The Fund supports networks of state health policy decision makers to help identify, inspire, and inform policy leaders.
The Milbank Memorial Fund supports two state leadership programs for legislative and executive branch state government officials committed to improving population health.
The Fund identifies and shares policy ideas and analysis to advance state health leadership, strong primary care, and sustainable health care costs.
Keep up with news and updates from the Milbank Memorial Fund. And read the latest blogs from our thought leaders, including Fund President Christopher F. Koller.
The Fund publishes The Milbank Quarterly, as well as reports, issues briefs, and case studies on topics important to health policy leaders.
The Milbank Memorial Fund is is a foundation that works to improve population health and health equity.
April 29, 2025
Quarterly Article
Briana S. Last
Jane M. Zhu
Apr 29, 2025
Back to The Milbank Quarterly
Policy Points:
Access to affordable, effective, timely, and appropriate behavioral health (BH) care remains elusive for most Americans despite health insurance coverage expansions.1-3 Demand for BH services has increased in recent years; nearly one in four American adults now have a diagnosed BH disorder, but only half report being able to access treatment.4-9 The inaccessibly of BH services is partly driven by supply-side constraints, namely the lack of an adequate and well-allocated BH workforce, which includes one million licensed health care professionals (e.g., psychiatrists, nurse practitioners, psychologists, clinical social workers) and support workers (e.g., psychiatric aides, peer support specialists).10 There are not enough BH providers in specific geographic regions (e.g., rural and nonmetropolitan counties, beyond the Northeast), with specialized training (e.g., child psychiatrists, addiction specialists), or providing care to the most economically underresourced Americans (e.g., the Medicaid insured and uninsured).10, 11 For example, there are less than half as many psychiatrists and addiction counselors than can meet current national demand, and there is enormous regional variation, with 70% of rural counties lacking a psychiatrist, relative to 27% of urban counties.10-13
With the support of increased federal investments, states have recently deployed strategies to address these BH workforce challenges, focusing on increasing the capacity of the BH workforce serving Medicaid enrollees.14 In this paper, we describe some of the most common policy strategies states have deployed, discuss their potential impacts, and highlight unanswered questions about their effectiveness and implementation. We then suggest how states can strengthen these investments with a coordinated, longer-term approach. We conclude by identifying some of the novel pressures the BH system is facing amid rapid technological innovations and underscore the need for broader health care transformation to comprehensively address BH workforce shortages.
Breslau J, Han B, Lai J, Yu H. Impact of the Affordable Care Act Medicaid expansion on utilization of mental health care. Med Care. 2020; 58(9): 757–762. https://doi.org/10.1097/MLR.0000000000001373
Einav L, Finkelstein A. The risk of losing health insurance in the United States is large, and remained so after the Affordable Care Act. Proc Natl Acad Sci. 2023; 120(18):e2222100120. https://doi.org/10.1073/pnas.2222100120
Ortega A. Medicaid expansion and mental health treatment: evidence from the Affordable Care Act. Health Econ. 2023; 32(4): 755–806. https://doi.org/10.1002/hec.4633
About mental health. Centers for Disease Control and Prevention. August 8, 2024. Accessed April 7, 2025. https://www.cdc.gov/mental-health/about/
Theriault KM, Rosenheck RA, Rhee TG. Increasing emergency department visits for mental health conditions in the United States. J Clin Psychiatry. 2020; 81(5): 5456.
Bommersbach TJ, McKean AJ, Olfson M, Rhee TG. National trends in mental health–related emergency department visits among youth, 2011–2020. JAMA. 2023; 329(17): 1469–1477.
Bommersbach TJ, Olfson M, Rhee TG. National trends in emergency department visits for suicide attempts and intentional self-harm. Am J Psychiatry. 2024; 181(8): 741–752. https://doi.org/10.1176/appi.ajp.20230397
Reinert M, Fritz D, Nguyen T. The State of Mental Health in America 2024. Mental Health America; 2024. Accessed December 9, 2024. https://mhanational.org/wp-content/uploads/2024/12/2024-State-of-Mental-Health-in-America-Report.pdf
Richesson D, Magas I, Brown S, Linman S, Hoenig JM. Key Substance Use and Mental Health Indicators in the United States: Results From the 2023 National Survey on Drug Use and Health. Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration; 2024. Accessed April 7, 2025. https://www.samhsa.gov/data/sites/default/files/reports/rpt47095/National%20Report/National%20Report/2023-nsduh-annual-national.pdf
National Center for Health Workforce Analysis. State of the Behavioral Health Workforce,2024. Health Resources and Services Administration; 2024. Accessed February 4, 2025. https://bhw.hrsa.gov/sites/default/files/bureau-health-workforce/state-of-the-behavioral-health-workforce-report-2024.pdf
Andrilla CHA, Patterson DG, Garberson LA, Coulthard C, Larson EH. Geographic variation in the supply of selected behavioral health providers. Am J Prev Med. 2018; 54(6): S199–S207. https://doi.org/10.1016/j.amepre.2018.01.004
Andrilla H, Woolcock S, Garberson L, Patterson D. Changes in the Supply and Rural-Urban Distribution of Psychiatrists in the U.S., 1995–2019. Washington, Wyoming, Alaska, Montana, Idaho Rural Health Research Center; 2022. Accessed April 7, 2025. https://web.archive.org/web/20250211083008/ https://familymedicine.uw.edu/rhrc/wp-content/uploads/sites/4/2022/10/RHRC_DBOCT2022_PSYCHIATRIST_Andrilla.pdf
National Academies of Sciences, Engineering, and Medicine. Expanding Behavioral Health Care Workforce Participation in Medicare, Medicaid, and Marketplace Plans. National Academies Press; 2024. doi: 10.17226/27759
Saunders H, Guth M, Eckart G. A look at strategies to address behavioral health workforce shortages: findings from a survey of state Medicaid programs. Kaiser Family Foundation. January 10, 2023. Accessed April 7, 2025. https://www.kff.org/mental-health/issue-brief/a-look-at-strategies-to-address-behavioral-health-workforce-shortages-findings-from-a-survey-of-state-medicaid-programs/
