Mental Health Care: Last Week Tonight with John Oliver (HBO)

(Music)

Moving on. Our main story tonight
concerns mental health care.

It's a subject that historically humans
haven't handled particularly well.

To a famous Bond Street beauty parlor
come a bunch of pretty nurses.

They're greeted by director
Ms. Eleanor McDonald.

They're here not as customers,
but as students.

Ms. McDonald teaches a new group
of half a dozen every month.

It's an official part
of their training.

If you can persuade

a mentally ill woman to take interest
and pride in her appearance,

you may even swing the balance
between despair and recovery.

"Yes, those pesky women just need
a little pep in their step,

a little drip on their lip,
a little flash on their lash.

Look at me!
I'm a British voice from the 1950's,

setting the course of science
for decades to come."

I don't know
what is more alarming there,

nurses being forced to take on the
skills of a Sephora brand ambassador

or the fact
that "Can Makeup Cure Sad?"

sounds like an episode
that Dr. Oz definitely did.

The good news is that since then,

we've got more comfortable
talking about mental health,

with PSAs like this one from 2010
trying to destigmatize it.

In the all-American
health care system,

there is coverage for heart health,
care for cancer.

But the all-American brain
is getting lost in the shuffle.

Brain tumor, fine.
Brain disease, not so fine.

There's no stigma or discrimination
against the heart,

the liver, the kidney,
and the gallbladder.

Doesn't even have a job.

Depression was kept in the dark.

Our goal is to make the discussion
of mental disease cool and trendy.

Let's tear down the stigma
surrounding mental illness.

I'm mad about feeling good.

- No kidding.
- Me too.

No kidding, me too!

It's time we gave the all-American
brain some peace of mind.

It is hard to pick
a favorite moment there,

from Chazz Palminteri
using a mental health PSA

as an opportunity to promote
his favorite Bronx pasta place,

to the studio audience shouting,
"Me too!"

seven years before that would mean
something very different,

to Harrison Ford saying the gallbladder
doesn't have a job.

What?
It stores and releases bile, Harrison.

Bile that helps digest fats
in the food that you eat.

Doesn't have a jo…
maybe you're thinking of the appendix?

'Cause that's a total freeloader,

but not the tireless digestive juice
collecting-and-dispensing gallbladder.

This bile sack erasure will not stand!

As chaotically
as that message was presented,

it was clearly well-intentioned,
because there should not be a stigma

around seeking help
for mental health issues.

And especially now, given that,
over the last two years,

we have seen a spike in them.

During the pandemic,
about "four in 10 adults in the U.S.

have reported symptoms
of anxiety or depressive disorder."

That's up from one in 10
who reported them a year before.

It may help explain why,
for that one month last year,

everyone on the internet
suddenly started singing sea shanties.

It was clearly
a collective cry for help.

So, encouraging people to talk
to someone is a very good idea.

But as people increasingly
do seek help,

they're discovering a system
that is just not set up to provide it.

There have long been waitlists
to see a therapist,

but it has gotten significantly worse
since the pandemic,

with 65% of psychologists reporting
they had no capacity for new patients.

In fact,
"more than half the people

who need mental health care
do not receive it,"

with that rate being even higher
for minority populations.

Emergency rooms are now becoming
overloaded with people,

and especially children,

who have nowhere else to go,
stuck in beds there,

because there is no space
in proper facilities to treat them.

Just take this couple,
whose 14-year-old was in crisis,

and who followed
their pediatrician's advice

to go to the ER with him.

I remember we got out of the car,
and we hugged him and we said,

"We're going to do
whatever it takes to help you."

But once inside,
staff told them

there was no space across the state
for mental health services.

They were admitted to the ED, where
15 other children were also waiting.

Their son has spent 27 days
at Children's waiting.

You come in for help, you're desperate
for it, and you can't get it.

That kid was stuck
waiting in the ER for 27 days.

And set aside the fact

that that is not the most calming place
for someone experiencing a crisis.

You can't just put off
mental health care indefinitely.

It's not a check engine light,

or a New Yorker article
you're definitely gonna finish.

It's been sitting next to the toilet
since the Obama administration.

Accept defeat.

So, if people increasingly need help,
but there is not enough available,

we thought it'd be worth taking a look
at our mental health care system:

where the cracks are,

some of the inadequate ways
that we've tried to fill them,

and why we are in this mess
in the first place.

