This white paper is part of the USC-Brookings Schaeffer Initiative for Health Policy, which is a partnership between Economic Studies at Brookings and the University of Southern California Schaeffer Center for Health Policy & Economics. The Initiative aims to inform the national health care debate with rigorous, evidence-based analysis leading to practical recommendations using the collaborative strengths of USC and Brookings. We gratefully acknowledge financial support from The Commonwealth Fund.
Rates of serious consequences associated with mental illnesses – suicides, overdoses, and emergency department visits for behavioral health emergencies – are high and have been rising in the U.S. Many of these consequences can be ameliorated through mental health treatment, but roughly half of people who meet criteria for a diagnosable mental illness do not receive behavioral health care, and lack of access is particularly a problem for people from racial and ethnic minority groups. This shortfall in access to (effective) services is an important policy target.
Prior policy has helped – expansions of the extent and breadth of health insurance coverage through the Affordable Care Act (ACA), the Mental Health Parity and Addiction Equity Act (MHPAEA), and the Medicare Improvements for Patients and Providers Act of 2008 have improved financial access to services, but even those with coverage often report that needed services are not available. This has led to a renewed focus on the supply side of the mental health sector and specifically on the lack of access due to workforce shortages. The Health Resources and Services Administration (HRSA) classifies certain areas as mental health provider shortage areas (MHPSAs); in 2022, 2774 of the 3144 counties in the U.S. had been designated as shortage areas. The workforce shortage framing has led those concerned about workforce, including HRSA, to focus on interventions that strive to increase the number of providers, especially in MHPSAs, through funding for education and incentives to work in these areas.
While the goal of expanding supply in this way is compelling, its strategy rests on several concepts and assumptions whose validity are uncertain. First, it is not clear whether there is an aggregate shortage of mental health providers in the U.S., especially considering the possibilities for substitution among providers discussed below, and the logic used in defining local shortages leads to a classification of MHPSAs that is insufficiently targeted. Second, these interventions are predicated on a belief that modest incentives will induce substantial changes in location choice, but such policy efforts have, to date, been largely ineffective. Third, even if these policy efforts did function successfully, it would take many years to substantially increase the behavioral health professional workforce in MHPSAs. Addressing supply-side access challenges in the near term requires a better understanding of the problem of low access to mental health services and how it is related to the size, composition, location, and utilization of the mental health workforce.
Below, we show that geographic maldistributions of mental health providers, limited access to quality services for specific, underserved communities, and a misallocation of treatment resources by illness severity are important factors in the problem of low access to mental health services. These factors suggest a new set of policy responses that focus on improving the utilization of the existing workforce to address these maldistributions and misallocations. Our recommendations, described in detail at the end of this brief, fall into the following categories: Make it easier for people to receive care through telemedicine; Set up regulatory rules to encourage appropriate utilization and allocation of services; Improve measurement of the adequacy of access to care; and addressing the needs of underserved groups.
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Authors
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Acknowledgements and disclosures
The authors thank Richard Frank, Vikki Wachino, and John O’Brien for comments on an earlier draft. They would also like to thank Vani Agarwal for excellent research assistance.
