite resources.
Rosalynn Carter’s mental health advocacy began in the mid 1970s when her husband was Governor of Georgia. She was a member of the Governor’s Commission to Improve Services to the Mentally and Emotionally Handicapped.
After Jimmy Carter was elected President, Rosalynn became the honorary chair of the President’s Commission on Mental Health in 1977. This Commission pushed for systemic changes in mental healthcare, at the local, state and federal levels.
In October 1980, Congress passed the Mental Health Systems Act, which targeted the unmet needs of categories of people who had often been overlooked, including minorities, children, the elderly, the indigent and people living in rural America.
After her husband’s presidency was over, Carter continued her leadership through the Carter Center, which she and Jimmy Carter founded in 1982. For several decades she organized annual symposia and forums devoted to finding feasible solutions to the multifaceted problems in mental health. She authored books on the topic, testified in Congress and established the Rosalynn Carter Fellowships for Mental Health Journalism and the Rosalynn Carter Institute for Caregivers. The Institute addresses a frequently forgotten group, those who take care of people suffering from mental illnesses, including among others depression, schizophrenia, bipolar, substance abuse, generalized anxiety and obsessive-compulsive disorders.
Raising awareness of issues surrounding mental health and articulating what needs to be done marked the start of a process and roadmap to address the problems. Here, Rosalynn Carter was instrumental as a trailblazer. She leaves behind an immensely valuable legacy.
But there’s currently a critical lack of funding at the state and local levels to accommodate the growing demand for mental health services. Society isn’t doing enough to fund mental health research, provide adequate resources to alleviate shortages in inpatient beds, pay healthcare providers sufficiently, build infrastructure and cover medical costs for patients.
To put it bluntly, mental health services in the U.S. are woefully inadequate despite more than half of Americans (56%) seeking help, according to the National Council for Mental Wellbeing. Limited options and long wait times are the norm for patients, especially with respect to psychological therapy, but also critical care when patients experience crisis episodes. There are numerous cost and insurance coverage barriers coupled with the fact that physical health is still better insured than mental health.
And as is evident throughout the U.S. healthcare system, stark disparities in access persist. Differences in access to mental healthcare depend on a person’s ability to pay or where they live. Individuals located in rural areas and those with less means are unlikely to have sufficiently accessible mental health services.
There is also a dearth of consistent messaging by public health authorities on where to get appropriate treatment.
More than one fifth of U.S. adults experienced mental illness in 2020, which is almost 53 million people. And 5.6% of U.S. adults, or 14 million people, had an episode of “serious mental illness” in 2020.
Psychiatric hospitalization is the treatment option of last resort for individuals with acute or chronic serious mental illness who need intensive inpatient care. However, beds are in short supply.
The number of psychiatric beds per 100,000 people in the U.S. ranks 29th among all 38 countries in the Organization for Economic Cooperation and Development.
What’s happening in Massachusetts is representative of the situation nationwide. In 2020 and 2021 more than 350 beds in psychiatric facilities were eliminated amid staffing shortages in the state’s behavioral health system.
In worst case scenarios, not being able to access care can lead to self-harm. According to the Centers for Disease Prevention and Control, provisional data for 2022 show a record high of 49,369 suicide deaths.
The system is dysfunctional from top to bottom. There aren’t the necessary resources for a suitable physical foundation—appropriate facilities and building space—for accommodating increasing numbers of mental health patients.
Misconceptions regarding mental health remain. Nearly a quarter of Americans still don’t view mental health as being as important as physical health. Given this attitude, society appears willing to spend disproportionately more on somatic diseases than on mental illness, despite the heavy disease burden. And so, there are gaps everywhere, from lack of research dollars—mental health receives nowhere near as much in public donations as somatic diseases do—to subpar treatment coverage.
Legislators have attempted to close some of the insurance coverage deficiencies. To illustrate, prescription drug coverage for mental health has improved in the past decade, at least in certain insurance markets. In Medicare, for example, anti-depressants and anti-psychotics are included among the six so-called “protected drug classes,” which means that “all or substantially all” medications in those therapeutic categories must be covered by Medicare Part D (outpatient) plans. Also, the Affordable Care Act provided for an expansion of mental healthcare coverage when it was enacted in 2013. Specifically, the law requires that most individual and small employer health insurance plans, including all plans offered through the ACA exchanges, reimburse a fairly broad assortment of mental healthcare and substance abuse services.
However, a large segment of the commercial insurance sector isn’t subject to the ACA regulatory guardrails. Additionally, the legislative measures and regulations often don’t extend to guaranteed coverage of psychotherapy: For instance, cognitive behavioral therapy. In many instances, CBT is used in conjunction with pharmacotherapy. Yet insurers in the public and private sectors often only cover the latter, not the former, or only on a very limited basis.
What’s more, psychotherapy reimbursement rates for healthcare providers have been stagnant or in decline for several decades, which is extraordinary in light of the growing mental health crisis during this period.
Rosalynn Carter paved the way to find solutions to our mental health crisis. She was a driving force for change throughout her public service career. Nevertheless, while there’s improving awareness around mental health and the significant burdens posed by mental illness, to achieve what she set out to accomplish society will need to devote more resources.
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