Community Health, Local Solutions with Malcolm Furgol

welcome to Mental Health Evolution, a podcast about what's changing in mental health and why it matters. I'm your host, Rachel Harrison, inviting you into honest conversations with people from all perspectives in the field. Clinicians, tech founders, investors, insurance companies and all the folks in between. Let's explore what's working, what's not, and what's next. Welcome back everyone to the Mental Health Evolution Podcast where we talk about how the landscape is quickly evolving in the mental health industry and why it matters. Today we are joined by Malcolm Fergal. He is the Executive Director of the Coalition for a Healthier Frederick County. We are getting to record this in person, which is always fun. As you know, we've done some of those before, but Malcolm leads collaborative community based efforts to improve health outcomes across Frederick county by bringing together partners from health care nonprofits, government and other sectors. His work focuses on systems level change, particularly around equity access to care and how communities can address the structural barriers that affect mental health. With a background in nonprofit leadership and community impact work, Malcolm brings a grounded local perspective to some of the biggest challenges facing mental health care today. So as always, before we dive into some questions with Malcolm, I'd like to highlight a few articles related to today's topic. These are going to focus on mental health equity, affordability and the insurance related barriers that shape who who can actually access care. All articles will be linked in the show notes, so go ahead and dive into those further. We're only going to address the name the article and talk briefly about what's there just to set an even playing field for everybody as we talk more. The first article is called Affordable Therapy is Hard to Find Even with Insurance, and this New York Times article explores why mental health care remains unaffordable for many people and even when they are insured. It looks at things like low reimbursement rates, narrow provider networks, and how these systemic issues push care out of reach for many individuals and families. The second article is titled New Policies Affecting Access to Mental Health Care and this article is from the American Psychological association or the apa, and it outlines recent policy developments impacting mental health access. It highlights ongoing challenges related to insurance reimbursement, administrative burden for providers, and the gap between mental health parity laws and what patients and clinicians experience in practice. One quote that really stuck out to me in this article is they say, contrary to concerns about provider shortages driving access issues, recent research indicates that insurance reimbursement disparities represent a significant barrier to access and great financial burden burden for mental health. And so you can dig more into that article at the link at the bottom on the show Notes and last and very importantly and related to our guest is an article called Health Equity Framework, the Coalition for a Healthier Frederick county. And this report was developed by Malcolm and his team by the Coalition for a Healthier Frederick county and offers a detailed look at how health equity shows up locally. So even if you are not in Frederick county and listening to this, you should know that these coalitions exist all over and there is data and there is research happening that is really relevant to the work that you do if you are a provider or if you are someone in the business side of providing, or if you are a patient or client trying to access care. And this report explores how structural barriers, including insurance affordability, access to care, awareness of available resources, and broader systemic inequities affect health outcomes, including mental health. So this report is health in general. I just want to be clear about that. It also includes mental health. And we are kind of zeroing in on the mental health aspect for this podcast, but it is a broader focus on health in general and it outlines shared strategies for community partners to figure out how do we identify gaps, align efforts, and work toward more equitable access to care across the county or across whatever county that you're in. This team has really inspired me. The coalition report is great data and information, but the team and their approach to bringing providers, bringing government, bringing nonprofits, bringing businesses together to kind of talk about these issues that are raised and how we fix them is part of what I'm really inspired by. It's someone who is already trying to bring in the data, trying to facilitate solutions. And that is why I wanted to have Malcolm come here today, because we started talking when we were meeting one day about this idea of insurance affordability, about the idea of how can more providers accept more insurances, especially insurances like Medicaid and Medicare. There are so many things going on around Medicaid right now especially. But this report helps us to try to figure out creative solutions. And just a little shout out I want to give to a movie I watched last night, actually. It was called Boomtown and it is a movie about Frederick county and how they economically rebuilt their downtown. And that was pretty inspirational because I think a lot of what the coalition is doing is trying to bring people together to come up with creative solutions where we can. I think it's kind of that spirit of people working together and Figuring out how we can make this a better place for everyone. So with that, Malcolm, I'm really glad you agreed to be on the podcast. Thanks for being here.

Thank you so much for having me. It's great to be here. I'm very happy, excited to talk to you today.

Yeah. So let's talk about the coalition specifically. There might be listeners that don't know about one in their county. They don't know exactly what you all do. Can you just give a brief background to that?

