We’ve heard a lot in the past year about America’s mental health crisis and the importance of access to behavioral health care, from President Biden’s proposals in his state of the union address, to the mental health provisions included in the Bipartisan Safer Communities Act, to the debut of 988, the nation’s first standardized number for help in a mental health, substance use or suicide crisis. These actions represent a step forward in the national conversation on mental health, reflecting opportunities for more funding, and hopefully, improved access to necessary behavioral health care. The timing is critical; in 2022, almost 20% of Americans report experiencing a mental illness, with almost 5% experiencing serious mental illness (SMI).[i] Americans enrolled in Medicaid, the joint federal and state insurance program for those who are low-income, have the highest overall prevalence of behavioral health issues compared to those who are privately insured or uninsured (Figure 1).[ii]
Despite this recent focus on mental health, little is being done to address the insufficient supply of behavioral health providers in our country, or the underlying drivers causing this insufficient supply: provider reimbursement, lack of diversity in the workforce, costs of provider education, and credentialing barriers. Absent policy and programmatic change that addresses supply, the national conversation on mental health will be only that – a conversation.
For example, there have been simultaneous concerns about the 988 crisis line’s ability to meet demand or provide helpful resources. Or, you may have heard about the 2,000 mental health workers who just recently went on strike from Kaiser Permanente, demanding that the health system provide “sufficient staffing and resources” as the current “workload [for providers] is unsustainable.” These challenges are personal for many – Americans across the country struggle to gain access to needed behavioral health care, facing long wait times for services, or worse – flat-out rejections from providers due to full panels, limited accepted insurances, or not accepting any insurance at all.
HIGHER DEMAND, LOWER SUPPLY
Even worse, the limited behavioral health provider supply is further declining (Figure 2). The Health Resources and Services Administration (HRSA) estimates that between 2017 and 2030, behavioral health supply will decline by 20%, while demand will rise by 3%.[iii] This estimate includes psychiatrists, mental health social workers, counselors, and other specialty behavioral health professions. And, as evidenced by the Kaiser Permanente strike, many of the behavioral health providers currently in practice are already overworked and under-resourced.
SUPPLY OF NON-WHITE PROVIDERS IS EVEN MORE TROUBLING
Although Black, Hispanic, Asian, and Native American individuals experience adverse behavioral health outcomes at disproportionately higher rates than white individuals in the U.S., an overwhelming majority of U.S. behavioral health providers are white (Figure 3).[iv,v] This lack of diversity exacerbates existing health disparities; racial and ethnic patient-provider concordance is correlated with patient engagement and retention in behavioral health treatment. Very few people of color are able to access a behavioral health provider who looks like they do, and who may be better positioned to provide support for the daily challenges of being a person of color in today’s America.[vi] For some people of color, this inability to find a relatable mental health provider could be a deterrent from seeking any help at all.
FEW BEHAVIORAL HEALTH PROVIDERS ACCEPT NEW MEDICAID PATIENTS, DESPITE THEM HAVING THE HIGHEST NEED
At least 30% of all Black, Hispanic, American Indian and Alaskan Native, and Native Hawaiian and Other Pacific Islanders aged 0-64 received their health coverage through Medicaid in 2019. [vii] In addition to being the single largest source of health coverage in the U.S., Medicaid is also the single largest payer for mental health services and is increasingly playing a larger role in the reimbursement of substance use disorder services.[viii] But a 2019 MACPAC study found that psychiatrists accepted new Medicaid patients at much lower rates than patients with Medicare or private insurance and accepted new Medicaid patients at a much lower rate than other physicians overall (Figure 4).[ix] These Medicaid acceptance rates among psychiatrists were consistent regardless of state managed care penetration status or state Medicaid-to-Medicare payment ratio. In sum: there’s not enough behavioral health providers to go around generally, and for those on Medicaid, who have the highest need and include significant proportions of Black, Indigenous, and people of color, access to care is even more limited.
Like many public health issues in America today, access to behavioral health care has strong implications for perpetuating health disparities and health inequities. All state Medicaid programs reported at least one initiative to expand behavioral health care in state fiscal year 2021 and/or 2022, including crisis service and other benefit expansions, initiatives to expand telehealth and address equity, and managed care changes.[x] While benefit expansions and innovative care delivery models will incrementally improve access, efforts must be made to significantly expand and diversify the national behavioral health provider pool. The initiatives mentioned at the beginning of this blog represent significant steps forward in behavioral health care and crisis services, but improved screening efforts can also lead to more referrals and greater demand for services that are already understaffed and under-resourced.
More robust behavioral health provider supply is necessary to maintain and improve access to care for both Medicaid beneficiaries and the public at-large. Doing so will require both increased public and private funding and support to:
- Raise reimbursement for behavioral health providers, particularly under Medicaid, including mental health social workers, counselors, and other specialty behavioral health professionals, to attract more professionals to the field
- Expand the behavioral health provider types able to bill under public insurance programs like Medicaid and Medicare
- Improve outreach and educational support for people of color interested in pursuing the field of behavioral health to encourage the long-term success of their careers
- Develop tuition reimbursement partnerships or scholarships between provider organizations and medical schools for those entering the behavioral health field to reduce the financial barrier to entry
- Streamline credentialing requirements, allowing providers to deliver services across state lines via telehealth to address unmet demand in rural or health professional shortage areas
Through upstream interventions like these, the U.S.’s supply of behavioral health providers can slow its rate of decline – if not reverse – and be more reflective of our country’s diverse population. Without intentional approaches that address underlying factors of provider supply, policy discussions about our broken mental health system fall flat, furthering disparities for the most underserved and socioeconomically disadvantaged in our nation.
 Racial and ethnic concordance refers to having a shared identity between a physician and a patient regarding their race and ethnicity, whereas racial and ethnicity discordance refers to patients and physicians having different racial and ethnic identities.
 In 2019, 19% of white Americans aged 0-64 were on Medicaid, compared to 37% of Black Americans, 32% of Hispanic Americans, 38% of American Indian and Alaskan Natives, and 30% of Native Hawaiian and Other Pacific Islanders.
[iv] National Council for Mental Wellbeing, 2021. Minority mental health worsened during the COVID-19 pandemic. https://www.thenationalcouncil.org/news/minority-mental-health-worsened-during-the-covid-19-pandemic/
[v] National Alliance on Mental Illness (NAMI), 2022. https://www.nami.org/Blogs/NAMI-Blog/March-2022/Addressing-the-Lack-of-Diversity-in-the-Mental-Health-Field
[vi] Agency for Healthcare Research and Quality (AHRQ), 2019 National healthcare quality & disparities report. 2019. https://www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2019qdr-cx061021.pdf