John Oliver delved into the woeful state of mental healthcare in the US, which has only been strained more by the spike of mental health concerns during the pandemic. In 2020, four in 10 Americans have reported symptoms of anxiety or a depressive disorder, compared with one in 10 in 2019. “It may help explain why for that one month last year, everyone on the internet suddenly started singing sea shanties,” the Last Week Tonight host said on Sunday evening. “It was clearly a collective cry for help.”
But despite widespread awareness of the problem, people looking for help are encountering a system “that’s just not set up to provide it”.
For one thing, there’s overwhelming demand for a short supply of mental health professionals. According to the American Psychological Association, in 2021, 65% of psychologists reported that they had no capacity for new patients. A Senate report found that more than half of Americans who need mental healthcare do not receive it, with higher rates for minorities. Oliver pointed to one Black man in an NBC News report, who said he couldn’t find a Black male therapist “for my life”.
“Wow, ‘I couldn’t find a Black man for my life’ isn’t something you expect to hear about finding a therapist,” Oliver said. “It’s something you more expect to hear about the crowd on January 6th or all 10 seasons of Friends.”
“Across the board, whether in small towns or big cities, we don’t have enough mental health professionals,” he said, a gap that has proven attractive to Silicon Valley. Tech companies such as Woebot, Talkspace and Chatbot “claim to hook you up with therapists and in some cases, medication,” said Oliver. “They’re basically Uber, but for your brain.
“And look, there is nothing inherently wrong with teletherapy,” he continued. “In theory, it can help fill in some of the very real gaps in access” but “the reality of these services has often been deeply underwhelming”. The company Cerebral, for example, became subject of a federal investigation over whether it over-prescribed controlled substances like Adderall.
“It is clear mental health apps are not going to save us here, because they’re not dealing with the main underlying issue,” Oliver said, as they “can’t suddenly hire more clinicians if not enough exist. And that shortage speaks to a mental healthcare system that is so dysfunctional, it seems almost designed to prevent people from accessing it or providers from entering the field.”
This is despite so-called “parity” laws at the state and federal levels, which require insurance companies to reimburse for mental healthcare at the same rate as other health services. Nevertheless, Oliver pointed out, insurance companies have found ways to deny coverage, such as through “ghost networks”, which are lists from insurance providers padded with clinicians who either don’t take new patients or are no longer in the coverage network.
Insurance companies have also overturned coverage in the middle of treatment; Oliver pointed to the case of one Ohio family left on the hook for $88,000 of their own money after insurance deemed inpatient care for their suicidal teenager to be “medically unnecessary”.
“If you’re wondering how insurers can get away with that sort of thinking,” Oliver explained, “it’s partly because the government has, to this point, done shockingly little when it comes to enforcing parity laws”. Federal and state agencies rarely penalize insurance plans – the Labor Department closed just 74 parity investigations in fiscal year 2021, finding violations in only 12; state-level enforcement have levied fines just 13 times since 2017, “which is absolutely pathetic”, said Oliver. Public insurance such as Medicare and Medicaid also reimburse community health providers, whose own funding has deteriorated, at “woefully insufficient” levels.
“Basically from top to bottom, we significantly underpay mental health professionals,” Oliver said, “many of whom do difficult, high burnout work”.
Overworked, underpaid, struggling to make ends meet unless they practice in a high density, high wealth area – “therapists are in a no-win situation here”, Oliver added, referring to a news clip in which anonymized mental health providers say they’re being run into the ground by low reimbursements. “For what it’s worth, it is just not a great sign that insurance companies are now so powerful that mental health providers feel like they have to go on the news like they’re in witness protection after seeing someone get whacked.”
The costs of not addressing the crisis are high: mental health problems drive homelessness and force people into contact with the criminal justice system. “It is often said the correctional facilities have become the largest providers of mental healthcare services in our country,” Oliver said. “Basically, we’ve gone from warehousing people with mental illness in buildings that felt like prisons,” such as the sanatoriums of the early 20th century, “to warehousing them in actual prisons instead. It’s very much the new look, same great taste of America’s failures.”
How to fix it? “Clearly, this is an absurd way to operate a healthcare system, and for the umpteenth time, I would argue single-payer healthcare is the way to go,” Oliver said. In lieu of that political non-starter, it’s strengthening and enforcing mental health parity laws – such as in California, which in 2020 passed a measure requiring insurance companies to base decisions of “medical necessity” on current standards, not criteria they impose themselves.
“In the past, so much of the problem here was that people would not ask for help. And thankfully, that’s now less of an issue,” Oliver concluded. “But now when people do reach out for help, we’re just not in a position to give it to them. If we want to be a society that truly respects and values mental health, we have to respect and value mental healthcare, and that means supporting the people who deliver it.”