LOUISVILLE, Ky. - Terri Hall's anxiety was back, making her hands shake as she tried to light a cigarette on the stoop of her faded apartment building. She had no appetite, and her mind galloped as she grasped for an answer to her latest setback.
In January, almost immediately after she got Medicaid coverage through the Affordable Care Act, she had called a community mental health agency seeking help for the depression and anxiety that had so often consumed her.
Now she was getting therapy for the first time, and it was helping, no question. She just wished she could go more often. The agency, Seven Counties Services, has been deluged with new Medicaid recipients, and Ms. Hall has had to wait up to seven weeks between appointments with her therapist, Erin Riedel, whose caseload has more than doubled.
'She's just awesome,' Ms. Hall said. 'But she's busy, very busy.'
The Affordable Care Act has paved the way for a vast expansion of mental health coverage in America, providing access for millions of people who were previously uninsured or whose policies did not include such coverage before. Under the law, mental health treatment is an 'essential' benefit that must be covered by Medicaid and every private plan sold through the new online insurance marketplaces.
The need is widely viewed as great: Nearly one in five Americans has a diagnosable mental illness, according to the Department of Health and Human Services, but most get no treatment. If the law's goal is met, advocates say, it will reduce not only personal suffering but also exorbitant economic costs, like the higher rate of general health problems among those with mental illnesses, and their lost productivity.
Kentucky has been trying to overhaul its mental health system, partly by allowing private psychologists and social workers to accept Medicaid patients for the first time. The change is crucial, state officials say, because 85 percent of the 521,000 Kentuckians who got coverage through the state's new insurance exchange this year were poor enough to enroll in Medicaid. Previously, only psychologists and social workers at community health centers like Seven Counties, which are quasi-governmental agencies, could provide outpatient therapy to Medicaid recipients here. Now, more than 1,000 private mental health providers statewide have signed up to treat Medicaid enrollees, according to the state.
But shortfalls in care persist. In Louisville, a city of 600,000 where The New York Times is looking periodically at the law's impact, most new Medicaid enrollees are flowing to four adult mental health clinics run by Seven Counties. Calls to the agency's access line, the starting point for new clients, are up by more than 40 percent this year, said Kelley Gannon, its chief operating officer.
Seven Counties declared bankruptcy last year in the face of spiraling pension costs, and a federal judge ruled that the agency could leave the state pension system. Ms. Gannon says the services it provides are not in jeopardy.
The last time Ms. Hall had seen Ms. Riedel, in late June, they had talked about her plans to return to school with a Pell Grant and work toward an associate degree. But the next day, an eviction notice arrived in Ms. Hall's mailbox. She had fallen behind on her rent and was being ordered to court. The coping techniques she learned in therapy - taking long walks and deep, slow breaths, for example - were not helping. Nor were the antidepressants and mood stabilizer that a Seven Counties psychiatrist prescribed. And her next therapy appointment was still more than four weeks away.
Ms. Hall is 52, with spiky, short blond hair and a deeply lined face that attests to a life roiled by stress. Addictions to alcohol and the anti-anxiety drug Xanax ended her marriage and gravely damaged her relationship with her son, who is now 27. She faced losing her small downtown apartment, and with no income at the moment other than a $600 monthly alimony check, her forward momentum was under threat.
'I haven't felt this way since I got my divorce,' she said as she stamped out her cigarette, speaking fast and sweating in the damp morning heat. 'Then, I went back to Xanax, and I don't want to do that this time. I want to be able to handle this somehow.'
Treating the CommunityTana Jo Wright is doing her part to treat new Medicaid recipients with mental health problems. It is just not as easy as she would like.
A licensed clinical social worker, Ms. Wright opened her own practice last fall after working at a busy community clinic in the blighted West End of Louisville. In a tiny rented office with a vase of peacock feathers on her desk, she is seeing 15 clients, several of them new Medicaid recipients.