Sure. So the Coalition for Healthier Frederick county, which I'm privileged to be the executive director for, works to improve wellness and resiliency to equitably impact the lifelong health of all Frederick county residents. And as you mentioned, we serve an official role as local health improvement coalition for the county. And as you referred to, there's equivalent coalitions throughout the state of Maryland in respect in their respective counties, but of course, even around the country. So this is something that came into practice some places a little bit before the Affordable Care act, such as in Frederick. Our history goes back to 2006. But other places typically came online around the passing of the Affordable Care act and the implementation of it. And the concept was, as you just perfectly described. I mean, it's not. You can be on my board, Rachel. Is to bring together a multi sector approach to community health issues with the idea of looking at what are the root causes and systemic issues. And you mentioned some of them already impacting people's ability to have a positive quality of life and positive health outcomes. So they're not always independent. 500C, 501C. Three nonprofit organizations like ours.

Okay.

But there are many that are. And then other times they may be run by their local health department or by their local hospital. Again, in Maryland, they're referred to as local health improvement coalitions. Other states use different acronyms because that's where LIC stands for that. But you should be able to find it. And even if the health department in your community isn't running it, they should be able to point you towards where it does live.

Okay. Okay. And part of what I think is so valuable is that these coalitions, or whatever group it's called in a location are collecting data about the most important things, are the most impactful things. How would you say it to work on?

Yeah. So that's. There's two primary functions that each coalition executes. The first is the collection of data. And so that's both collating available data that's already accessible right. From the health department, from the State health department from the local hospital. For as it's one hospital, you may have more multiple hospitals in your community. So bringing all that together and then other research and analyses that are relevant. So if you can think about it, obviously we're talking about what impacts your ability to be healthy. So part of that is income, right. And financial stability. So we also look at reports like the ALICE report, standing for asset limited right, Income constrained and employed, that the United Ways of Maryland put out. And we've talked about a lot here in Frederick County. There's different philanthropic foundations that put out reports of needs. So we look at all the available data too. But then we also conduct a community health survey. And we do this every three years. This whole process, I'm just describing, so and collectively it's referred to as a community health needs assessment. And so we do a community health survey, which we've thankfully the last few times have had thousands of Frederick county residents respond to, which is considering we have a population of 300,000 and we work very closely to make sure with our partners it's as representative a sample as possible too. Right. So it's not just about the number, it's about the quality of the data and how much it represents the total population. Right. And then we also conduct focus groups on specific populations that are experiencing health disparities in our community to get more information. And you kind of, you know, alluded to it too in your question, which is that increasingly over the last few cycles, and we just completed one last year, so there's a great full report. Anyone who's interested, who's local can look up for Frederick county@healthierfredrick.org you can check it out there. But what we really shifted to is to look at the root causes of health disparities and negative health outcomes. And what we're looking to do is establish the health priorities, community health priorities, for a community to work on over the next three years. And so when we did that community health survey, we did the focus groups, we also did a looking at the issues that people brought up in the focus groups and the survey about why they weren't able to either access health or why they felt they had challenges with their health. We asked a root cause survey to the community. And then last January, as in January 2025, we held a community health summit where we discussed the top 10 root causes that were identified and then asked folks to give their input through survey on what they felt should be the top root causes. We focus. And so we ended up with that that process last year with five root causes that we have four work groups working on in the community. And again, I should mention and give credit to, our inspiration was from the process called MAP 2.0. We're mobilizing action through partnerships and policy that comes out of the national association of City and County Health Officials. Or I say nacho. I think they say nature, but I, you know, think about the foods as easy. But anywho, they put out those guidelines that we used to help make it as community facing as possible. And we, for example, welcomed anyone who lived or worked in Frederick county to be part of the steering committee that worked in that big process I just described to you. So that's the goal of that process, is both to put together that data, information, as you said, people can refer to, but then also to establish, okay, what are we going to focus on? Because you can't do everything. So what are we going to focus on over the next three years?

And so with mental health in particular, what is the focus?

Sure. So in the last cycle and in the cycle before it, we saw lots of respondents talk about isolation, mental health being big issues for folks. And that made sense. That came up in a high priority way when we did the report in 2020, I guess two, it would have been because you're coming out of the pandemic.

Right.

