'Not enough therapists': Georgia lawmakers aim to support mental health workforce

During the COVID-19 pandemic, more than 1,200 state psychiatric hospital employees left their positions, and just over half that number have been replaced, according to state officials.

Meanwhile, courts, aided by a COVID stimulus package, began quickly moving through cases among people suspected of mental illness who had been charged with a crime. That resulted in more orders for mental evaluations to determine whether they were competent to stand trial.

"It's kind of been the perfect storm," said Kevin Tanner, commissioner of the state's Department of Behavioral Health and Developmental Disabilities.

In the past two years, lawmakers in Georgia passed a slate of legislation targeting the mental and behavioral health crisis in the state, which has grown in size and severity since the COVID pandemic began. Those efforts have included a parity bill that requires insurance companies to provide coverage for mental health care and substance-use disorders at levels comparable to physical health care, reaffirming federal requirements, and the development of the 988 system for emergency mental health crisis calls.

Republicans and Democrats agree support for the mental health workforce is the largest issue that remains.

Low pay—the result of stagnant wages and out-of-date reimbursement rates for Medicaid—has beleaguered care providers. Meanwhile, licensure obstacles delay out-of-state therapists from practicing in Georgia.

These staffing shortages create challenges for people in need of timely care; Georgia ranked 49th in access to care, according to Mental Health America's 2023 report. People often wait months before getting an appointment, causing some mental health problems to escalate into crisis.

This year, lawmakers are seeking to build on the previous efforts by budgeting for increases in salaries for state employees and raising reimbursement rates, pending an agreement with the federal government. Several bills are also aiming to encourage more mental health counselors in private practice to work in the state by aligning Georgia's licensure requirements with other states and enabling people to take credentialing exams earlier.

How they get there is still being worked out.

'The perfect storm'

A massive departure of state employees meant that there were fewer people available to treat those with mental illness and get them through the mental health system. For example, more than 30 of the positions for psychologists, including those who conduct the evaluations, were vacant as of February, Tanner said.

Of the state's roughly 4,500 behavioral health and developmental disability employees, most work in state psychiatric hospitals. In Gov. Brian Kemp's proposal for the budget year beginning July 1, all state workers would get a 4% cost-of-living raise, in addition to the one-time $1,000 bonus sent out in December.

For private health care workers, such as doctors, psychiatrists, clinicians and anyone billing Medicaid, the state has requested an increase in federal reimbursement rates for providers. If the Centers for Medicare & Medicaid Services approve, providers serving people with intellectual and developmental disabilities could receive about a 45% increase in payment for their services, and behavioral health providers would get about a 30% increase, said Kaleb McMichen, a spokesperson for the DBHDD.

These rate increases could have made life-changing differences in pay for LaKlieshia Izzard, who worked for several years at community-based behavioral health and developmental disabilities services organizations. Ultimately, low pay as well as a desire to grow her skill set caused her to leave those workplaces and branch out on her own as a telehealth mental health counselor.

When she entered into this field, she knew she was doing so to help people in need—not to rake in money.

"You learn how to adapt to living with a salary that may be a little lower because you really want to help the individuals who are in difficult settings," she said.

Now, she said, it's critical that state legislators increase salaries for state behavioral health workers to allow them to stay in the field and provide services to the most vulnerable people in Georgia.

Georgia has some of the lowest reimbursement rates for Medicaid in the Southeast, which concerns Rep. Todd Jones, who co-sponsored a package of mental health legislation last year. Mental health professionals could be enticed to leave the state and seek better rates.

"Talent can transition when they see they have a better opportunity," he said. "We've got to keep them here."

Another barrier to entry for behavioral health workers is the high cost of education for degrees often required to work in the field.

Senate Bill 480, sponsored by Republican Sen. Mike Hodges, one of Kemp's floor leaders, would allow health care professionals working in mental health and substance abuse to apply to the Georgia Board of Health Care Workforce to get money to pay off student loans if they are caring for "underserved youth" or practicing in underserved geographic areas.

