Three Challenges to Accessing Care

Ron Mandersheid, Ph.D.
Executive Director, NACBHDD

Ron Manderscheid

On the May 1 “Access to Care” post, we asked, “If you or a family member needed care today for a mental health or substance use condition, would you be able to get it?”

Access to care can help prevent, delay, and treat mood disorders, other mental conditions, and co-occurring illnesses among the 45.6 million adults and 15.6 million children and youths who experience a mental health condition.

However, in reality:

  • Fewer than 40% of adults and youths with mental health conditions—including mood disorders—ever get any mental health services
  • Fewer than 7% of adults with co-occurring mental and substance use disorders get treatment for both.

Let’s explore access challenges to the prevention, diagnosis, and treatment of behavioral health conditions.


Getting in the Door
If you can’t open the door, you can’t get care.

You need a bunch of keys, too: there are impediments with health insurance coverage and cost; the nature of the provider; and physical or psychosocial distance.

1. Insurance-related challenges
The first key to open the access-to-care door for a mental or substance use problem is having health insurance, whether employer-provided, self-purchased, or made available through federal or state health plans.

But insurance is not itself sufficient to open the door because the insurance benefits may not cover, or adequately cover, behavioral health services.

Historically, health plans—including both Medicare and Medicaid—have excluded coverage for some, or all, behavioral health services, while other plans lack appropriate or sufficient coverage over the short or long term. Access to care can be limited by the amount and scope of coverage, as well as by the costs that you must pay.

  • Until recently, health plans have been able to impose annual and lifetime day or dollar limits on behavioral health services.
  • The kinds of care have been limited, such as the exclusion of substance use care and wrap-around services.
  • Copayments—the share of a provider’s charge you must pay—can be excessive, particularly when managing a long-term illness like depression, hypertension, or heart disease.
  • Deductibles—the amount that you must pay health providers before your insurance begins to share in the cost—can also be excessive, and they continue to rise annually.
  • Out-of-pocket costs associated with medications also increase regularly, presenting additional financial challenges for consumers.

2. Provider-related challenges
Health providers may hold another key to access, closing the door to care when they choose not to accept payment through your particular health insurance. Why do some providers decline to participate in selected or all insurance programs?

  • Low pay
  • Too much recordkeeping and paperwork
  • Delayed payment
  • And some believe patient-borne payments are part of the treatment process itself!

Beyond payment issues, health services may not be culturally or linguistically appropriate and accessible. Without an understanding of your heritage and language, neither provider nor staff can bridge a divide that can make even the best-intended services inaccessible. Some providers may view you as a patient rather than a partner in care. Without engaging you (and, as relevant, your family) as a partner in care, access remains limited.

3. Distance-related challenges
It’s also about “getting there” for care: physical and psychological environments hold a final key to open the door to access to care for a mental health condition or substance use problem.

If you are physically unable to get to a provider’s office, access is denied. Distances need to be bridged; costs of travel need to be held down; and facilities need to be physically accessible to individuals who are dealing with both behavioral health issues and physical limitations.

Another Challenge: Stigma

Psychological access is, perhaps, even more of a challenge to care. Too often, little if any effort is made to reduce the stigma that remains attached to seeking care for mental health conditions and substance use disorders. Provider staff attitudes may be dismissive or unsupportive; their language may be insensitive; they may not be sufficiently attuned to manage effectively or even understand waiting room concerns regarding privacy and behavior.

Once In, Can You Get Quality Care?
When you’ve managed to get in the door, here’s the question: Have you opened the RIGHT door?

Will you get care that is individualized and collaborative, based on best-practices, and centered on you and your health needs, including your family when appropriate?

The door you’ve opened to care is the right door if and only if your provider:

  • accurately recognizes and appropriately diagnoses the problem or problems.
  • understands cultural and ethnic implications of a behavioral diagnosis and knows how to respect and work within any limits or differences they may pose for the individual, treatment, or family.
  • intervenes early to help prevent, delay, or limit the effects of behavioral and/or physical problems.
  • engages you (and/or your family, as individually and culturally appropriate) as active partners and collaborators in the process of care and recovery.
  • uses evidence-based treatment, rehabilitation, and recovery practices.
  • offers integrated/coordinated care that focuses on the whole individual, treating all of the problems presented and/or working with other providers to do so.
  • helps ensure that other needed services and supports (housing, education, transportation, job training, etc.) are available to you..

Your Turn
What has been your experience with gaining access to behavioral health care? What do you think are the most pressing challenges, and do you have thoughts about solutions?