Like their physician counterparts, many private therapists refuse to accept Medicaid, which pays on average about 66 percent of what Medicare does. In addition, some therapists say, the paperwork takes too much time and the poor - who often experience more violence and trauma than those who are better off - are too challenging to treat. But Ms. Wright, 47, has a different outlook. She grew up in rural Lebanon, Ky., had a tumultuous relationship with her adoptive parents and was battered by a boyfriend at 16.
'Those experiences told me that people really need someone who will listen to them,' she said. 'And I thought: 'You can do that. You would be a good therapist because you know what people go through.' '
She has worked with drug addicts at a methadone clinic, with abused children and teenagers at Seven Counties, and with low-income adults at Family Health Centers, the clinic in the West End. Now that she is building her own practice, she sees more clients with Medicare and private insurance. But she said she remained committed to treating people on Medicaid, motivated by the therapists who agreed to see her when she was struggling.
'I believe in treating the whole community,' Ms. Wright said, 'including people who can't afford to pay.'
The new law is a big opportunity for mental health providers to reach more people of all income levels. But in Kentucky and the 25 other states that chose to expand Medicaid, the biggest expansion of mental health care has been for poor people who may have never had such treatment before.
Still, private providers face considerable headaches in taking on Medicaid patients, beyond the long-term deterrent of low reimbursement. Ms. Wright, for instance, is still waiting to be approved by some of the managed care companies that provide benefits to Medicaid recipients. Eager to build her client base, Ms. Wright has taken on a handful of new Medicaid enrollees for free while she waits for those companies to approve her paperwork.
'It's been months and months,' she said. 'It's always there in my mind: Am I going to make it?'
Her clients, and the progress she sees in them, are her sustenance. There is a young man scarred by gang violence; an older woman whose daughter was murdered years ago; a veteran with post-traumatic stress disorder. And there is Sarah Davis, a Louisville native struggling to get past the bullying she experienced as a child and her negative feelings about her hometown.
Ms. Davis, 30, was teaching English in Japan when the devastating earthquake and tsunami struck in 2011. She came home, suffering nightmares and panic attacks and clashing with her parents as she tried to readjust. Earning less than $15,000 a year as a home health aide, Ms. Davis qualified for Medicaid under the new law. She heard about Ms. Wright from someone at a meditation session and has been seeing her once a week.
'So what's happening?' Ms. Wright asked as Ms. Davis settled into a soft chair in her office one summer afternoon, tucking her legs underneath her.
They talked about Ms. Davis's precarious finances and her trouble finding a job she loved. Then they returned to a familiar theme: Ms. Davis missing her life abroad and chafing against the realities of adulthood in Louisville, where she felt isolated and judged.
'My life used to be so beautiful and colorful, and I want that back,' she told Ms. Wright.
'There are some great things about this town if you open yourself up to experiences,' Ms. Wright countered as a small fan ruffled the peacock feathers.
Ms. Davis allowed that she had gotten back in touch with an old friend the previous week and struck up a conversation with a new neighbor. Ms. Wright, who has an emphatic laugh and a penchant for colorful 'bling rings,' leaned forward and smiled.
'Two times you've told me you stepped out of your comfort zone. That is progress!' she said. 'Take that in.'
Feeling Abnormal
As a teenage loner in Elizabethtown, Ky., Ms. Hall never felt normal. 'I knew something was wrong with me,' she said, 'but I didn't know what.' She had a chronically ill mother and a domineering father. Always anxious, swinging between high moods and low, she started drinking heavily after she got married at 22.
Ms. Hall temporarily stopped drinking when her son was born a few years later. But then she became addicted to Xanax - 'I was still numbing myself,' she said - and resumed drinking once her son started kindergarten.
Her husband divorced her in 2004 and married one of their friends. She made several suicide attempts, she said. After her father paid for her to go to rehab, she moved to Louisville in 2011 to live in a halfway house for recovering addicts. When she found the rental apartment last year, she sold her last asset, a car, so that she could afford the rent of $475 a month plus utilities. She was working at the time, running concession stands at sporting events, but making only about $500 a month.
