In March of 2020, Taylor*, 27, a graduate student at Stanford University in California, was having a phone session with her psychiatrist when they told her they could no longer treat her.
She hadn’t seen it coming. She met with the psychiatrist through Stanford's mental health services. And though Taylor had paid the on-campus health clinic fee and was up-to-date on the university-sponsored health insurance, due to the pandemic, she was currently residing outside of California. And that, apparently, was a problem.
"My psychiatrist on campus told me since I was outside the state of California, they could no longer treat me. I’m on the university-sponsored health insurance and because I’m an international student, I had no coverage back at home, either," Taylor messaged Refinery29 via Twitter. "At my last appointment, my Stanford psychiatrist basically told me to find a provider at home — although I hadn’t lived at home for eight years. Then [they] more or less hung up the phone."
Taylor says her anxiety was already high due to the pandemic. Having her mental health care suddenly ripped away only worsened her symptoms. "It made me feel like Stanford couldn’t give less of a shit about their students, which frankly reflects their general attitude around mental health even pre-pandemic," she says.
The inability to provide care for out-of-state and out-of-country students is not unique to Stanford University. Colleges and universities across the country have been facing this same issue throughout the pandemic. The problem lies in licensing and legal requirements: Healthcare providers, like psychiatrists and therapists, get licensed in a particular state; with a few exceptions, they’re generally unable to practice outside of that state.
During the beginning of the pandemic, some states were given temporary emergency allowances. These permitted counsellors to continue treating students who’d left campus due to COVID-19, regardless of where they currently resided, explains Amy L. Hoch, PsyD, associate director of the wellness centre at Rowan University in Glassboro, NJ.
For instance, while COVID-19 was declared a public health emergency, New Jersey has been allowing out-of-state healthcare providers to provide healthcare to NJ residents, via telemedicine or in person. But even while this emergency program has been in place, providers licensed in New Jersey who were hoping to provide care to residents of another state would have to look up the regulations of that state to see what’s allowed. They may have to submit proof of their license to that state, or apply for an emergency out-of-state licence. And right now, a counsellor could be working with five students who are currently residing in five different states.
At Rowan, “we can’t cross state lines in providing mental health services,” Hoch says. “Since many students have been sent home or are choosing to stay at home, there might be a gap in services for those students. It's a huge issue.”
This withdrawal of access to mental health care for college and university students couldn’t have come at a worse time. "Even before the pandemic, mental health for young adults is a key issue to really navigating this transition from childhood to adulthood," Hoch says. "Prior to the pandemic, mental health issues were on the rise for young adults." During nationwide lockdowns, she adds, students were feeling isolated, and may have lost their sense of community because they were unable to connect with their classmates and peers in the ways they were used to. As a result, college students became more vulnerable than ever before.
Young adults have reported elevated levels of anxiety, depression, and mental health symptoms during the pandemic, the Centers for Disease Control and Prevention reports. Black people of all ages have been disproportionately affected. In general, LGBTQ+ youths are also more likely to experience mental health disorders, according to a 2020 survey conducted by The Trevor Project.
As the pandemic continues, students need more mental health care — not less.
The problem of providers being unable to provide care across state lines predates the pandemic, though “COVID has kind of amped it up on steroids,” Deborah Baker, JD, director of legal and regulatory policy at the American Psychological Association, tells Refinery29. She says the APA is looking at supporting national legislation that could help address this gap.
One option is PSYPACT, an agreement that lets psychologists practice via telemedicine in states other than where they’re licensed, with the goal of improving access to mental health care. PSYPACT legislation has been enacted in 17 US states, according to the APA: Arizona, Colorado, Delaware, Georgia, Illinois, Missouri, Nebraska, Nevada, New Hampshire, North Carolina, Oklahoma, Texas, Utah, Pennsylvania, and Virginia, with Alabama, Kentucky, and Washington, D.C., joining the ranks in 2021.
"The hope is that eventually all 50 states plus D.C. will sign onto the PSYPACT," Baker tells Refinery29. She says there has been an increase in interest from states since COVID-19 began. "[States are] considering more seriously the needs of interstate practice as it relates to telehealth,” she says. Besides college students, many of whom travel frequently between states, in certain areas it’s relatively common to live and work in different states. “Technology has enhanced mobility and the licensing laws aren't nimble enough to be flexible for other options," Baker says.
Getting a PSYPACT agreement signed by all 50 states is a long-term process. In the meantime, Hoch tells Refinery29 that if a student is in crisis and needs their services, the school’s mental health providers wouldn't turn them away. "If a student calls from out of state, we would never say that we can't provide crisis service," she says. “And I hope most universities would follow that route. We would get them the help they need in the moment." But, she continues, they aren’t able to provide ongoing care for out-of-state students. And that leaves a lot of people — like Taylor — in a lurch.
Refinery29 reached out to Stanford University in September 2020 to ask about the school's inability to continue providing Taylor with treatment. At the time, they responded with this statement: "Our Counselling and Psychological Services (CAPS) remains focused on student mental health and wellbeing, especially at this time of crisis and isolation for so many students. Licensing laws change from state to state and vary according to the degrees of the mental health providers (psychiatrists, psychologists, and master’s level therapists), which can affect the support and access we can provide across state lines. For students outside of California, we provide care management services, help students connect with mental health resources in their local communities, and provide interim support for their needs. Regardless of where they live, we encourage students to reach out to CAPS when they need support. We want to hear from students so we can help address their needs and concerns in real time."
In response to Refinery29’s request for an additional comment in March 2021, Stanford re-emphasised that out-of-state students can call CAPS for “care management services.” The school also noted that they are “working to finalise an arrangement for CAPS to cover the cost of brief therapy sessions, provided by a national/international organisation” for out-of-state students.
Stanford University also voiced support for the TREAT Act, which is legislation that was recently re-introduced in the U.S. House and Senate that would support the ability for full cross-state care for all licensed providers through the duration of the pandemic emergency. In Stanford’s March 2021 statement to Refinery29, the school said it “is strongly advocating for Congress to pass the TREAT Act… Most recently, Dr. Megan Mahoney of Stanford Health Care testified before the House Energy and Commerce Committee in support of lessening barriers to telehealth, including the TREAT Act.”
But for now, students like Taylor may still be without care. "It took me two years to get a therapist [at Stanford], because all of the providers taking the Stanford health insurance in the area weren’t taking new patients," she says. “Who knows how long I’ll be out of state, so I don’t even know if it’s worth trying to find a provider.”
*Name has been changed