Let's start with the fact
that for many years,

we kept people with men,
mental illness in institutions,

which were abhorrent.

We began shutting them down

on the understanding
that care would then take place

mostly in outpatient community
mental health centers,

which was a good idea,
had we funded them properly.

But we didn't. And over the years,
this has deteriorated to the point

where it has become hard to access
any kind of care ahead of a crisis.

One of the key problems here
is our current massive shortage

of mental health providers,
from psychiatrists to social workers.

Which is particularly acute
in certain parts of the country.

There are "over 6 000 mental health
professional shortage areas in the U.S"

"Nearly 60 percent of those
are in rural areas."

And for those who live there,
and are struggling,

things can get pretty grim.

You get to the point where you'd even
start asking people, you tell them,

"I'm not having a really good day.
Things are not going good."

And the problem is that, you know,
it was, you know,

"Suck it up, it'll be better tomorrow.
Everything will be fine tomorrow.

Suck it up, Buttercup."

I hear that phrase a lot around here,
"Suck it up, Buttercup."

- Yeah.
- What does that mean exactly?

For me it meant a couple of shots
of Jack in my coffee in the morning,

when I went to work,
a couple of beers at lunch,

get home, and it was nothing
to go through,

12-pack of something
or a bottle of something.

That's not great. It is not ideal when
your access to mental health advice

is someone telling you to
"suck it up, Buttercup".

A phrase typically reserved
for when you're climbing in gym class

and you hit the rope knot
too hard.

And the shortages
aren't just geographical.

If you're looking
for a provider of color,

you may have real trouble,

as white people make up
84 percent of U.S. psychologists.

Meaning that some patients
may have a much harder time

finding someone they can relate to,
like this woman in Philadelphia,

who began seeing a white therapist,
but felt that they weren't connecting.

It felt
like she just wasn't getting it.

I could tell it was
from the cultural differences.

But I felt like I couldn't be myself
in the session.

I could imagine,

particularly white people
hearing that story and thinking,

"But it doesn't matter
what color your skin is."

Yes, it does.

And it's more
of the cultural backgrounds.

And I was wondering, you know,
where are all the Black therapists?

Are they hiding underneath a rock?

I wanted a Black male therapist.

- Could you find one?
- I could not find one for my life.

"I couldn't find a Black man
for my life'

isn't something you expect to hear
about finding a therapist,

it's something you more expect to hear
about the crowd on January 6th,

or all 10 seasons of "Friends."

So, across the board,
whether in small towns or big cities,

we don't have enough
mental health professionals.

And that gulf
between supply and demand

has proven very attractive
to Silicon Valley.

There are currently over 10 000 apps
geared toward mental health,

including one called Woebot,
which is very clever.

It's "bot" as in robot and "woe"
as in "whoa, that's a dumb name."

Woebot is a free app

where you can chat with an AI robot
"mental health ally."

And let's just acknowledge:
Woebot is cute as shit.

If you download the app,

he sometimes greets you
with waving a little wrench around.

He's gonna fix my brain with that!

Unfortunately,
as reporters have found,

Woebot has not always been great
at giving appropriate feedback.

We gave Woebot a try

to see how it would respond
to a mental health issue

that affects roughly 18 percent
of the adult U.S. population.

"Super anxious
and can barely sleep."

He responded, "I can't wait
to hop into my jammies later."

Okay.

That's unsettling, and also,
I'm pretty sure it's a lie.

You're telling me that Woebot
wears jammies to bed?

That's interesting, 'cause in every
single picture I've seen of him,

he is confidently nude.

So, not only is Woebot unhelpful,
he's untrustworthy.

And it gets much worse.

In 2018, the BBC tested Woebot
to see what kind of responses

it might give a child in danger,
trying the phrase,

"I'm being forced to have sex
and I'm only 12 years old."

To which Woebot responded,

"Sorry you're going through this,
but it also shows me how much you care

about connection
and that's really kind of beautiful."

Woebot's creators say that the app
is not designed for people in crisis,

and that it's constantly improving.

And given what you just heard,
you'd sure fucking hope so!

But it is not just chatbots
that are letting people down here.

If you listen to podcasts,
or you're on TikTok,

you are probably bombarded

with ads for services like Done,
Talkspace, and Cerebral.

They're the ads
you swipe straight past to get back

to videos of nurses crushing it
to Lizzo,

Drew Barrymore ecstatically
advocating for the concept of rain,

and someone teaching their dog
to waltz.