By the beginning of this year, loneliness and grief about her severed relationships with her ex-husband, son and other family members threatened to swallow her again.
Without therapy, 'I would have gone back to drinking and using drugs, because I was hurting so bad that there was nothing left for me to do,' she said. 'I knew I would not live the rest of this year.'
In an interview, Ms. Riedel, 33, said that Ms. Hall's therapy sessions had been successful because she had been so motivated - so desperate - to change.
'She's still struggling with some pretty serious life issues,' she said, 'but her attitude has changed so much. She's so much more optimistic.'
As her outlook improved in recent months, Ms. Hall busied herself with other projects. Besides registering for community college and applying successfully for a Pell Grant, she used her new health insurance to get treatment for spinal stenosis, which causes pain and numbness in the legs and back, and forced her, she said, to leave her job. She also sought assistance from an agency that helps people with disabilities, which gave her some tuition money and is helping her look for jobs.
Even when adversity struck, Ms. Hall stayed purposeful. Within a day of getting the eviction notice, she gathered the names of a dozen organizations that might provide rent assistance, dialing one after the other from her mother's antique rocking chair in her apartment. She did not find any organization willing to help pay her back rent, but her relentless research did lead to another option. For $248 a month, she could move to a privately operated 'sober living' house. She started packing her apartment, but took a break one recent morning to attend a group-therapy session with Ms. Riedel.
'We haven't really gotten to talk, and so much has happened,' she said. 'I just want her to be proud.'
As of that morning in mid-July, Ms. Riedel's schedule was booked six weeks out; her caseload had grown in the past year to 263 clients, up from 100 just a year before. But Seven Counties was hiring new therapists, Ms. Riedel said, and she hoped to soon return to seeing Ms. Hall once every two weeks.
Given the long waits for individual therapy sessions, Seven Counties is urging new clients to also try group therapy, for which there is no wait. Ms. Hall has sometimes attended Ms. Riedel's weekly 'Empowering Women' group, and at one recent session, she sat at an oval table with Ms. Riedel and four other women, paper and pen before her in case she gleaned something interesting. She was quiet as several of the others discussed their own problems: an abusive relationship; binge-eating; regret about growing old.
Finally, it was her turn. 'Terri, how about you?' Ms. Riedel asked.
'Well, I got an eviction notice,' she said. 'But I found a place, it's for sober living. The woman who runs it accepted my application, but she wants to meet with me and talk first. I'm just praying everything goes well.'
A week later, things took another turn for the worse. Ms. Hall went home to Elizabethtown and stayed a day longer than she had planned to attend a family funeral. When she returned, she learned that she had lost the room in the sober-living house because she had not arrived on the appointed date.
She moved in temporarily with a neighbor, and then a friend, leaving her few possessions in the basement of her former building. She attended more group therapy sessions, thought about college starting and pictured herself in her first class: psychology. Last week, she finally returned to Ms. Riedel's office, her hands shaking again as she unloaded weeks' worth of tribulations. She talked about the pain of being judged by her family - if they knew about her eviction, she said, 'they'd be madder than heck at me.' With Ms. Riedel's support, she decided to stop contacting them for now.
She also discussed her fear of not finding a new home, and Ms. Riedel offered reassurance. 'You are taking steps toward a career that will give you a steady income,' she said. 'You are a very resilient person. I see this as you bouncing.'
The 45 minutes flew and they made another appointment, only two weeks away. Ms. Riedel said that in the meantime, she would see if Medicaid would pay for a caseworker to help Ms. Hall with things like finding housing.
'Are you feeling O.K. right now?' Ms. Riedel asked as Ms. Hall got up to leave.
'Yes,' Ms. Hall said, tucking away her appointment card. 'I'll be fine.'