'Hit the road running'

One of the challenges slowing down the pipeline of new behavioral workers into the state is licensing. It can take months for therapists to get credentialed in Georgia, and sometimes they have to repeat courses or meet additional requirements, even if they've been practicing for several years.

Several bills moving through the Legislature were crafted to expedite licensing for marriage and family therapists, mental health counselors and social workers who have worked professionally in other states to practice in Georgia.

Senate Bill 373, sponsored by Republican Sen. Larry Walker, would allow marriage and family therapists who are coming to Georgia from other states to get licensed in the state so long as they hold a valid license in another state, are in good standing, satisfy a criminal background check, complete an application and pay required fees.

House Bill 1344, sponsored by Republican Rep. Katie Dempsey, would allow the Georgia Composite Medical Board, which licenses many health care workers, to waive requirements for licensed professional counselors, licensed clinical social workers and licensed marriage and family therapists to obtain supervisory hours if they have completed two years of work in another state. A similar version, Senate Bill 336, did not pass out of its chamber.

"I'm optimistic that we're actually going to get the key pieces of mental health legislation passed," said Republican Sen. Kay Kirkpatrick, who sponsored SB 336.

Similar to the agreement among states to recognize each others driver's licenses, House Bill 839, also sponsored by Dempsey, would create an agreement between Georgia and other member states that would enable bachelor's and master's level clinical social workers to practice in those states, without having to get individually licensed in each state.

"There's no doubt that one of the lessons we learned during COVID was a shortage of social workers that are needed throughout our state," Dempsey said in a committee hearing. The bill, which would allow counselors in member states to practice in Georgia and Georgia counselors to practice in other states, passed the House chamber last week.

Trenese Johnson, a clinical social worker and therapist, said in the hearing that she began working in Louisiana and is now licensed and lives in Georgia, where she operates an online telehealth business.

"This interstate compact bill will allow me to see and provide specialized service to even more clients outside the state of Georgia," she said.

However, a bill that would have addressed licensing for international physicians stalled in committee.

Ruth Cordova said she is spending about $40,000 to get a degree in marriage and family therapy because her licensure in clinical psychology, which was obtained in Guatemala, is not recognized in Georgia.

At her internship, she is one of only two therapists who speak Spanish serving clients who are victims of human trafficking and have other therapeutic needs.

"There are so many people who need therapy in different languages, but there are not enough therapists to provide it, and not everyone can go back to school," she said.

Another bill, House Bill 793, sponsored by Republican Rep. Matt Barton, would allow social workers to take exams to become credentialed in their last semester of graduate school, so that "once they graduate, they can go ahead and hit the road running," he said. HB 793 passed the House, and the Senate is considering the bill.

'They're exhausted'

Increasing demand for mental health services and a shortage of workers has put pressure on the existing providers. In 2022, 46% of health workers reported feeling burned out often or very often, according to the Centers for Disease Control and Prevention.

Counselors have to take care of their own mental health, too. Salary increases would go a long way to address burnout, said Izzard, the online mental health counselor.

"They're getting home and they're exhausted," she said. "There's usually no time for them to do anything, whether that's working out or doing meditation. If you're too exhausted, not to mention not getting the full compensation that you would like to get, all of that contributes to more stressors."

House Bill 455, sponsored by Republican Rep. John LaHood, would create a safe haven for health care professionals to get therapy to combat career fatigue or burnout, without fear of losing their license or damaging their reputation. The counselor providing treatment to the health care worker, which could include physicians, pharmacists, nurses or any other credentialed professional, would not be required to report their services to any licensing board unless he or she has reason to believe patients could be at risk.

HB 455 has passed both chambers and is awaiting Kemp's signature.

"In this era when we're battling a tough workforce crisis, health care is not immune to that," LaHood told members of the Senate Committee on Regulated Industries and Utilities. "We want to create a safe place and encourage physicians to go seek help and stay in the game, instead of silently suffering and compromising their ability to render good services."

Izzard said the stakes are high to improve the demanding workload expectations placed upon mental health providers.

"They're leaving the field because they're burned out," she said. "We're losing really good counselors."

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