Marketplace Pulse: The Challenge of Obtaining Mental Healthcare in the Marketplace

The Marketplace Pulse series provides expert insights on timely policy topics related to the health insurance marketplaces. The series, authored by RWJF Senior Policy Adviser Katherine Hempstead, analyzes changes in the individual market; shifting carrier trends; nationwide insurance data; and more to help states, researchers, and policymakers better understand the pulse of the marketplace. This blog was co-authored by David Schleifer, Vice President, Director of Research at Public Agenda. 

A range of intersecting factors make mental healthcare difficult to access and afford. These include a scarcity of mental healthcare providers, growing demand for mental health services, and greater cost-sharing burdens on people accessing behavioral health services compared to those accessing physical healthcare. And while someone might need to see a primary care physician or OB/GYN once or twice annually, mental healthcare typically involves meeting with a provider far more frequently. This can make episodes of care more expensive and appointments scarcer.

To increase access to mental health services, the Biden Administration has proposed new rules to strengthen mental health parity. They would tighten requirements for insurers, who would have to demonstrate that their enrollees have equal access to physical and mental health services. The rules would also target “ghost networks” (inflated and inaccurate lists of in-network providers), and limit other common roadblocks to mental healthcare, such as requiring a referral to see a mental health provider or charging differential cost-sharing for mental and physical health services.

What is at stake for people who are trying to access mental healthcare as the Administration considers these new rules? Marketplace enrollees are often asked to pay more for mental health services compared to physical healthcare. For example, nearly 20% of silver plans in 2023 subjected mental health visits but not primary visits to the deductible. While not necessarily a violation of the Mental Health Parity Act, this benefit design clearly creates a differential affordability barrier to mental healthcare.

Recently released findings from in-depth qualitative research conducted by Public Agenda with support from RWJF explore how people with Marketplace insurance try to find in-network healthcare providers and the challenges they encounter in accessing care. Public Agenda’s diary study closely followed a group of 17 people covered by insurance plans purchased on state and federal Marketplaces for four weeks in the fall of 2022 as they tried, largely fruitlessly, to find in-network mental healthcare providers. They answered weekly structured prompts as they searched for providers, tried to figure out which were in-network, obtained referrals if needed, and tried to schedule appointments.

Sago, a market research firm, recruited the study participants to Public Agenda’s specifications. All were trying to find a mental health professional for feelings such as mild or moderate depression, sadness, anxiety, stress, or grief. All were 18 years or older and covered by insurance purchased from a state or federal health insurance Marketplace. Potential participants were excluded from the study if they had ever been hospitalized for a mental health condition. In order to avoid including people who might be unusually good at navigating health systems and benefits, potential participants were also excluded if they or anyone in their household worked in healthcare in any capacity.

Most participants had already been searching for a mental healthcare provider before the study began, but none managed to schedule an appointment with an in-network provider that took place during the study. Participants described piecing together information across a variety of sources during their searches to identify prospective mental healthcare providers, confirm whether they were in network, and gauge potential fit. Most participants contacted prospective mental healthcare providers directly in order to inquire about the next available appointment and whether the provider would accept their insurance.

Nearly all participants experienced challenges in their search for a mental healthcare provider, with most experiencing multiple concurrent challenges. The most commonly cited challenges were a lack of in-network providers, a lack of appointments available at feasible times, and the time-consuming nature of the search process itself. Some participants’ plans required them to get referrals from their primary care providers, further delaying care.¹

“Two months ago, I went to see my primary care doctor. I received a referral, and I had been attempting to contact the psychologist for six weeks. I finally got through to the doctor's office a week and a half ago to make an appointment. And the first available appointment they have is about two months away.”  —Howard, in his 50s

“A big hang-up is having to go to the doctor, get the referral, wait for the insurance to okay it, wait for the mental health place to have an opening. It's just too long of a process and it should be a shorter, streamlined type of process. I hope that policymakers in Washington, that they will consider a different way that we could get mental health.” —Lucia, in her 50s, Florida

Participants were asked how they believed that challenges or delays in finding a mental healthcare provider and getting the care they need had affected them. The most common impacts that they reported were on their mental health, physical health, relationships, and work.

“I definitely have increased anxiety over the inability to find a provider. It leaves me feeling defeated and depressed.” —Nathaniel, in his 40s

“I have had debilitating anxiety this week because I am overwhelmed by how many more hoops I have to jump through to get help. I don't have the extra time or money to start all over again and look even harder for a mental health provider.” —Sharon, in her 40s

One participant reported that he was able to take better care of his physical health when he was able to book an appointment with a mental healthcare provider.

“Knowing that I had the upcoming appointments, I made it to the gym today and worked out. It made a great difference in my physical wellbeing and mood.” —Ted, in his 50s

All study participants struggled with accessing mental health services. Study participants expressed the view that mental healthcare should be more affordable and easier to access, both by including more providers in networks and by lowering cost-sharing. Some criticized policies requiring referrals, because they felt that this prolonged the search process, created stress, and necessitated scheduling and waiting for expensive primary care appointments.

To learn more about Public Agenda’s findings and methodology, and to access findings from a companion study that followed people covered by marketplace plans as they tried to access in-network diabetes care providers, go to https://publicagenda.org/resource/netad-2023/.

¹ Quotations have been minimally edited for clarity. The names used are pseudonyms.