Make therapy free for everyone

The COVID-19 pandemic has helped to draw greater attention to mental health issues that can be neglected in public policy debates. Even as the worst of the pandemic recedes, this is a good moment to consider improvements in mental health policy, especially better screening for mental illness; real parity between mental and physical health; and the provision of cognitive behavioral therapy (CBT) for all, and for free.

1. Better mental health screening

Mental health problems typically present early in life, with three quarters of lifetime mental health conditions beginning by the age of 24. Yet an average of 11 years elapses between the onset of symptoms and diagnosis. Early detection allows for early and more effective treatment. Screening for depression and substance-abuse disorders has received the necessary approval from the U.S. Preventive Services Task Force and must be covered (often without cost-sharing) under private insurance plans, Medicare, and most Medicaid coverage, due largely to provisions of the Affordable Care Act. But too often it is not provided. Mental health screenings ought now to be universal in schools and colleges, as well as in all clinical settings, including those serving pregnant women and new mothers.

2. Real parity between mental and physical health

Additionally, while laws are in place to require insurance plans to cover mental and physical health care on equal terms, that does not always occur in practice – in part because the legal framework has significant gaps. A good place to start would be the implementation of the recommendations of the Mental Health and Substance Use Disorder Parity Task Force in 2016, especially leveling the field in terms of pre-authorization requirements, introducing parity “templates” for insurance companies, and imposing civil financial penalties for parity violations. All employer plans should also be legally required to cover mental health care.

3. Free universal cognitive behavioral therapy (CBT)

When it comes to the provision of mental health treatment, a simple step in the right direction would be enabling universal access to cognitive behavioral therapy (CBT). CBT is a “problem-focused, empirically based psychotherapy that teaches patients to detect and modify thought patterns and change behavior to reduce distress and promote well-being.” It has been proven to be highly effective and relatively inexpensive. One study in the U.K. even concluded that the fiscal benefits of higher employer and lower disability claims would outweigh the direct fiscal costs of free universal provision.

The U.K. has now introduced free access to therapy without referral through its National Health Service. The U.S. Army is now providing psychological support to soldiers to promote “mental fitness.” As Brigadier General Rhonda Cornum, director of the Comprehensive Soldier Fitness program, put it, “We need to attend to psychological fitness the same way we do physical performance.” This is true for everybody. Universal coverage would also send a signal that mental health problems of one kind or another are the norm rather than the exception, which can help reduce stigma.

In the U.S., providing universal access to therapy will be more complicated than in the U.K., but it is still achievable through improvements such as:

• Providing access to CBT in all public schools and colleges, while also making it accessible to those performing civilian or military service.
• Ensuring that Medicare, Medicaid and private health plans (as well as any new public option) provide first-dollar coverage of CBT for all.
• Making the more flexible rules on teletherapy introduced during the COVID-19 pandemic the norm.
• Expanding community health centers, which can provide high-quality mental health support in a primary care setting, especially to traditionally under-served groups.

CBT is relatively cheap and quite effective. Of course, there are other forms of therapy that are equally effective for certain conditions – Medication-Assisted Treatment (MAT) for substance abuse disorders, for instance –and these treatments should also be available at no cost. The argument for CBT in particular has been presented here because of its broad effectiveness and low cost; but it should simply be viewed as an example of the kind of reforms necessary to elevate mental health care more broadly.