May is Mental Health Awareness Month and this year the novel COVID-19 has complicated an already fraught system of behavioral health care in the United States. Many people experiencing new or exacerbated grief, anxiety, and depression because of the pandemic and the ensuing economic recession. As more people become eligible for Medicaid as a result of losing their jobs, Medicaid’s unique role in providing behavioral health services is more important than ever, along with other public health interventions to support people in crisis.
During the 2008 economic crisis which resulted in increased unemployment, suicide rates increased by 20-30%. While suicide is already a concern with approximately 48,000 suicides in the U.S. in 2018, we also know that each suicide is accompanied by about 20 suicide attempts. During a time of social distancing and emergency services stretched to capacity by COVID-19 infections it is difficult for people to get the care they need when they experience a mental health crisis or suicide attempt. Innovative crisis services are needed to care for the increasing population of people with mental health conditions. One important type of mental health support are crisis hotlines. Crisis hotlines calls have increased during this pandemic and serve as an important safety net. Crisis hotlines provide rapid crisis response to those in distress and are trained to deescalate, assess suicide risk, and support the person calling the line.
State Medicaid programs can also provide community-based mental health services to support people in crisis. Telehealth – specifically therapy and counseling by phone, video call, or other remote methods – is crucial during this time of social distancing. Many state Medicaid programs have relaxed rules to allow for sessions via telehealth. Yet, the demand for therapy and counseling is rising, in some cases, wait times can stretch for weeks. Telehealth also requires access to a reliable phone and internet connection, which are not readily accessible to many low-income people or people in rural areas. In addition, some people living with housing insecurity still need mental health professionals to physically check up on them. States are using Medicaid to adapt their service delivery to people with mental health conditions during the pandemic: for example, California is working with counties to deliver mental health services in person or by telehealth to people experiencing homeless who are quarantining in hotel rooms, and New York expanded its existing crisis services to include in-person wellness checks to people with certain mental health conditions who are unhoused.
People who have substance use disorders also have an increased risk of experiencing a behavioral health crisis, especially an overdose, during the pandemic. The pandemic has hit at a time when the U.S. was already in the midst of a public health crisis of drug overdoses involving opioids and stimulants, with overdoses the leading cause of death for U.S. residents under age 50. And access to substance use disorder treatment was already difficult before the outbreak of COVID-19, especially in rural parts of the country.
The necessary physical distancing required to slow the spread of COVID-19 interferes with many of the support systems that people who use substances rely on to obtain support and treatment. As clinics close to walk-in patients or reduce the number of people they can see, many are having difficulty accessing medication-assisted treatment for opioid use disorders, which are the most effective way to prevent people from dying from overdoses. And the need for services is likely to be increasing, as many people appear to be using substances more frequently to cope with things like isolation, stress, financial insecurity, and grief related to COVID-19. At the same time, because of the physical distancing measures that many jurisdictions are using to prevent the spread of the virus, when someone overdoses, the likelihood that someone will be present to rescue them with naloxone is much lower.
Given the challenging times we are in, the need for creative crisis-services to prevent and address overdoses is more important than ever. Federal rules that required frequent in-person visits to obtain medication-assisted treatment have been relaxed, making it easier for people to receive services by telehealth, and obtain longer prescriptions for the medications they need. Most states have worked swiftly to implement these changes in their Medicaid programs; Medicaid is the single largest payer for substance use treatment in the U.S. States have also sought other creative ways to prevent and treat overdoses: for example, New Jersey increased home-distribution of naloxone to its Medicaid beneficiaries with known substance use disorders, New York has been delivering methadone to homeless individuals in treatment who are quarantined, and many non-profit needle exchange programs are finding ways to deliver supplies to people from a distance, including protective equipment like gloves and face shields that can reduce the risk of COVID-19 transmission among those who use substances.
The need for services to address and prevent behavioral health crises is more important than ever during the COVID-19 pandemic. Medicaid programs must shift rapidly to provide necessary behavioral health services in ways that increase access while also reducing the risk of transmitting COVID-19.