Americans Are Struggling with the Mental Health and Economic Impact of COVID-19

SHANOOR SEERVAI: Hi, everyone. Welcome to The Dose. The COVID-19 pandemic has made life very hard for most Americans and for almost everyone around the globe, but in some countries the response from political leaders has eased some of that pain. On today’s show we’re going to be talking about how the pandemic is taking a toll on the mental health and economic well-being in the U.S., and how this compares with other high-income countries. My guest is Reggie Williams, vice president of the Commonwealth Fund’s program on international health policy.

Reggie, welcome to the show.

REGGIE WILLIAMS: Hi, thank you for having me.

SHANOOR SEERVAI: So let’s get started with talking about the survey. You and your team have been analyzing the results of a survey of more than 8,000 adults in 10 countries to learn about how the pandemic has impacted the mental health and economic well-being of people. So what’s the most important finding?

REGGIE WILLIAMS: Well, it’s clear that the mental health and economic impact of COVID-19 has taken a substantial toll on people across the globe. Data from our research demonstrates that U.S. adults, when compared to people in other countries, face greater mental health and financial consequences from the COVID-19 pandemic. For mental health, one-third of adults reported experiencing mental health concerns — significantly higher than what we saw in other countries. On the financial side, over 30 percent of Americans faced negative economic impacts due to the pandemic — significantly more than in the comparison countries that we focused on. It really reveals that the existing and underlying mental health issues that were there before the pandemic are potentially exacerbated now. Same for the economics. People are struggling with jobs, food, housing, and that’s really taking a toll on people.

SHANOOR SEERVAI: So what you’re saying, Reggie, is that things were bad in the U.S., when it comes to mental health and economic well-being, even before the pandemic hit, and now things have gotten worse. So let’s start with mental health. What were things like before COVID-19?

REGGIE WILLIAMS: So mental health has been a major concern in the U.S. when you compare it to other countries. And we really have an issue with capacity. We do not have enough mental health care providers, particularly psychologists and psychiatrists, to meet the needs of people. We also have the problem of integration. Mental health is not integrated into primary care. And if it was, like it is in other countries, it would make it a lot easier for people to get services.

SHANOOR SEERVAI: So we have a capacity problem. There’s a lack of integration. And then what happened after the pandemic hit?

REGGIE WILLIAMS: So the pandemic really exacerbated a lot of the underlying issues. So we have a situation where people are looking for care, they’re looking for different types of supports and services, so they can get along with their daily lives. And so other countries, you see that they have taken an approach where if you contact your provider, like say in France, primary mental health care is included as a part of home visits and other activities. Or if you say, look at Norway, there’s actually an integrated team-based approach to care being delivered. And people often get access right as they go get a checkup for normal care. And so the pandemic has just really created a situation with social distancing, with people living in kind of quarantine, with people not being able to go and access regular services, where there could be an exacerbation of those underlying mental health concerns that people have.

SHANOOR SEERVAI: So let’s back up a little bit and talk about some of the examples you mentioned in Norway. You say that this is sort of built into the regular care that people would be getting otherwise. So there isn’t really a distinction between medical or physical medical condition and perhaps a mental health one.

REGGIE WILLIAMS: Yes. And in many countries, primary care services are the first setting for mental health care. And so you see ongoing treatment supports and services developed for moderate conditions, kind of right in the normal stream of activities. In Norway, local governments have multidisciplinary mental health teams that do community outreach. We’re starting to see some of those models here in the U.S., but they are by no means the regular way in which care is provided.

SHANOOR SEERVAI: And so now, as we’re talking about a time when people are social distancing and they aren’t even going to see their primary care provider, at least avoiding it if they can, I imagine that diagnosis for a mental health conditions must be way down. But also the pandemic is stressful and everybody is anxious and depressed and worried about whether they’re going to get sick or whether they’re going to lose their job. I mean, that just sounds like a perfect storm.

REGGIE WILLIAMS: It certainly is. And I think where we’re starting to see the promise of telehealth, telemental health services and the like, for all health care telehealth has really exploded to be a much more widely available service because of COVID-19. And we are starting to see some of those same basic things in mental health. But I want to touch upon the idea about mental health and economic consequences, really kind of interplaying. It was clear from our research that in many countries, the struggles associated with mental health and economic well-being kind of go hand in hand. For example, our survey found that half or more of those who faced economic problems during COVID-19 also reported mental health distress.

This was not just for Americans, but also those in the U.K., Canada, and Australia. So we know that when there’s financial concern, the uncertainty associated with a crisis and an event like the pandemic, the mental health impact is definitely going to be high. And you see people reporting more mental health distress.