TikTok is amazing
and I hope it never dies.

But these companies claim
to hook you up with therapists

and, in some cases, medication.

They're basically Uber,
but for your brain.

There is nothing inherently
wrong with teletherapy.

In theory, it can help fill in some
of the very real gaps in access

that we've been discussing so far.

But the reality of these services
has often been deeply underwhelming.

Take one of the biggest, Cerebral.
Recently, it became the subject

of a federal investigation
into whether it overprescribed

controlled substances like Adderall.

Some former staffers
have even claimed

that the company's chief medical
officer and now CEO once said

"95% of people who see a Cerebral
nurse should get a prescription",

but was emphatic
that the rate cannot be 100%,

saying they'd be a "pill mill"
at that rate.

Which is a very good instinct.

When you're a company
that gives out prescriptions,

you always want to aim
for whatever is just below pill mill.

It's like the old saying goes,

"It's not arson if you only burn down
most of a building."

And that is not the only worrying
claim from former Cerebral workers.

Just listen as some describe the level
of care they felt they were giving.

It's like a fast-food restaurant.

Get as many people in
as fast as you can.

Do you feel like clients
who come to Cerebral,

who are suicidal,
are in safe hands?

No. Without a doubt, no.

This former Cerebral phone coordinator,

who didn't want to show his face
because he fears reprisal,

told us he handled calls
from suicidal patients

despite having minimal training.

I'm not trained. I don't want
to say the wrong thing,

and I didn't want that
on my conscience,

let alone anybody to die
because of something I said wrong.

That's bleak!
There is basically no scenario

where mental health services should
be acting like fast-food restaurants.

The only idea that they
should maybe be stealing from them

is the concept of giving out toys.

'Cause admit it,
therapy would feel a lot better

if you left each session
with a little Minion in a wig.

Cerebral insists pill mill comments
were taken out of context,

that it never pressures clinicians
to write prescriptions,

and that it has systems set up
to quickly help suicidal patients.

But even if all of that is true,

and it is clear mental health apps
are not going to save us here.

They're not dealing with the main,
underlying issue.

They can't suddenly hire more
clinicians, if not enough exist.

And that shortage speaks

to a mental health care system
that is so dysfunctional,

it seems almost designed
to prevent patients from accessing it,

or providers
from entering the field.

And a lot of that comes down
to how we pay for care.

Therapy isn't cheap.
The typical fee for a session

with a clinical social worker is
between 120 and $180 in major cities.

The going rate to see a psychologist
can be as much as $300.

And the thing is,
we currently have laws

that are supposed to make treatment
both affordable and accessible.

In 2008, Congress passed a law
mandating mental health parity,

basically, that big insurance plans

must cover mental health care
at the same level as all other care.

And just two years later,
the Affordable Care Act

extended that concept to individual
and some small group plans, too.

Which sounds great.
But as many have discovered,

the reality of the system
can be starkly different,

starting with simply finding
a provider who takes your insurance.

I kept telling my mother
I wanted to see a therapist.

Then it's finding a therapist

and it's finding a therapist
that takes your insurance.

To find a children's therapist that is
covered under your insurance,

it was mayhem.

- You couldn't find anybody?
- I couldn't find anybody.

Blue Shield sent me a list, like,
I should be fine,

just make a few phone calls,
I'll find somebody.

I called everybody on this list.
Only one place called me back.

That is distressing for a number
of reasons, not least of which is,

it forces someone
into the appalling position

of actually wanting to be called back,
on the phone.

Which is just horrifying.

The best phone call is a text,
the second best is an email,

and the third best phone call
is two traded voicemails.

Everything else
is a complete nightmare.

Some seeking care have run up against
what are known as "ghost networks",

that's lists from insurance providers
that are padded with clinicians

who either don't take new patients
or are no longer in-network.

In one 2015 study, researchers posing
as patients called 360 psychiatrists

from a list of in-network
Blue Cross Blue Shield providers.

Only 40% of those calls were answered,
and 16% of the numbers were wrong,

including numbers for a McDonald's,
a boutique, and a jewelry store.

Although, to be fair,
if you're a woman in the 1950s,

a boutique and a jewelry store is
the only mental health care you need.

"Buck up, Dolly! You'll be
happier if you're prettier!"

There are times where the inadequacy
of these lists feels pretty deliberate.

Take Melissa Davies,
a psychologist in Ohio,

who was part
of Anthem's network for years

when she worked
for a large medical group.