We already know isolation is a big issue. But what we were surprised to see, and I guess maybe a little sad to see, to be honest, was that experience had only increased in the 2025 report that I mentioned we put out last year. And what we had done to tweak our survey a bit to get better data is we had asked, does someone who's responding, do they care for a minor in their household? Right. So caregivers and adults. And we had seen previously that seniors were the population that seemed to be of most concern experiencing social isolation leading to mental health issues. But we saw that it was also very prominently adults, adults who take care of minors, so caregivers and parents. So that led to us looking at both examining that issue. And then we asked people what we found the two biggest barriers people had to addressing that were either stigma, you know, being a barrier to accessing care. Maybe they're the first ones in their household who'd ever access mental health care. And then also, which is, I know people who listen to this podcast maybe not be surprised to hear the lack of awareness of where to even access mental health treatment, not knowing where to start. In other words, I like to talk about it as if imagining a first generation college student. Right. Navigating all the federal aid forms and all that process, it's very overwhelming and daunting. And without assistance, sometimes people flounder and can even drown in that. And it's the same kind of thing. I think when you're navigating the mental health system, if you don't know where to start and you're scared because of stigma, to ask your primary care provider, for example, for advice, then you're just, you know, you need help, but you don't even know where to start, what to do.

Yeah. I'm curious to talk about this stigma piece a little bit because that part of the data surprised me because I guess coming from where I am coming from, like stigma has always been a thing that in mental health we've talked about overcoming. And it feels to me like with the pandemic in particular, people started talking about it so much more. I feel like when I watch TV or when I'm looking on social media, I hear people talking about their therapist all the time. It feels a little more like it gets more acceptable culturally for people to do that. So I'm curious, are there specific populations or how do we break down this stigma thing?

That's a great point. And I think there definitely has been some mainstreaming of mental health because I've been in different ways, but, but like you, active in, either in the periphery or in the focus on mental health for many, many years. And I agree, I feel the same way. So there's definitely been a mainstream of it. But I think the population that most positively has impacted has been those who are of higher financial means, you know, who do have insurance, who are insured, who, even if they've not asked mental health directly, they know someone who has. Right. So I think there's definitely been an improvement there. But we also are the fastest growing county in Maryland, right here in Frederick county and a lot of other counties. Maybe you're experiencing growth, maybe you're not, but there's usually been a lot of changes to demographics. And one of the changes we've had also as part of that growth is we've had a fast growing immigrant population where we have people coming from all over the world where there's even more stigma that, you know, in their culture and heritage to accessing mental health or they don't even acknowledge mental health exists. And I'm very serious about that.

Yeah.

And so that mainstreaming has not happened, affected those populations the way it has. As I said, those who would say above, Alice Right. We're going back to the Alice comparison. So that's one of the populations, the other one we continue to see. And this sport out in our survey. We actually did a men's mental health focus survey last year with the mental health work group that was finishing up from the previous cycle, handing it off to the new one. And that we saw, too, as well as in the data that men are still very resistant to accessing mental health care if they've not had experience with it before. And we heard repeatedly in the survey that men said, well, we asked them, well, what do you do? Because you still probably talk about some things to some people, right? You know, what's bothering you, what's stressing you out, what makes you anxious? And the two biggest things that men said they would do is talk to their partner or if they were, you know, religious, talk to their spiritual leader. So that is great. That's good. But obviously, especially if it's your partner, they're not necessarily a mental professional, right? So. And they are probably dealing with their own things. So that was very interesting. So what? Because you would think we were wondering, because one of the options was not at all, but not most people. Men did not choose that. So that was interesting to see that. So it's like, okay, we just need to nudge you a little wee bit. So. But, you know, as you may have talked about, because I haven't been able to listen to all your past episodes, but we've had some very serious issues of intimate partner violence over the last few years here in Frederick county, some of which have even made national news. And we definitely recognize that we need to do something to address the male mental health issues and not. And I want to be clear, I'm not saying that, you know, having mental health challenges or things you want to work through means that you're, like, more, you know, likely to be violent. I want to make that very clear. I'm not making that correlation because I know it's not true. But we don't want to wait till we get to crises, right? That's the whole point. We want to be preventative. We don't want to wait till we get to crisis points to intervene, because then the hardest parts, the tragedy has already happened. The care is much harder to provide, and in some cases, you know, damage that can't be undone has been done. So we want to see what we can do to reach men in places where they're comfortable now so that they don't get to crises. And we can provide that access to mental health supports.

