1Introduction

BACKGROUND

A large proportion of the nationwide struggle to access behavioral health care services results from either limited availability or limited affordability (Mental Health America, 2022; Wang et al., 2023). Amidst the global challenges of addressing mental health and substance use disorders, the United States stands out for its array of cutting-edge research and treatments and its vast network of specialized behavioral health care providers. However, even with substantial investments and advancements, disparities in access to care and fragmented delivery systems persist (Coombs et al., 2021). While the United States spends more on health care than any other high-income country, meaningful metrics such as life expectancy and ongoing deficiencies in accessibility, affordability, and outcomes remain a consistent problem (Gunja et al., 2023; Wager et al., 2024). This underscores the need for ongoing efforts to address more structural and foundational issues challenging the U.S. mental health system.

The United States embarked on a distinct path in 1965 when it established Medicare and Medicaid to address critical gaps in health care coverage and accessibility, though the nation still grapples with addressing issues related to health care access and coverage (Berkowitz, 2005). Medicaid was designed to provide health coverage to low-income individuals and families who could otherwise not afford health care services, while Medicare was designed to offer health coverage primarily to Americans aged 65 and older as well as to some younger individuals with disabilities. Congress created these programs to ensure that vulnerable populations, including the elderly, low-income individuals, and people with disabilities, could access essential health care services, thereby promoting health equity and improving overall well-being in the nation. The creation of the Affordable Care Act (ACA) Marketplace, also known as the Health Insurance Marketplace® and referred to in this report as Marketplace insurance, was a key provision of the ACA enacted in 2010. It was established with the aim of centralizing health insurance shopping for individuals and small businesses. Through subsidies and tax credits, it strives to make coverage more affordable, while also incentivizing competition among insurers to enhance care quality and drive down costs.

Despite the creation of the Marketplace and enactment of the Mental Health Parity Act and subsequent amendments, access and affordability barriers remain. While the laws require parity in coverage, enforcement and compliance remain a challenge. Some insurers may still impose discriminatory practices or impose higher out-of-pocket costs for mental health and substance use disorder services than out-of-pocket costs for non-mental health and substance use disorder health care services (Rapfogel, 2022). Gaps arise in the scope of covered services, network adequacy, and access to behavioral health providers, particularly in determining what adequate care for an individual is (Rapfogel, 2022). Some insurance plans may lack transparency regarding mental health and substance use disorder benefits, making it difficult for consumers to understand their coverage and appeal denials for services.

There is also an ongoing shortage of mental health and substance use disorder providers, particularly in certain geographical regions and for certain populations who are part of accessible networks (Mongelli et al., 2020). Limited care provider availability hinders access to care, even with parity laws in place, affecting the quality of treatment and the willingness of individuals to seek help. Furthermore, the COVID-19 pandemic revealed existing vulnerabilities, arising from longstanding inequities, that only grew worse for children and families. Emphasizing this evolving crisis, in 2021, the American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry, and the Children’s Hospital Association joined together to declare a national state of emergency in children’s mental health, stating that between 2010 and 2020 the rates of childhood mental health concerns and suicide rose steadily (AACAP, 2021). By 2018, suicide was the second leading cause of death for youth of ages 10 to 24 (AACAP, 2021). Addressing these challenges requires continued efforts to strengthen enforcement, improve transparency in coverage, expand provider networks, combat stigma, and ensure comprehensive coverage for the full continuum of mental health and substance use disorder services.

MEDICARE, MEDICAID, AND MARKETPLACE BENEFICIARIES

Millions of individuals with mental illness rely on Medicare coverage. Approximately 18.7 percent of the population, or 66 million people, experience some form of mental health condition. Serious mental illness, such as bipolar disorder or schizophrenia, is notably prevalent among beneficiaries under 65 who qualify for Medicare disability benefits, with roughly a third of all disabled Medicare beneficiaries facing severe mental disorders (Center for Medicare Advocacy, 2013). Moreover, dually eligible beneficiaries—those eligible for both Medicare and Medicaid—are more likely to struggle with mental disorders compared with individuals solely covered by Medicare (Center for Medicare Advocacy, 2013).

