Liane Freels, an associate licensed counselor based in Florence, sits in her office on Jan. 24, 2025. Freels has taken on some adult clients with maternal mental health issues knowing she won’t be reimbursed. “We are so passionate about reaching these moms and families who are suffering, that it is more important to us to make sure that happens and wait for the grant funding later,” said Freels. “But we’re both able (financially) to do that. A lot of counselors could never do this.” (Eric Schultz for Alabama Reflector)
Last fall, Patricia called her counselor in a panic. A 29-year-old North Alabama mom, she was about to lose her Medicaid coverage, which was set to expire in October, one year after the birth of her son.
Without Medicaid, she feared she would have no way to pay for the counseling sessions that helped her navigate a deep bout of postpartum depression. In the months since the birth of her son, she had weekly telehealth therapy with Liane Freels, an associate licensed counselor based in Florence.
“It’s helped a lot,” said Patricia, who asked to be identified only by her first name, said of the sessions. “I still have bad days, but they’re less frequent. I don’t feel like I’m constantly in a dark hole.
“It’s given me an outlet to process my emotions, to feel validated, and to learn coping techniques to get through panic attacks.”
But when Patricia called Freels, concerned about her loss of coverage, she got a shock: Medicaid wasn’t paying for her therapy sessions. Freels admitted she’d been providing them pro bono.
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Alabama Medicaid covers mental health counseling by therapists like Freels for children and people under 21, but not for other adults. Freels takes on some adult clients with maternal mental health issues knowing she won’t be reimbursed. She and her business partner, Alisha Dreiling, have been working to secure grant funding so that their practice can provide maternal mental health services to families that struggle to afford it — and still keep the lights on.
“We are so passionate about reaching these moms and families who are suffering, that it is more important to us to make sure that happens and wait for the grant funding later,” said Freels. “But we’re both able (financially) to do that. A lot of counselors could never do this.”
On paper, Alabama Medicaid covers mental health treatment for moms with low incomes up to one year after a birth.
But in practice, say providers, advocates and patients, Medicaid’s severe underfunding and structural barriers keep treatment out of reach for many new moms until conditions like postpartum depression balloon into mental health crises.
“The majority of moms in our state are not screened, not educated, are not provided direct access to maternal mental health care from pregnancy through postpartum,” said Sarah Parkhurst, a Birmingham woman who founded Previa Alliance, an organization dedicated to connecting moms with mental health services. Parkhurst herself experienced postpartum depression and suicidal thoughts, and struggled to find a therapist who accepted her insurance.
“Moms are dying,” she said. “And babies are suffering.”
Nearly half of all births
In Alabama, it’s difficult to qualify for Medicaid. A single parent with one child, for example, can’t make more than $3,684 per year and get coverage under the program. Alabama is one of 10 states that hasn’t expanded Medicaid to adults making up to 138% of the Federal Poverty Level, or about $21,000 annually for an individual in 2024.
But for pregnant Alabamians, the limit is higher, making coverage available to more people with low incomes. As a result, Medicaid covers nearly half of all births statewide.
While Alabama lawmakers have spent years dithering over Medicaid expansion, the state did finally expand coverage for one group: pregnant women. Two years ago, in an effort to improve Alabama’s abysmal health outcomes for women and babies, the state followed most other states and extended its pregnancy Medicaid coverage from 60 days to one year following a birth.
The goal was to keep new mothers from losing their health coverage within weeks of having a child. Nearly half of pregnancy-related maternal deaths in the U.S. occur in the weeks or months after a birth. In Alabama, more than half of women who died from pregnancy-associated causes died between 43 days and one year after giving birth, according to the most recent data from the Alabama committee that investigates maternal deaths.
Mental health conditions, including suicide and overdose, are the leading underlying cause of pregnancy-related deaths. And they raise the chance of serious health complications for women during or after childbirth by 50%.
‘A hell of a year’
For Patricia and her family, the months leading up to the birth of her youngest felt almost unbearably hard.
Her husband’s mother unexpectedly died. Soon after, her older son — at the time not quite one-a year- old — was diagnosed with a life-threatening blood disorder that required regular trips to a St. Jude Children’s Research Hospital clinic. Her husband eventually lost his job after missing too many days of work, taking their son to medical appointments.
The family had to remain secluded to try to keep their son from getting sick, but he was hospitalized several times, including once with a COVID-induced infection that turned septic.
“We had a hell of a year before my youngest was born,” Patricia said. By the time he was 2- months- old, she said, “I felt like I had been through the biggest wringer of my life. I knew I needed help. I was really struggling with any bit of everyday life. Just brushing my teeth felt like the biggest chore in the world.”
She saw a post online that Freels’ clinic, WAC Counseling, was going to begin accepting clients with Medicaid. She assumed that because Medicaid covered her prenatal and childbirth care without any issues, that it would cover counseling, too.
Had she gone through the proper Medicaid channels, she likely wouldn’t have been able to choose a counselor like Freels. Medicaid recipients under age 21 can get mental health services from any provider who accepts Medicaid. But moms over 21 who use Medicaid are referred to either the state’s mental health crisis line, or to a community health center that contracts with Medicaid, according to an Alabama Medicaid representative.
