Testimony of Elizabeth J. Clark, PhD, ACSW, MPH
Executive Director, National Association of Social Workers

Submitted to the President's New Freedom Commission on Mental Health
The Omni Shoreham Hotel, Washington, DC
Friday, July 19, 2002

July 19, 2002

Good morning. I would like to thank the Commission for their invitation to come before you this morning. The National Association of Social Workers (NASW) applauded the establishment of this entity by President Bush and we stand ready to assist you as the Commission moves forward with its important work.

I will begin with a brief description of NASW and clinical social work, then discuss obstacles to prevention, assessment, and treatment that face Americans experiencing mental illness, specifically the lack of coordination between systems of care, workforce shortages and challenges, and restricted access to care.

NASW is the oldest and largest professional social work organization in the world, with 145,000 members in the United States. NASW promotes, develops, and protects effective social work practice. NASW is also committed to policy advocacy to support appropriate funding for research on evidence-based practice and program evaluation, as well as adequate funding for public services for at-risk populations.

According to the Substance Abuse and Mental Health Services Administration, clinically trained social workers constitute the largest group of mental health services providers in this country, roughly 192,000. Also, professional clinical social workers constitute the majority, 40%, of the licensed mental health practitioners providing disaster mental health services for the American Red Cross.

Designated as one of the five core mental health professions by the Health Resources and Services Administration, clinical social workers are well prepared for professional practice by completion of post-graduate education from accredited social work education programs. In addition, clinical social workers acquire additional training and supervision after their formal education and are regulated by licensing or certification in every state. Social workers are guided by both NASW's Code of Ethics and practice standards developed by the Association such as the recently published NASW Standards for Cultural Competence in Social Work Practice.

Clinical social work uses the biopsychosocial approach, which examines people, groups, or communities within the context of their environments and facilitates appropriate problem solving within that framework. As a result, clinical social workers are knowledgeable not only about human development and behavior, but also about the social, economic, and cultural issues affecting daily living.

Thus, clinical social workers are skillful diagnosticians and practitioners working with adults and children experiencing mental illness or emotional disturbance including mood, anxiety, substance-related, psychotic, cognitive, and traumatic disorders.

Professional social workers are widely dispersed throughout American society, both institutionally and geographically. Social workers are the practitioners on the front lines in delivering mental health services—indeed, the majority of NASW's membership, 72%, are actually engaged in direct services—including providing therapy, negotiating fragmented systems, and coordinating a continuum of care that ranges from prevention to intervention and recovery. In a recent survey, nearly 36% of NASW members identified private practice or outpatient mental health clinics as their primary employment setting.

Because social work practice is centered in community-based services, social workers offer an important perspective on the interface between the need for mental health services and the resources available within the community to meet that need.

Obstacles

Recognizing the prevalence of mental disorders and the costs they exact, social workers are invested in the prevention of mental illness. When mental illness does manifest, social workers want to ensure that the most effective treatment available is rendered. Social workers are aware, however, of several issues that stand in the way of effective prevention, assessment, and treatment.

1. People seeking help are often hampered by the lack of coordination between systems of care. In the aftermath of September 11, we were reminded just how complicated and overburdened the mental health system is to the average citizen. There is a significant lack of coordination among municipal, state, and federal entities. In addition, the managed behavioral health strategy has sought to reduce the cost of mental health care by reducing provider supply, placing limits on the duration and kind of mental health care provided, and establishing a complex infrastructure that mental health professionals and clients must navigate. There is also a great need to integrate behavioral health services with primary care service delivery. We need to reduce stigma and link health and mental health so Americans are treated in a more holistic manner—uniting the physical and the mental aspects—rather than looking at each one separately without regard for the other. The numbers of treatment visits and hospital stays are limited, which results in the reduction of services. Like our colleagues in psychiatry, psychology, and nursing, social workers spend too much time seeking permission from insurance companies to treat patients that desperately need our services.