Medicaid, the primary payer for behavioral health services in the United States, plays a crucial role in facilitating access to care for individuals grappling with behavioral health conditions by extending health coverage to approximately one in four adults facing mental health issues. In 2020, Medicaid supported 23 percent of nonelderly adults who were coping with mental illness, 26 percent of nonelderly adults who had serious mental illness, and 21 percent who had substance use disorder (SUD), compared with its 18 percent coverage for the general nonelderly adult population (Saunders and Rudowitz, 2022).

Marketplace plans expanded coverage to 21.3 million Americans during the 2024 open enrollment period, yet affordable access to mental health care remains elusive. Nationwide, Marketplace networks can often limit the number of available behavioral health providers and restrict options for beneficiaries resulting in more narrow networks. Analysis of 2016 ACA Marketplace data of 531 provider networks revealed considerably lower participation of behavioral health providers compared with primary care providers (Zhu et al., 2017). While this practice aids cost control for plans, it may deter enrollment and leave people who need services without access, exacerbating health equity disparities (GAO, 2022). Because of these coverage provisions, beneficiaries of Medicare, Medicaid, and Marketplace plans often experience unmet needs and encounter barriers to accessing appropriate behavioral health care services. Factors such as state coverage policies affect access to treatment for Medicaid and Marketplace beneficiaries, while specialty mental health services remain insufficiently available in community outpatient settings. Beneficiaries may also struggle to find behavioral health care providers willing to accept new patients, which has been attributed to challenges perceived by care providers, such as cumbersome paperwork or lower reimbursement rates via Medicare or Medicaid (MACPAC, 2021).

PROJECT ORIGIN AND STATEMENT OF TASK

In response to these challenges, the White House launched a new mental health–focused initiative in 2022, which was aimed at revolutionizing the understanding, accessibility, treatment, and integration of mental health care. Many states, supported by recent legislative measures, are also taking steps to bolster access to mental health care services (Pestaina, 2022). However, the effect of these efforts may be limited if mental health care providers are unwilling to consistently accept patients with Medicare, Medicaid, or Marketplace coverage.

The landscape of the mental health workforce across the United States exhibits significant variations, not only between states but also within counties. Despite the evident variability, almost universal concerns arise when examining both the current and projected numbers of mental health professionals.

The Mental Health Access Improvement Act of 2022⁴ broadens the range of eligible care providers under Medicare to include licensed professional counselors, potentially granting Medicare beneficiaries access to over 225,000 additional mental health professionals. Still, questions linger regarding how this change will affect overall and equitable access to behavioral health care among Medicare beneficiaries. A recent report from the Office of Inspector General (OIG) found that there was a shortage of behavioral health professionals providing care to Medicare and Medicaid beneficiaries, with only one-third of the behavioral health care workforce in the 20 counties they reviewed participating in these programs (OIG, 2024). While the report found that most enrollees in public insurance programs had access to in-person appointments with their behavioral health providers, many of them faced substantial travel distances to get to those appointments.

Adding to the complexity is the issue of diversity within the mental health workforce. Specifically, there is a relatively low number of providers who identify as racial minorities: 6.2 percent of psychologists, 5.6 percent of advanced practice psychiatric nurses, 12.6 percent of social workers, and 21.3 percent of psychiatrists. It is important to have more providers who are racially, ethnically, and linguistically diverse to provide much-needed care to the diverse population (Hoge et al., 2013). However, to effectively address access to care issues, it will be necessary for all providers to strive to be culturally competent and to demonstrate cultural humility. The report proposes several measures to improve access to behavioral health services for publicly insured enrollees. These include encouraging more care providers to serve these populations, expanding network participation coverage to additional behavioral health professions, using network adequacy standards to boost care provider numbers in Medicare Advantage and Medicaid, and enhancing monitoring of enrollees’ use of behavioral health services. The Centers for Medicare & Medicaid Services (CMS) agreed with or supported the intent behind all four recommendations of the OIG report. Compounding these challenges is the impending retirement of a significant portion of the behavioral health workforce, further underscoring the urgency of addressing workforce issues. Recent projections from the Health Resources and Services Administration underscore the pressing need for comprehensive strategies that encompass a wide array of factors affecting the mental health workforce. Only through targeted and concerted efforts can the nation respond adequately to the escalating demand for mental health and SUD services and ensure equitable access for all individuals in need.