SHANOOR SEERVAI: I mean, it makes sense that these two issues go hand in hand. If people are worried about where the next paycheck is coming from, that’s bad for their mental health, because the only thing on their mind is: “How am I going to make rent?”

REGGIE WILLIAMS: Exactly. So when you look at something like the CDC’s recent decision to halt evictions, that’s like a great step forward in helping to address concerns from day-to-day life that people have, but it comes without financial assistance. And so when you look to other countries, there were many interventions put in place to make sure that the financial burden was taken away from individuals during this time. European countries gave employers money to keep people employed on staff. In France, Germany, and the U.K. lost wages for displaced workers were upheld over several months. And so it wasn’t just a small bump in unemployment pay, but the government stepped in to ensure that people could one, either keep their jobs, or two, maintain their wages. And that really helped people in the early days of the pandemic when our survey was fielded.

SHANOOR SEERVAI: And what we saw in the U.S. at that time was that businesses were able to apply for loans, but a loan is just a deferred payment. You have to pay it back. And so, even if you have funds for the short term, you’re worried about what you’re going to do when you have to pay that loan back, maybe in the medium to long term.

REGGIE WILLIAMS: Yes. I think it really shows that the higher levels of inequity in the United States really exacerbate some of the problems that people face. In addition, we have a weak social safety net. Other countries have put in place systems around income support and others to protect vulnerable populations. Also, there has been a greater emphasis on meeting people’s social needs. For example, those that were infected with coronavirus and isolating in Germany, there was actually a food service that was put in place to deliver food to people’s doorsteps. In France, the government actually paid to move people into hotel rooms if they were feeling some sort of concern for their safety by living or being in the community. And so in those cases, you see greater social safety-net services being put in place to meet people’s needs. And we don’t really have that same federal response. It’s much more of a patchwork of services.

SHANOOR SEERVAI: And what did your survey find for people who were living on the poverty line, how did the pandemic and how did the federal aid impact them?

REGGIE WILLIAMS: It’s hard for us, from our data to say exactly how the relief monies that came in the United States helped people, but what was clear from our data and our analysis that Americans, Australians, or Canadians were most likely to report losing a job or losing a source of income because of the pandemic. And so we have the situation where people are really concerned about their ability to live a healthy life, address their daily living needs. And the steps that we put in place to address those needs were not as robust as what we have seen in other countries. And so when you look at countries like France, Germany, and the Netherlands, where just 7 to 8 percent of people reported losing a job, that says that Americans are going to face a greater burden. And that there’s an opportunity to provide more supports and services to people in this time of financial uncertainty.

SHANOOR SEERVAI: Listeners, I want to take a minute to check in with you and ask you some questions. Has the pandemic impacted your mental health? Has it changed your financial circumstances? Are you worried about your job, how you’re going to pay rent next month, or something else? These past few months have been sad and anxiety-provoking for all of us. If you want to tell us how you’re feeling, send us an email. Our address is [email protected].

Now back to Reggie, who’s talking about how people in different countries are having different experiences with COVID-19.

SHANOOR SEERVAI: So Reggie, can you talk more about how the pandemic has impacted hunger and food security in the U.S.?

REGGIE WILLIAMS: If you kind of turn on the nightly news or look at articles in the newspaper, you see that people are in need of food, and there’s this real concern as relates to these things around social determinants of health. Like housing, like income, like food. And we really can do more to help people around these social determinants of health. I think about a model of care that we recently evaluated in Italy, and this really focused on addressing the acute mental health needs of people. It dealt with helping them find homes. It dealt with helping them with job training. It focused on ensuring that people had access to food. The types of care models that we see, that take into account these broader social determinants of health, ultimately help people live healthier lives. And it also deals with those economic insecurities that we have talked about earlier.

SHANOOR SEERVAI: Why don’t we have programs like this in the U.S.? Why, in the richest country in the world, are there so many people who are struggling economically?

REGGIE WILLIAMS: I think part of this goes back to the higher levels of inequality in the U.S. For example, the average income earned by the top 20 percent of the richest Americans is more than eightfold higher than the average income earned by the bottom 20 percent. In contrast, the top 20 percent earn only around four times as much as the bottom 20 percent in the Nordic countries, the Netherlands, and France. And so there’s vast income inequality that exists in our country. So if you couple that with a weaker social safety net, you see why we have a number of people in need when crisis comes.

So I think there is an opportunity in the coming weeks, months, and years to really build back up our social safety net, but then also the health care system and health care organizations, hospitals, and insurers have really stepped up to address social determinants of health. Some of the largest investments we have seen in addressing homelessness or dealing with transportation or food insecurity issues have come from the health care sector, because there’s this realization that to live a healthy life, you need to have these other things in place. And so I’m actually kind of hopeful that we have placed small bets and investments that will ultimately lead to addressing these issues over the long term. But it doesn’t take away from the very kind of dire circumstances that people will face today because of the COVID-19 pandemic.