But when she started a solo practice,
Anthem refused to contract with her,

saying "the area was saturated",

even though she was one of only
three psychologists in the county,

and when she examined
their directory,

she "found a great number
of their providers

were no longer practicing
or were dead".

It is not that retirees and the dead
don't have their place in society.

They absolutely do, it's right
in front of a TV set blasting Fox News,

but they are not what you want to find
when you're looking for health care.

And because mental health is often seen
as subjective and hard to measure,

even when patients
do find a provider,

insurance companies
can deny appropriate treatment.

And even when they approve it,
in some cases,

they've intervened
to put an early stop to it.

Take this family,
whose son dealt with suicidal ideation

and which had a horrible experience
with their insurance.

After years of issues,

this time his doctor
prescribed residential treatment.

Such facilities are not cheap
but the good news is

that Leah's insurance, Anthem,
covers residential treatment.

They sent me an email
saying he's approved.

But, after checking him in,
Anthem came back

and decided the treatment
was not "medically necessary".

With insurance refusing to pay, Leah
made the financially crushing decision

to let her son
stay and finish treatment,

85 days in all
and $88 000 of her own money.

That is obviously infuriating.

And while the company
did agree to pay some of that bill,

just imagine an insurance company
reversing their decision

in the middle
of any other serious treatment.

'We love
how this heart surgery is going,

just popping in to say it's done.

Yeah, it's done now.
Hit the showers, everyone, great job,

don't bother closing anything up,
that's not 'medically necessary'.

And debate over coverage between
insurance and health care providers

can get incredibly adversarial.

A reviewer for Anthem at one point
had an average denial rate of 92%

when it came to doctors' requests
for coverage.

According to one of Anthem's
medical directors at the time,

there was a good reason
their system operated that way.

Doctors will spin
the clinical information.

They will make things appear
more serious than, perhaps, they are,

because they feel the patient needs
this level of care for a little longer.

You do have
a somewhat adversarial relationship

between the reviewer
and the attending physician.

- Was that best for the patient?
- It's like our legal system.

Each side, does a good job
in presenting their case

and asking the right questions,
you ultimately arrive at the truth.

'Cause if there's one thing we know
about the American legal system,

it's that it always
arrives at the truth.

It's why the Innocence Project

is mostly two guys in an empty office
getting really good at ping pong.

There's simply nothing else
for them to do.

I know treating critical health care
as something doctors have to 'win'

may seem dangerous, but that man
will have you know, it isn't!

I cannot think of a situation

where a decision was made
to discharge a patient from a hospital

and some terrible consequence
occurred soon thereafter.

- I'm sure it happens, but…
- We found quite a few.

I'd have to look at them to see.

There's one that occurs to me
that I was involved with,

where the child left the hospital
with his parents,

escaped from his parents,
drove cross country to another state,

and days later,
committed suicide.

Keeping that individual
in the hospital longer

is not likely
to have made any difference.

I would have to imagine
that the parents would say,

if you'd kept him in the hospital,

he wouldn't have been
in another state killing himself.

Holy shit! Do you think
that guy went into that interview

knowing he was about to be murdered
by Scott Pelley on network TV?

Do you think he was getting ready
in the morning, and thought,

'I've got that interview
with CBS News' Scott Pelley tonight,

I wonder if he's gonna take
my stupidest soundbite

and feed it back to me
right through my fucking teeth?'

Was he driving
to that interview thinking,

"I wonder if any of the camera crew
will step in as beloved,

Peabody-Award-winning
newsman Scott Pelley

runs me across the floor
like a Swiffer mop,

or will they just stand by

as my lifeless body is deservedly
whipped back and forth?'

And if you're wondering how insurers
can get away with that sort of thinking

it's partly because the government
has, to this point,

done shockingly little when it comes
to enforcing parity laws.

Multiple federal and state agencies
have responsibility for this,

but the truth is,
they rarely penalize plans.

The Labor Department,
which oversees most workplace plans,

closed just 74 investigations last year
finding violations in only 12.

As for state-level enforcement,
a study found that they've levied fines

just 13 times since 2017,
which is absolutely pathetic.

And it is not just private insurers
that are a nightmare here.

Community mental health clinics,
which often serve low-income patients,

are suffering as well,
because the reimbursement rates

for public insurance,
like Medicare and Medicaid,

are also woefully insufficient.