We are so passionate about reaching these moms and families who are suffering, that it is more important to us to make sure that happens and wait for the grant funding later. But we’re both able (financially) to do that. A lot of counselors could never do this.
– Liane Freels, associate counselor, Florence
There’s a community mental health center in Patricia’s county, she said, but it’s mainly associated with substance use disorders.
“Most people think if you go there, you must have a drug addiction,” she said.
But Freels took her on. And slowly, Patricia said, things began to look brighter.
‘Not in this for the money’
Freels is a former pediatrician who pivoted to counseling a few years ago, after seeing many of her pediatric patients’ parents struggling with mood disorders like depression and anxiety.
She and her partner are focused on providing maternal mental health services to people with low incomes. They hope that their practice, which opened last year, will be able to secure more grants to allow them to continue providing services while also keeping the doors open.
“We are not in this for the money, let me tell you,” Freels joked.
In her experience, most private counseling practices don’t accept Medicaid, largely due to extremely low reimbursement rates. Even when Medicaid covers therapy, it reimburses counselors at a rate far below what private insurers like Blue Cross Blue Shield of Alabama will pay. Blue Cross is the largest private insurer in the state.
Parkhurst’s organization recently finished a pilot program with Alabama moms across the state, providing screening and mental health services via telehealth. She said the program could only take women with private insurance because of the limited number of therapists that accept Medicaid and limited telehealth options. She said she’s also searching for grants or federal funding to help pay for moms with Medicaid to access counseling services.
“I know a lot of providers who want to serve these moms, but they have to make a living wage,” she said.
In addition to better reimbursement, Freels would like to see Medicaid’s administrative requirements eased or streamlined.
“That’s a big reason why (therapists) don’t want to take Medicaid,” she said. “If it’s not the reimbursement, it’s the headaches. We have to spend a lot of time on the phone to find a person (the client) can access who can give them a referral.”
Meanwhile, those with private insurance like Blue Cross don’t need a referral and can just call to make an appointment, she said.
Women like Patricia who have pregnancy Medicaid and want mental health services are supposed to contact their case manager to get connected with a provider — often a psychologist at a mental health center. In Parkhurst’s experience talking with moms on Medicaid, case managers sometimes have a difficult time getting clients timely care.
And then there are the practical barriers. Many women lack adequate transportation or child care, or can’t afford to take time off work to travel that far for appointments.
Medicaid does allow telehealth services, but Parkhurst said some services are required to be offered in person, via video chat, or require the recipient to first “jump through hoops.” Lack of high-speed internet can effectively shut off a telehealth option for some moms on Medicaid, she said.
“I think allowing telehealth with no limitations is important when you talk about mental health care,” said Parkhurst. “For some moms, we need to come to them.”
Amy Moor, a licensed professional counselor who’s based in Florence, said there’s still work to be done to improve how Alabamians are screened for pregnancy or postpartum mental health issues.
Because it’s so hard for adults to qualify for Medicaid in Alabama, many women only have coverage while they’re pregnant and during the first year after they give birth, which means they don’t have a primary care provider who sees them regularly and could notice that something’s not right.
“Women may have to have a psychotic mental health emergency to be seen,” she said. “It takes them being in a scary place, mentally, to be seen before that six-week checkup at the obstetrician.”
Hotlines, visiting nurses, and speaking out
There are solutions.
Freels, Moor and others praised Alabama Medicaid’s Nurse-Family Partnership program, which provides home visits and other services to families from pregnancy through two years postpartum. It also offers services led by a mental health nurse practitioner that include telehealth sessions.
It’s not available everywhere in the state, however, and there are restrictions on who qualifies.
But overall, “it’s an amazing program for Medicaid’s pregnant people,” said Freels. “They are on the front lines and recognize people who may benefit from counseling.”
National organizations like Postpartum Support International have helplines designed to connect people with providers, and the state also operates a 988 mental health crisis line.
But the biggest solution, advocates and providers say, is expanding Medicaid to cover more people, and lawmakers allocating funding to support mental health services for people who fall in the insurance coverage gap.
If Medicaid is going to cover nearly half of the births in the state, said Parkhurst, “we have to reimburse well so providers can actually serve these moms. We have to allocate the appropriate funding. We have to have an even playing field so all moms can be served.”
Patricia continues to see Freels for counseling and said life has improved since those dark days after the birth of her youngest. Her husband found a new job with more flexible hours, and her older son is now much healthier.
In the meantime, she said she’s tried to be more open with friends and family about her struggles. For a long time, she said, she believed that she suffered from depression because she wasn’t praying hard enough, or didn’t trust in God enough.
But since she got help, she said, her husband and another relative have also sought treatment for their own mental health issues.
“The thought that these two people I love who also grew up in places where they were told if your mental health isn’t strong, your faith isn’t strong enough — just to know that I helped destigmatize this for them is amazing,” she said.
Next: Public schools are working to address a growth in mental health issues among students.
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