Divisive Conversations

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A few days ago I came across an article in The Conversation which contained a couple of errors and points worth clarifying. I’d hoped to put them in the comment thread, but found that I’d missed the 72 hour window. Seems a bit short to cut people off after that, but in any case I have a blog so here are my reflections on that article.

The short opinion piece was by Louise Stone and Christine Phillips, focusing on the recent Federal Budget announcements for mental health care. I support many of the valid concerns the authors raise. My focal interest is in the claims made about Medicare-supported access to psychological care.

Quite rightly, the authors point out that we currently don’t have much information about the needs of those who do not present to mental health care services in Australia. Less than half of those who are diagnosed with a mental health condition receive therapy of any kind. If our goal is to help more Australians access supports and services that they need, then it’s important to find out what their needs are and how to best support them.

However that doesn’t mean we should disregard the needs of those populations who currently do access mental health care.

For many Australians, ten sessions of psychological care are not enough. From research we know that providing access to a longer duration of care will help countless Australians, regardless of whether we are talking about Medicare or indeed any other system of care. When Medicare support is cut off, a large proportion of people who started accessing therapy simply stop getting help. Without the support of Medicare, psychological care is out of reach to the majority of Australians. The authors claim that offering Medicare support for a longer period does not address equity issues, however it’s rather obvious that Medicare provides tangible support for huge numbers of Australians who would otherwise go without. Coming back to those horrifying statistics about people who receive no care at all, it is surely a bad outcome for us to provide such inadequate levels of support that people are forced to disengage from seeking help entirely.

The authors go on to say that “all people who need mental health care should be able to receive it”. It’s a lofty and noble goal that I’m sure has many of you nodding in agreement. And it’s a sentiment I strongly agree with, however I feel the need to point out that was never actually the intention of the program. When the Better Access program was launched in 2006 by John Howard, the goal was far more modest: to better utilise psychologists in the Medicare system (read the policy announcement from 2006). Note that the former PM’s statement stresses there’s “no quick fix” and that a range of other support services will be required from both the States and the Commonwealth across many years. Expectations that Medicare should reach every person, or address every single equity issue are, to put it mildly, a tad excessive. So claiming that this was the basis of the Better Access program is absolutely a straw man argument.

The crux of the position seems to be that there is a zero-sum funding game for mental health. That is, the authors suggest we choose between funding therapy for depression/anxiety, or otherwise spend that funding on housing, trauma, and so on. Suggestions of that kind mischaracterize those with anxiety or depression as undeserving of care. By dismissing their needs in favour of those who require other types of services, we discourage people who experience anxiety and depression from seeking help. If you’re reading this, I remind you that suicide rates remain alarmingly high in Australia, so we really need to encourage people who reach out for help when they need it. Why put one group of our population at odds with the other, particularly in mental health care? That’s just uncalled for.

Is it fair to say critics want the projected $100 million in funding to be directed to their own projects? I’m not sure, but that’s how it comes across. In any case, zero-sum funding arguments let politicians off the hook in a context where Australia significantly underfunds mental health care to the tune of at least $5 billion annually. We can and really should be investing across all of these domains, not cutting off Medicare support to fund other areas. As for the other three planks of the value-based care movement listed in this piece, the Better Access program appears to be a pretty good fit. So if you’re looking for more equity in the Medicare system, then by all means, campaign for policy changes which will reduce gap fees and increase the rate of bulk billing. But for now, let’s get the number of sessions right.