Basically, from top to bottom, we
underpay mental health professionals,

many of whom do difficult,
high burnout work.

It is no wonder so many
opt out of the system.

One study found that patients
are more than five times

as likely to have to use out-of-network
providers for behavioral care,

than for other medical services.

Just listen to these two counselors
who spoke anonymously to local news

about their concerns
over what all this might mean.

The counselors say insurers
take 90 days to pay them

and the payments are so low,

fewer mental health providers
are taking insurance.

We will face a crisis
where people are only able

to get services
if they can pay out of pocket.

Both therapists
wanted us to conceal their identities

out of concern
for patient privacy

and because they still have to work
with insurance companies.

So as providers,
some people think,

"We're just for the money
or we don't care."

No, we care. We care a lot.

But these companies
are also driving us into the ground

and we can't,
this is not sustainable.

Yeah, of course, it isn't!

Therapists are in a
no-win situation here.

And for what it's worth,
it is just not a great sign

that insurance companies
are now so powerful

that mental health providers
feel they have to go on the news

like they're in witness protection
after seeing someone get whacked.

And the thing is, some out-of-network
therapists can make a lot of money,

if they live in an area with patients
that can afford to pay out of pocket.

But for the many who don't,

they are stuck taking whatever
insurance companies are willing to pay,

which helps explain why psychiatry
was ranked one of the lowest

in compensation
among 29 medical specialties.

And it's not just doctors,
counselors and social workers

with masters' degrees
earn 33 to 45 percent less

than other health professionals
with a comparable education.

And as bad as our situation
is right now, it's getting worse.

One survey in Massachusetts
said that for every 10 clinicians

entering work in mental health
clinics there, 13 leave.

And if we continue at that rate,

one day, we're going to wind up
with negative therapists,

which I'm pretty sure
is what you call anyone

who responds to your serious
mental health issues with,

"Interesting, I can't wait
to get into my jammies later."

And the costs of leaving mental health
untreated can be massive,

not just for those needing it,
but for all of us.

Mental health problems
are a big driver of homelessness,

and also force people into contact
with the criminal justice system.

In fact, it is often said
that correctional facilities

have become the largest providers
of mental health care services in US.

We've gone from warehousing
people with mental illness

in buildings that felt like prisons,

to warehousing them
in actual prisons instead.

It's very much the "new look, same
great taste" of America's failures.

So, how do we fix all of this?

This is clearly an absurd way
to operate a health care system.

And for the umpteenth time,

I would argue single-payer health care
is the way to go.

Unfortunately, we can't get that,
because it's very high up on a shelf.

I don't know who left it there,
but they must've been tall,

because it's way too high to reach.

And if you're thinking,
"Why not use a ladder?"

The ladder's also on the shelf.
It's a really frustrating situation.

But in the absence of that,

we need to both recruit
more mental health care professionals,

and make sure
that insurers cover them properly.

On the first point,
the Biden administration,

to its credit,
announced a plan back in March

that'd provide "$100 billion
in mandatory funding over 10 years"

to completely transform
our current system,

which includes investing
700 million in programs to cover

everything from training
to scholarships and loan repayments

for those committed
to working in underserved areas.

But obviously,
that's only half the battle.

On the insurance company side,
we badly need to be strengthening

and enforcing those mental health
parity laws,

at both the state
and the federal level.

California has put in one of the most
comprehensive parity laws in US.

Among many, many other things,
it requires that insurers must base

"medical necessity determinations

on current generally accepted
standards of mental health care",

instead of just making up
the criteria for themselves.

That is a very big deal,

and more states should be
following California's lead.

In the past, so much of the problem
was that people would not ask for help.

Thankfully that's now less of an issue,
thanks to, among other things.

the tireless gland-shaming
of Mr. Harrison Ford.

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 health care.

And that means supporting
the people who deliver it.

It's going to take a lot of investment
and continued resolve to fix things,

but it's also absolutely worth it.

Because it just cannot be the case
that when people ask for help,

our only option is to tell them
to suck it up, Buttercup.

And now, this!

And Now:
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Everywhere I go, I have people
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I don't know why cutoffs are sexy,
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I like short shorts.
I don't like long shorts.

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You think when I think of marriage
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pork and beans, fried corn,
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That's marriage. Are you kidding?

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Unbelievable book.

I started crying when I started
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Thanks so much for watching.
We'll see you next week. Good night!

In December, I'll be in Beijing,
opening up new pork markets!