Share your stories and ideas by posting your comment below. Also, stay tuned throughout the week to hear examples of people who’ve experienced each of these three major challenges to accessing care.

Ron’s next Expert Perspective explores ways consumers, providers, policymakers, and administrators can work together to address and overcome access challenges. It also examines how the Patient Protection and Affordable Care Act (ACA) affects prevention, early intervention, integration, and collaboration in behavioral healthcare access, care, and services.

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Are you aware of any statistics regarding receiving treatment for those with both mental illness and intellectual disabilities? Here in New Hampshire, the two completely separate systems make it nearly impossible and I know most states have a similar structure. Not that many clinics have anyone with experience to deal with both.


Recent stories posted on this blog emphasize access of mental health care issues faced by many people. In Maine, a recent state budget proposed to eliminate licensed clinical mental health counselors from being able to provide services to folks who are dually-eligible (i.e., who have Medicare and Medicaid). This was proposed as a cost-saving measure. It has been argued, however, that the proposal would simply shift costs to other providers not targeted by the legislation, as well as diminish access to quality mental health care in a State that is largely rural. After much ground work and lobbying, a comprise 5% reduction was proposed - but only for licensed mental health counselors.

When I testified at the State Capital on behalf of mental health counselors and the people who are served, I listened to the Commissioner of the Department of Health and Human Services make her case for this and other program cuts. Clearly, the States are facing budget challenges. But in this case, her argument before the committees was basically that licensed clinical counselors are not reimbursable under Medicare and are therefore the most reasonable group to cut. This position has impacted hiring practices in Maine as well as the aspirations of those who wish to serve as LPC's in our State.

This access to care issue can be reminded in Maine and across the country by the passage of the "Seniors Mental Health Access Improvement Act of 2013". This Senate bill, introduced by Senators Wyden and Barrasso, would establish Medicare coverage for both LPC's and Marriage and family counselors. With Medicare enrollment projected to grow in the next 20 years, this bill would significantly impact access to care issues as well as costs related to emergency room visits, chronic conditions, etc. It would also correct the tone on the State level where implementation of local practices is viewed in light of the Medicare guidelines.

This Senate bill needs co-sponsorship. Companion House legislation needs to be introduced. In Maine, members of the Maine Counseling Association (ACA Branch), and the Maine Mental Health Counselor Association (AMCHA State Branch) have been working to influence our Senators and Representatives. Recently, we are happy that Senator Susan Collins has signed on as a co-sponsor to this bill on the national level. On the State level, a ground-swell of activism from many places (professional, providers, consumer council representatives, university personnel and students, and concerned citizens!) has made an impact on many of our State representatives and Senators.

Access of care issues are not going to go away easily or soon. But advocacy can work. It is so important to give these concerns a public voice. Networking and "bending the ear" of State representatives and actively exhorting our Congressional Friends to pass legislation in support of mental health services is a part of the overall picture.

Working with these issues has underscored two beliefs of mine. First, if we don't speak up, we don’t exist. Secondly, mental health and social justice are one, inseparable process.

John Yasenchak, President Maine Counseling Association


I feel that the most pressing challenge to accessing behavioral health care, specifically for adolescent male onset of mental illness, is the active and often times aggressive denial that it exists. The ease, with which first and foremost parents, lay blame on boys just being boys or teenage boys needing to "man up" or "push through" instead of getting him to a place or person that can help to determine if a mental illness is presenting itself. Mental illness onset in adolescent through young adult males is never fully discussed. Their suicide completion ration rate is so incredibly high that the discussion ends before it even begins. We need to successfully get through to first line caregivers that their actions and reactions will define how their young mans struggle either progresses towards wellness or deteriorates into drugs, incarceration or successful suicide completion.


  1. […] In Tuesday’s Expert Perspective, Ron Manderscheid outlined three common kinds of challenges to accessing mental health care: insurance-related, provider-related, and distance-related challenges. We’ve heard first-hand from Jennifer and Doug how these barriers have impeded their access to mental health care. […]

  2. […] In my last post, I identified the significant economic, geographic, service system, and interpersonal challenges that can slow or thwart entirely the ability to get needed prevention, diagnosis, and treatment services for behavioral health conditions. I pointed out how, as a result, few people with mental health problems ever get either behavioral or physical health care services, resulting in shortened lives by as many as 25 years.  […]

  3. […] Challenges In Tuesday’s Expert Perspective, Ron Manderscheid outlined three common kinds of challenges to accessing mental health care: […]