SHANOOR SEERVAI: It strikes me as a little bit strange that the health care sector should be investing in something like transportation when health care costs are so high in the U.S. anyway. Is it like that in other countries?

REGGIE WILLIAMS: This is a unique U.S. phenomenon. We have a situation where individuals that need health care, that spend a lot on health care to achieve better health, they actually need other social services and supports to achieve those health outcomes. And so when you look at other countries, your transportation, your housing, your nutrition, are services that are supplied through other social services. In the United States, the health care system has essentially picked up on those needs because of the impact on health. When you look at people that experience high needs and high cost in health care, it’s often not just the health care services that are driving their needs, it’s the need to get to doctor’s appointments on time. It’s the ability to have good nutritious food. It’s the roof over their head that they may be lacking that impacts their overall medical care and their needs. And so we had this unique situation in the United States where health care organizations — hospitals, health systems, insurers — are placing a greater emphasis on the things that ultimately improve health. And those things are often outside of health care.

SHANOOR SEERVAI: Where does this leave us, Reggie? It’s been more than six months of the pandemic. We’re getting very close to a presidential election. What are Americans going to do?

REGGIE WILLIAMS: Well, we found some really interesting things when we asked people about who they believe has done a good job in handling the pandemic. And our international survey found that just one-third of Americans say the president has done a good job of handling the pandemic. The lowest when compared to other countries on our survey, where at least half of the people rated their president or prime minister as having done a good job. And so I think people will be going to vote thinking about how are their lives being impacted by the moment we’re living in now. And I can’t imagine that the pandemic and pandemic response wouldn’t play into their thinking.

SHANOOR SEERVAI: So Reggie, tell me why people are so unhappy with the response to the pandemic in the U.S.

REGGIE WILLIAMS: So it should be noted that we did not look at this issue of dissatisfaction specifically as a part of our analysis, but prior to the outbreak, levels of public trust in government and national leaders were relatively lower in the U.S. when compared to other high-income countries that we included in our survey. So the findings that we report are in line with other surveys on the topic. I think leadership is a really important factor that people will be considering around the pandemic response. Having clear, consistent messaging based on scientific evidence and ensuring coordination and planning to reduce the stress in the health care system is important. And so early lessons suggest that clear and concise and evidence-based communication from leaders is vital. And I think that’s something that we could hopefully improve upon in the future.

SHANOOR SEERVAI: I mean, I’ve kind of felt that way. We do this for our jobs, and I felt sort of responsible for finding information for myself. The governor of New York says one thing, the president says another thing, the mayor of the city says a third thing. It’s really hard to figure out what the right thing is to do.

REGGIE WILLIAMS: It’s really difficult. I mean, the U.S. does not have a national kind of coordinated approach to addressing the coronavirus. It’s a multilevel response where you have the national government, mayors, and other local leaders moving things ahead. And so at times, as an individual receiving this information, it kind of comes at you from all angles. I think the pandemic really illustrates the critical role that federal leadership can play. And its absence kind of creates a little bit of chaos and definite heterogeneity in how people access, use, and kind of implement information.

SHANOOR SEERVAI: So before I let you go, and since we are so close to the presidential election, I have to ask: How do you think the mental health and economic consequences of the pandemic, paired with this general sense of unhappiness with the way the government has handled the pandemic, how will this play out in people’s voting behavior?

REGGIE WILLIAMS: So I think there are many issues that have been exacerbated by the time that we’re in now. You have the mental health and economic consequences of the pandemic. You have overall negative public opinion of the way the pandemic has been handled. And so, it remains to be seen if those will be kind of ultimate drivers of change, but it’s clear that the mental health and economic toll of the pandemic is something that’s top of people’s minds.

SHANOOR SEERVAI: All right. Well, thanks so much for joining me today, Reggie.

REGGIE WILLIAMS: Thank you for having me.

SHANOOR SEERVAI: The Dose is hosted by me, Shanoor Seervai. I produce this show along with Joshua Tallman for the Commonwealth Fund. Special thanks to Barry Scholl for editorial support, Jen Wilson and Rose Wong for our art and design, Oona Palumbo for mixing and editing, and Paul Frame for web support. Our theme music is “Arizona Moon” by Blue Dot Sessions, with additional music from Podington Bear. Our website is thedose.show. There you’ll find show notes and other resources. That’s it for The Dose. Thanks for listening.