That's interesting. And so you're talking about the above Alice population potentially is more open to mental health care. But I think there is also an accessibility piece and it struck me when you had said to me when we sat down and had coffee, like you asked me the question, how can we get more providers to be able to accept more insurances in Medicaid and Medicare? And being where I am running a business in this space, it is really difficult running a practice to accept a lot of those for so many different reasons. But I do see that the. I think most people in mental health, we want to provide services to as many people as possible. The ability to do that and to accept certain insurances, then we are unable to pay a living wage to our highly trained therapists and nurse practitioners and medical doctors and the people that serve the community to accept those insurance rates. So I think it's really interesting to think about a lot of what has happened in my view, and you may know situations of this too, is that a lot of providers get to the point where they say if I don't have to take insurance anymore, I'm not going to. Or they even start their practice entirely from the beginning saying it's a out of network practice. Everybody's going to have to pay for their care if they get reimbursed by their insurance. Great. And there's no shade from my, from where I sit, there's no, no shade there at all. People need to be able to their families, people need to make the income that they need to make. And I think it's too bad because those same people would probably be happy to take an insurance and see those people if they could find a way to make that work for themselves and their situation. So I'm just curious if you have any thoughts about that or what you've kind of seen.

Yeah, I think there's two things that are barriers in some ways on both sides. Right. Both for the patient, patient and the provider. And one is the bureaucratic and administrative burden of just the paperwork. Right. Of processing insurance claims and, and figuring out how that works and making it work into your cash flow and your model. Right. So that's very much there on the provider level, by the way, on the individual equivalent of that is if you're a patient, prospective patient, is figuring out how your insurance even works.

Oh yeah, right.

Which, which a lot of us who work in this space, you know, we figured how to navigate and to use it and to leverage it. But think about how maybe there was A point in time where that you didn't know that. And that's what most people are at, right, is that they aren't aware of how their insurance works and they may not be aware even of all the benefits they have. So that's a barrier on their side too. There's administrative barriers on both sides. Right. And then the other piece of it is, and you alluded to it we met, is the reimbursement rates. Right. Which is invisible to the patient. Right. But they may have co pays. Right. Or if they have a high deductible plan, they may that should be paying out of pocket. And to them it may feel like a lot of money even if it doesn't compare to the reimbursement that a provider typically receives from either private patient or non public insurance. Right. So those are all there as issues and barriers. And I think there's a few things too because you think about, well, does this happen in physical health? Of course it does. The thing is, is that to be frank, there's been a lot longer Runway timeline for physical health providers to figure this out. And even there we've seen the impact of the high skyrocketing cost of care and liability insurance, etc. By seeing more and more private primary care providers shut down, more, you know, conglomerations, you know, bigger primary care associates, right. Coming together hospitals, you know, being bought out by bigger hospital networks because it's easier if you're a bigger business, frankly, to control costs. In Maryland, all our hospitals are nonprofits and so they have access to grants and donations and other things to help make up when they don't receive enough money from the provision of care. Right. And there's probably, and I would throw in there, there's often probably a value issue in the sense of on the public insurance side, there's needs to be probably more advocacy to argue why this rate should be higher. But then as I mentioned before the we started recording the podcast today, we have some big changes either coming or already have happened to Medicare, Medicaid, from HB1 from last year being passed in Congress. And actually a lot of places it's going to be lowering rates and reimbursements. And that's one of the challenges and increasing the share of the payments either by the patient or by this local state government. And so that's not going to make solving the issues you and I just talked about any easier.

No.

So but I think the opportunity goes back to what you brought up earlier, which is that at least in the mainstream and Again, for those who are above Alice, let's say there is more awareness of mental health and the importance of it. And honestly, sadly, we do have almost instantaneous coverage these days of crises that do happen when mental health is not addressed. And I'm hopeful that enough of that story can be put together to advocate successfully or looking at both, how can we make it easier and simpler for providers who want to take insurance to take it? And then how can we also look at the appropriate reimbursement rates? Because frankly, the way it's set up now is not working, I think is what you basically were getting at.

And I would agree it is. Yeah. I mean, and it's, you know, I've been in mental health care for 28 years now and it has been the same this whole time in the sense that this has always been an issue. This has always been a provider's not wanting to take it and the need to take it being there. And I think too, another just piece I would raise is that there's this concept of clawbacks. So you can get paid by an insurance company and they can review that a year later and say, oops, you had the wrong date or you made a typo there. And so even though you performed the service, we're now taking that back from you. Yeah, Medicaid particularly does that yearly and typically always finds reasons to take payback. And that is one of the biggest reasons I hear on the provider side for not being able to take it.