2. There are regional shortages among trained social workers and other mental health professionals. Both the need and demand for mental health services have increased exponentially without corresponding increases in qualified credentialed providers and service system capacity. Although mental health is the predominant area of practice for clinically trained social workers, there are regions of the country facing significant shortages of trained social workers to provide mental health services. On average, there are 35.3 social workers for every 100,000 Americans. Yet there is a wide variance in the concentration across the United States, ranging from nearly 100 social workers/100,000 residents in the District of Columbia to just under 15 social workers per 100,000 residents in Arkansas. In fact, 11 states have fewer than 20 social workers per 100,000 residents—Georgia, North Dakota, Nebraska, South Dakota, Virginia, Alabama, Mississippi, Tennessee, Arkansas, Oklahoma and Texas—all states with significant rural populations. If left unaddressed, this current trend of shortages in rural areas can be expected to continue into the next decade. Experienced professional social workers are dropping out of the mental health field because of low salaries, poor reimbursement rates, cumbersome administrative processes, and impediments to service delivery. Who suffers most? Children, elderly people, struggling parents, people with disabilities, immigrants, those with serious mental illnesses, and poor people are clearly most vulnerable. However, the lack of accessible mental health services affects all levels of our communities—and millions of lives. We are in danger of losing an experienced core. Although projections for the next five years indicate continued infusion of social workers into the workforce, a decline in the numbers of more experienced social workers will create gaps in training, mentoring, and supervision for both social workers and paraprofessionals. This continuing supply of new professionals does not assure sufficient workforce retention. Given the fact that the National Institute of Mental Health and the Surgeon General estimate that 1 in 5 Americans, adults and children alike, suffer from a diagnosable, treatable mental disorder in a given year— who is going to be left to treat this 20% of the population?

3. Mental health care access is restricted for far too many Americans. The struggle to provide adequate and appropriate mental health care for adults, families and children continues—in every community in every state. There is a tendency to limit attention to only those who experience serious mental illness, which limits care for millions of Americans. Early detection and prevention are critical across the range of diagnoses. One effective strategy that our nation can use in its effort to provide adequate mental health treatment resources is full mental health parity. Without a broader federal parity statute, the notion will persist that mental health conditions do not warrant the same level of treatment and services as medical and surgical conditions. This misconception is widely held as many think that mental health parity is too expensive. This is untrue. The Congressional Budget Office has estimated that the implementation of mental health parity would cause insurance premiums to rise by an average of only 1.1%—far less than the insurance companies would want you to believe. Furthermore, even the federal government's Medicare program presents structural challenges for those trying to obtain access to mental health services. First, there is the imposition of a 50% copayment for outpatient psychotherapy services under Medicare Part B, whereas all other Part B services have only a 20% copayment. Second, Medicare places an arbitrary limit of 190 days on the number of inpatient days a beneficiary may have covered by Part A in a specialized psychiatric facility, public or private. This limit does not apply though to psychiatric wards or units in general hospitals or to other types of hospitalizations—only to psychiatric facilities. Third, Medicare benefits do not encompass the entire range of treatment with a heavy emphasis on either outpatient or inpatient treatment with no consideration for intermediate levels of care, such as partial hospitalization, intensive case management, day treatment, and group homes. Finally, for the poorest Medicare recipients who are considered to be dually eligible for Medicare and Medicaid, all of their Part A and Part B premiums, deductibles and copayments are paid by their state Medicaid programs—except for those stemming from psychiatric outpatient treatment. This disparity has effectively reduced the reimbursement rates for this population in some areas of the country, thereby creating a disincentive for mental health providers to render services in some instances. Finally, addressing the uninsured and underinsured will also help to break down the access barriers for many Americans.

Conclusion

Chairman Hogan and the other commissioners, NASW commends you and the President for your commitment to improving mental health services for all Americans. Although the path to reform may be long and full of obstacles, NASW reiterates its willingness to work with you and your staff to develop policy and service delivery reforms. We have much more information and many resources than may be presented here. Social work has a unique perspective to bring to the mental health discussion table. NASW looks forward to continuing our collaboration with you and the other stakeholders on this matter of true national importance.

Thank you.