Millions Being Cut off Medicaid: How Will it Impact Mental Health?

Monday, August 21, 2023

By Don Sapatkin

Doctors and nurses plead for help in emergency departments overwhelmed by children with emotional problems. States have kicked nearly 5 million people off Medicaid in just over four months. In Ukraine, “How are you?” is an open invitation to talk about how you’re coping with the trauma of war. Plus, tips for young professionals with performance anxiety.

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A stealthy approach to mental health treatment for the elderly

Older people face significant barriers to treatment: Mental health professionals are under-trained in treating the elderly. Medicare doesn’t cover many types of mental health providers, although a proposed rule would add social workers, counselors and others starting next year. Stereotypes that depression and anxiety are normal developments of aging get in the way. And then there’s the stigma.

One way to overcome it is what NPR calls “stealth mental health” — an approach that New York City’s Department for the Aging uses in senior centers that serve some of  the largest and most diverse populations in the country. Beyond speaking visitors’ language and understanding their culture, the department has found that indirect approaches – like Uddin’s workshop discussion of self-reflection – can encourage them to open up on everything from their physical health to depression.

“It’s a different generation, different thoughts…different than me,” says one participant in Uddin’s workshop.  Toward the end, the 92-year-old man tells her he’d like to talk privately about his relationship with his son. She agrees and reminds the dozen or so men and women that this is an option: “You can always make an appointment, we’ll sit down, we’ll be totally private, and we can really connect on what’s happening,” Uddin says.

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Five million adults and kids cut off Medicaid. The mental health impacts could be profound

But there’s another looming impact – and one that’s barely been mentioned in media coverage of the removals: Medicaid is the largest payer of mental and behavioral health services in the country. At a time when rates of mental illness, overdose and suicide have been spiking, eliminating the ability of millions of people to get services won’t help.

The mass removals that began in April are the result of the expiration of a pandemic-era rule that temporarily barred states from disenrolling Medicaid beneficiaries. As a result, the number of people insured through Medicaid swelled by 32%, significantly lowering the uninsured rate. With the rule’s expiration, states around the country have been sending enrollees renewal notices to determine if they are still eligible.

As of August 17, at least 4.8 million had lost coverage in 44 states plus Washington, D.C., according to the Kaiser Family Foundation’s Medicaid Enrollment and Unwinding Tracker. Some 75% of those removals are for procedural reasons such as not replying to notices that many people find confusing. The Centers for Medicare and Medicaid Services last month ordered a dozen states to pause terminations for certain people and restore coverage, at least temporarily, due to concerns that disenrollments may have violated federal rules.

Red states have removed the most people, many of them children. In Texas, according to the Kaiser Family Foundation, 72% of all Medicaid recipients have been cut off. Montana, Idaho and Arkansas have removed about 60%, while Florida has removed nearly a third, prompting this editorial from the South Florida Sun Sentinel:

After Gov. Ron DeSantis signed one of the nation’s strictest abortion bans in May, he said: “One of the things I’m most proud of is that the state of Florida stands unequivocally in defense of the family, and in defense of our children. And we have done more to protect children than any state in the country.”

As he said those words, state officials were rushing to dump hundreds of thousands of Floridians off the Medicaid rolls. Roughly one-third of those losing coverage are children. As the Orlando Sentinel reported, some of them are so sick they’re not supposed to lose coverage.

The impacts of this are only beginning to be felt.

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Overrun by children with mental health issues, ED doctors and nurses plead for help

With children and teens suffering from mental health problems still overwhelming emergency departments nationwide long after the pandemic has subsided, three national medical organizations put out a desperate call for help in both their hospitals and surrounding communities, NBC News reported.

“The scope of this problem is really great,” said Mohsen Saidinejad, a professor of emergency medicine and pediatrics at the David Geffen School of Medicine at the University of California, Los Angeles. “But our ability to solve it is not there.”

Saidinejad is lead author of a joint policy statement from the American Academy of Pediatrics, the American College of Emergency Physicians and the Emergency Nurses Association. The policy statement made 39 specific recommendations (summarized in a news release) in areas ranging from prehospital to the emergency department, community, systems of care and research. Among them:

• Develop community-based teams that can respond to pediatric mental health crises in schools, physicians’ offices and homes.
• Add pediatric mental health professionals to emergency departments.
• Support ED staff with information specific to groups at high risk for mental health concerns: victims of abuse, post-traumatic stress, depression and LGBTQ youth.

An accompanying report published in Pediatrics reviewed how the range of children’s mental health and substance use issues are managed before, during and after emergency department visits, and the myriad challenges along the way.

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In Ukraine, a simple question that goes far deeper than it appears: ‘How are you?’

The question is much more than a casual conversation starter, NPR reports. “It’s an invitation to express how you’re coping with the war.”

“We ask because we understand that it’s a part of our inner therapy,” said art historian Halyna Hleba, a curator of an exhibit – “How Are You?” – of paintings, sketches, sculpture and video made by Ukrainians since Russia’s invasion. It aims to get visitors thinking – and talking – about their mental health. These conversations have long been suppressed in Ukraine, a remnant of the Soviet era. But the trauma of war now touches everyone, and the whole country is in the midst of a collective mental health crisis. All Ukrainians are trying to cope.

The national “How Are You?” campaign is the brainchild of First Lady Olena Zelenska. “I am very pleased with the words and the tone of this program — kindly and friendly. It’s not a paternalistic approach,” she said in a recent podcast. And it appears more Ukrainians are seeking help.

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In other news…

Performance anxiety doesn’t have to hold you back at work or prevent you from being successful, according to Forbes’s how-to-overcome it guide for young professionals. Tips: Work to achieve “flow states” of intense focus that effectively wall off your inner critic. Take “opposite action,” by forcing yourself to act when anxiety pushes you toward avoidance and isolation. Notice recurring negative thoughts and cognitive distortions and label them, which reduces their power. Accepting anxious thoughts is more effective than trying fruitlessly to suppress them.

A majority of American adults have felt the impact of the addiction crisis, according to a Kaiser Family Foundation poll: Nearly a third say they or a family member has at some point been addicted to opioids. Two-thirds say that they or a member of their family has been addicted to alcohol or drugs, became homeless as a result, or experienced a drug overdose leading to an emergency room visit, hospitalization, or death.

Children who were physically assaulted may have triple the risk of mental illness during the following year, Medscape reported, declining to twice the risk later in childhood compared with children who were not assaulted. The study in JAMA Network Open used administrative records in Ontario to identify 5,487 children ages 0 to 10 (average age: 7) who had been assaulted and 21,948 controls, and followed them for up to five years. The primary outcome was diagnosis of mental illness or suicide.

Sixteen witnesses to last year’s grocery store massacre of 10 Black people in Buffalo, N.Y. have sued social media and firearms-related companies, as well as the white supremacist gunman’s parents, for causing emotional trauma, Reuters reported. The complaint filed in state court names as defendants YouTube and Reddit, where gunman Payton Gendron was allegedly radicalized through exposure to harmful content and learned information to help carry out his attack. Other defendants include Alphabet, Google, and three retailers that allegedly sold firearm equipment and body armor that Gendron used.

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If you or someone you know is in crisis or experiencing suicidal thoughts, call or text 988 to reach the 988 Suicide & Crisis Lifeline and connect in English or Spanish. If you’re a veteran press 1. If you’re deaf or hard of hearing dial 711, then 988. Services are free and available 24/7.

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