Yeah. And I was just going to add that to that, that I also know talking to some providers that there's some private insurance companies they just won't work with either for similar reasons on the clawback or because they just find it too cumbersome or they've seen too many denials over time and they don't even want to deal with that as a private insurance company. So, you know, it's definitely a challenge. And I think even though we've all been working in this for years, in some cases decades, I think there still is a value perception we're having to fight against that mental health is not. Is like a nice to have. It's a luxury. And that's not true at all. It's a basic need and absolutely is critical. In fact, I would argue, as I'm sure you probably agree, is that it actually impacts our physical health much more than people realize and if we can address it, can actually lead to cost savings on the insurance side, but also for society's societal cost. So I think that's Kind of got to be better at telling that story. We got to bring together groups to advocate more clearly on that story. And the states have a lot of power on regulating insurance. There's challenges with Medicare and Medicaid, you know, but on the state level with insurance regulation, there's a lot you can, there are some levers you can push and pull. So I think there's an opportunity there.

Yeah, yeah, I like that. And I like the idea of figuring out just your kind of conceptualization of on the physical health side. It's been figured out. That's, that's a hopeful statement to me of there might be some levers to pull as well for mental health providers to figure out how to make this work. It's just not doing it the way that we have been doing it. Maybe.

Yeah. And I want to be clear because I don't want anyone to think that we've totally solved the physical health side. It's just that frankly, they've had a little bit more time to work it out and, you know, it's very precarious there too, but they've definitely been able to make it work. And to that point, you know, part of that is threading together multiple revenue streams. So maybe that's something too that could be looked at on the mental health side.

Right.

Remember, I was alluding to grants and donations earlier, for example.

Right.

So, you know, I've thought of different things. I don't know if it would be something on a county level where you're looking at putting together a, you know, a mental health insurance processing system that small business providers can access so they don't have to do all that admin work themselves. Or maybe it's done at a state level so it's even more, you know, leverage available. And then maybe that body doesn't just help with the admin, but maybe they help negotiate. Right. And so it's not one provider negotiating, it's the whole states worth of providers, or at least in other words, the providers wanting to participate in taking insurance in that state, which is still a bigger group than one individual provider practice.

Right, right.

And a lot of the providers I've accessed myself on my mental health journey, some of them are part of small practices, but a lot of them are just one person, literally. So that can be a lot of work for one person. So those are just some of the thoughts I've had. And not just me. You refer to the work groups that we form to address the community health priorities that we identify in our community health needs assessment. Report. These are conversations that worker has had many times and it's obviously something that doesn't take just a month or two, it takes years. Right. And so that's why that timeline is really important of the community health work that coalitions like ours engage in is it needs to be, you know, years long work and organized in that fashion because that's the measurement by which you're going to achieve change. You can't think that it's going to be done in a few weeks, unfortunately.

I know. Don't we all wish. There's a lot to unpack, there's a, a big problem to solve. But we are at the end of our time for today's recording. I'm curious to just ask you one more question. If there was something that you would want to leave people with, whether they are a patient looking for care, a provider, someone in the business side of this industry, what would your kind of one meaningful piece of information be?

Yeah, I think for both audiences it would be to try to not be afraid to ask for help and to raise your concerns and issues. Right. Whether that's how do I get help if I'm an individual and I have to do a shout out to 2 on 1 and 988 or mental health hotlines because it's a great way to access help if you don't know where to start. And then on the brighter side, even if you don't feel like you have a lot of time, because you probably don't, I get it. But reach out to that local coalition that's acting on these issues that we just talked about today and find out what they're doing to address it. Because again, like I alluded to, I think it's only by coming together as a collective body to advocate for change are we going to see it happen.

Yes, I love, love, love that. Thank you so much, Malcolm. This has been an awesome conversation. Thank you all for listening. As always, if you have thoughts, we would love to hear from you and we would love to hear your thoughts on, on potential solutions even, or some of the issues that you're seeing in these areas. Next week we will be back with another conversation about what's changing in the landscape of mental health care. And for today, we are signing off. So thanks for listening and bye for now.