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AJN, American Journal of Nursing:
doi: 10.1097/01.NAJ.0000368948.88258.6e
AJN Reports

Mentally Ill and Uninsured in America

Walker, Isabelle T.

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A dangerous combination.

One in four American adults, or 26.2% of the population, is estimated to have some form of mental illness in a given year, according to the National Institute of Mental Health. But the stigma surrounding mental diseases, combined with financial barriers to care such as being uninsured, keeps many of those afflicted from ever receiving treatment.

In fact, of the 30 million Americans who are both indigent and uninsured, 7.6 million will require some kind of mental health care in the course of any given year, according to the National Council for Community Behavioral Healthcare (see And that number doesn't include Americans enrolled in Medicaid.

State mental health agencies serve 6.3 million people a year on a combined budget of $34 billion, said Elizabeth Prewitt of the National Association of State Mental Health Program Directors. But as tax revenues fall and lawmakers labor to eliminate their deficits, funds available to state mental health agencies are dwindling. Anything not specifically dedicated to matching their federal Medicaid plan—a collaboration that brings millions of health care dollars into state coffers—is an easy target for elimination.

Tim Whalen, mental health director for the Salt Lake County Division of Behavioral Health Services, said his county's allocation this year for Medicaid mental health services is $48 million, but only $4 million has been designated for those who don't qualify for Medicaid or have another payment source. And Utah has set aside only $2.8 million to serve the uninsured mentally ill this year.

In Ohio, a 30% reduction in the state's 2010 mental health budget has meant the loss of as many as 4,000 full-time employees of provider organizations, 70% of whom were clinicians, said Hubert Wirtz of the Ohio Council of Behavioral Health and Family Services Providers. "Folks who are uninsured or underinsured may not get access to services at all."

Other states, such as New York and Pennsylvania, have no provision in their budgets for mental health care for the indigent, according to a state-by-state evaluation of services by the National Alliance on Mental Illness (see

A confounding factor. A report by Gonzáles and colleagues in the January issue of Archives of General Psychiatry reveals that members of certain racial or ethnic groups in the United States are far less likely than others to receive adequate treatment for major depression. Examining data provided by the National Institute of Mental Health, the authors concluded that Mexican Americans and African Americans have a greater chance of receiving no care. Moreover, the authors wrote, "The proportions of Puerto Rican and non-Latino white individuals who used concordant therapies [medication and psychotherapy] in the past year were nearly twice those of Mexican American, Caribbean black, and African American individuals."

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One bright spot in an otherwise dim picture is the so-called federally qualified health center (FQHC), a community-based organization that provides comprehensive primary and preventive care to low income, uninsured or underinsured people. FQHCs receive federal grants and are eligible for additional moneys from the Health Resources and Services Administration. These organizations must offer behavioral health care on the premises or provide a referral, and some manage to go even further.

The Family Practice and Counseling Network (FPCN), a nurse-managed health network with three locations in Philadelphia, has more than 22 mental health professionals on staff (including psychiatrists, psychologists, and NPs), who provide long- and short-term therapy and free and low-cost prescription medications. Mental health staff at the FPCN logged more than 10,924 client visits in 2008, according to executive director Donna L. Torrisi, MSN. The 20% of its patients who are uninsured enter into agreements with the network regarding the level of payment they can afford, which is sometimes very little, Torrisi said.

In recent months, the FPCN managed to cut its waiting list for behavioral health to two weeks by assigning a clinical social worker to its primary care department. Working as a consultant to the primary care provider, the social worker is brought in immediately if a mental health condition is identified during an examination. The issue is addressed then and there, and, if necessary, the social worker provides the patient with several private sessions. Consequently, Torrisi said, as much as 80% of the network's behavioral health care is provided in the context of primary health delivery.

"People are integrated systems. We can deal with a patient's physical health better if we're also dealing with her or his mental health," Torrisi said.

Integrating mental health and primary health is a trend highly favored by the nation's mental health advocacy organizations, including Mental Health America (MHA). That's because a high percentage of people with serious mental illnesses are dying from preventable chronic diseases, according to Sarah Steverman, director of state policy in MHA's Healthcare Reform Department. In fact, data from the Substance Abuse and Mental Health Services Administration show that from 1998 to 2001 people cared for in the public mental health system died an average of 25 years earlier than did those in the general population, and those deaths were often the result of a preventable medical condition.

Another reason advocates envision a greater mingling of primary and mental health care is the shortage of mental health providers, Steverman said. "You can find some amazing statistics. There are something like three psychiatrists in the entire state of Alaska."

Because FQHCs are primary care providers, they circumvent the relentless cuts to mental health programs. FQHCs received $2 billion in stimulus funds from the American Recovery and Reinvestment Act of 2009. They also qualify for a federal program that allows the purchase of medications at low cost from a federal warehouse.

But not every FQHC provides as much mental health care as the FPCN. Some only refer patients for mental health care. And Amy Simmons, a spokesperson for the National Association of Community Health Centers, said that of the roughly 1,200 such centers around the country, she knows of only eight that are nurse managed.

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As of this January, federal mental health parity regulations enacted in 2008 require commercial health insurers to provide mental health benefits comparable to the medical services they offer in their plans. This may lower one barrier to care for insured Americans, but unless comprehensive health care reform is approved in Washington, DC, the 7.6 million uninsured Americans who don't have mental health care and need it will continue to scramble or go without.

Isabelle T. Walker

Go to and click on 'Podcasts' and then on 'Behind the Article' to listen to an interview with Patricia Gerrity, PhD, RN, FAAN, director of the 11th Street Family Health Services Center of Drexel University.

© 2010 Lippincott Williams & Wilkins. All rights reserved.


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