America’s Massive Gap Providing Mental Health Services

Several years ago, Janet Thompson, a Boone County, Missouri commissioner, said she saw first-hand the devastating consequences that a shortage of mental health counselors can have for the residents of a community. It’s a problem counties say has gotten worse, particularly in rural areas, at a time when many people are dealing with anxiety, depression and substance abuse.

Thompson said the son of a friend was waiting for an appointment with a mental health counselor and was doing all he was told to. But the counselor he was going to see quit for a less stressful and higher paying job, according to Thompson. Then, as the friend’s son waited again to see someone, he committed suicide. 

“This is happening across the country,” said Thompson, a vice chair of the National Association of Counties’ justice and public safety steering committee. “As a society, we don’t have enough people to address these issues.” 

And indeed, in a letter to congressional leaders, officials from 111 counties in 30 states noted that, according to the Robert Wood Johnson Foundation, 30% of Americans live in counties that are considered to have a shortage of mental health professionals.

As negotiations begin in earnest over a funding bill that Congress has to pass by a Dec. 16 deadline, the officials are asking lawmakers to provide help to increase the number of psychiatrists, counselors, and other mental health professionals.

The shortage is so large in Idaho, the officials wrote, that some counties have only one mental health professional for every 5,370 residents.

“What we're seeing is really a confluence of things. First is the increased demand for behavioral health services. Whether that's because of Covid, burnout or anxiety,” Jonah Cunningham, president and CEO of the National Association of County Behavioral Health and Developmental Disability Directors, said in an interview.

“But even predating Covid, we saw an increasing number of deaths from substance use, suicide and alcohol-related deaths, and those have continued to increase significantly,” Cunningham added. “On top of that, we also have a lot of burnout amongst the [mental health] workforce and a lot of shortages in general because of a lack of investment.”

The situation is particularly difficult in rural areas, he said, where 136 hospitals closed between 2010 and 2021, according to the American Hospital Association.

The odds of help coming from Congress are uncertain. 

Budget negotiators have not yet reached agreement on the total amount of spending for the remainder of the fiscal year. (The federal fiscal year began Oct. 1, but the government is now operating under a stopgap funding law.) Republicans, after winning control of the House, are also expected to press for any funding bill to last only until early 2023 when they are in the majority.

Cunningham, however, said there is some hope. A bipartisan group of senators, including the top Democrat and Republican on the Senate Finance committee, has proposed increasing federal funding to retain and increase the number of mental health professionals in rural and other underserved areas.

Mental health providers would also get extra Medicaid funding as an incentive to treat people in places where there can sometimes be only one provider for thousands of people, under the proposal from the group of senators, led by Senate Finance chairman Ron Wyden, an Oregon Democrat, and Sen. Mike Crapo of Idaho, the committee’s top Republican.

“The shortage of mental health professionals was one of our priorities in our bipartisan work in the Senate Finance committee and it will continue to be one of the areas that I'm going to be promoting,” Wyden said in an interview.  Wyden said he’s particularly interested in exploring public-private partnerships to train more mental health professionals, including a University of Oregon program funded by Connie and Steve Ballmer to train specialists in child and adolescent behavioral health.

“We’ll see. It’s going to be moving pretty fast,” he said when he asked if more funding for behavioral health professionals will be included in the year-end spending bill.

Idaho state Rep. Brooke Green, a Democrat, served on a behavioral health council established in 2020 by Republican Gov. Brad Little to recommend ways to improve mental health and substance abuse treatment in the state.

“Unfortunately, we have an incredible shortage of behavioral health services,” particularly in rural areas, she said.

As a first step, she said, the state focused on expanding the infrastructure to provide mental health services. Funded in part by $16 million in American Rescue Plan Act aid, the state this year set out to expand the number of community behavioral health clinics, psychiatric residential care facilities and programs, youth crisis centers and other mental health facilities.

“We didn't have youth crisis centers in Idaho, in particular residential treatment centers for behavioral health issues. Youth were being shipped out of state,” Green said.

Now, the focus is shifting to how to staff the facilities. “If we don't have a workforce to complement our facilities, what services are we actually providing?” she said.

In addition to addressing the shortage of mental health professionals, the county officials are asking for an array of moves by Congress, including removing an “unfair and harmful” federal law they say is a barrier to providing mental health services to inmates in county jails. 

A “staggering” 63% of county jail inmates suffer from substance abuse, the officials wrote. However, a law prohibits the use of federal funds like Medicaid to provide medication for prison and jail inmates. 

The county officials, among other things, also urged Congress to repeal a law that prohibits psychiatric facilities from receiving Medicaid funds if they have more than 16 beds. 

The decades-old policy was intended to reduce the institutionalization of the mentally ill, Los Angeles County Supervisor Kathryn Barger, said in an interview.

But the prohibition has instead discouraged the construction of larger psychiatric facilities. That has contributed to a shortage of beds in the facilities, which in turn, has “exacerbated the increase of the homeless, mentally ill on our streets,” Barger said. 

The Trump and Biden administrations granted waivers from the prohibition on using Medicaid funds for larger facilities to 34 states for substance abuse treatment, and 10 states for mental health treatment, according to the Kaiser Family Foundation. Still, the county leaders urged Congress to repeal the “arbitrary 16-bed limit.”

Here again, it’s unclear whether Congress will act on the issue as part of budget negotiations. 

A discussion draft of the Senate bill released in September would take a number of steps to try to address the shortage of mental health professionals in some areas. 

Medicare would begin giving additional payments to psychologists, clinical social workers, marriage and family therapists, mental health counselors, and other non-physician practitioners if they provide treatment in areas with a shortage of mental health service providers. The change, which would begin Jan. 1, 2024, would also increase the financial incentive psychiatrists already receive to treat people in those areas.

The proposal would also create planning grants and additional Medicaid funding for states to expand the number of mental health and substance use disorder providers. The funding would be available a year after it is signed into law.

To many state and local officials grappling with the gaps in services, federal help along these lines is viewed as crucial.

“You're seeing people from rural communities moving into urban environments, and it's leaving a lot of our rural communities without the services or the persons to actually conduct the services,” said Green, the Idaho legislator. “And so we're struggling with this.”