Responding to a request from the Substance Abuse and Mental Health Services Administration, the National Academies of Sciences, Engineering, and Medicine formed an ad hoc committee to examine the current challenges to ensuring broad access to high-quality behavioral health care services through the Medicare, Medicaid, and Marketplace programs and to propose strategies to address those challenges. The Committee on Strategies to Improve Access to Behavioral Health Care Services through Medicare, Medicaid, and Marketplace consisted of 17 members with diverse expertise, including clinical behavioral health care delivery, behavioral health care policy, economics of mental health and substance abuse care, insurance regulations and laws for mental health care, behavioral health and primary care integration, behavioral health informatics, revenue-cycle management in certified community behavioral health clinics and federally qualified health centers, and behavioral health professional education. Appendix A includes brief biographies of the committee members and staff. Box 1-1 provides the statement of task for the resulting study.

BOX 1-1

Statement of Task.

This consensus report, the product of the committee’s work, examines factors that incentivize or disincentivize behavioral health care provider participation in the Medicare, Medicaid, and Marketplace programs and considers ways to clarify, simplify, or streamline administrative processes and policies to reduce perceived barriers to participation and improve access to care. It also recommends innovative models, policies, and strategies to further increase and enhance behavioral health provider participation in these programs.

SCOPE OF THE REPORT AND GUIDING PRINCIPLES

The primary task before this ad hoc committee was to “propose strategies to increase the participation of the behavioral health workforce” in order to establish “adequate capacity and access to care” for Medicare, Medicaid, and Marketplace beneficiaries. While the ad hoc committee respected this request, it thought it was paramount to acknowledge from the outset two foundational issues that constrain the committee’s recommendations for how to best support access to high-quality behavioral services and supports for beneficiaries. First, recommendations should always prioritize the needs of the beneficiaries over any other aspect of the work. Individuals in need of behavioral health care require a system that can alleviate their symptoms and enhance their quality of life. This is a challenging proposition when considering the second foundational issue, which is that the current behavioral health system is incapable of meeting the nation’s needs. The structures of this system are flawed and need to be reassessed for it to become an actual system of care, one that delivers on the promise of quality, equity, and outcomes that the nation’s communities want and need.

The committee also recognized how essential it is to remember that all services, no matter who provides them, must be created and delivered in a manner designed to meet the specific needs of the individuals seeking the care. Individuals with behavioral health conditions are not a homogenous population, and their needs warrant a full continuum of services to address a variety of unique considerations. This also means that the issue of who provides care may also shift with where an individual falls on the continuum of care. While the committee gave some attention to this issue, the vast majority of its report addresses the current clinical workforce.

In addition to considering and discussing the research in this space, the committee also convened three public webinars to provide a perspective from people who interact or have been involved with the current behavioral health system. One public webinar involved two panels that focused on the needs of adults and the experiences of families and caregivers with children and youth. All the participants expressed the need for tools to navigate an increasingly complicated behavioral health system and find the right care provider who accepted their type of insurance to meet their specific needs. From their perspective, the system is fragmented and opaque, and individuals seeking behavioral health care do not fit neatly into the existing structures. Furthermore, they emphasized that the behavioral health system they encountered did not address their needs holistically, often limiting the effectiveness of those services and not providing the array of support they required to sustain their recovery and rehabilitation, let alone facilitate thriving.

The landscape of behavioral health care delivery is undergoing a profound evolution, propelled by advances in technology, shifting societal norms, and patient preferences. While these transformations unfold, it is becoming increasingly evident that traditional clinical settings alone are insufficient to meet the diverse needs of individuals seeking behavioral health treatment. Embracing new ways to deliver care, whether through telehealth platforms, community-based interventions, or digital therapeutics, is essential in ensuring equitable access to behavioral health services. The behavioral health workforce must be responsive to these trends.

Navigating the complexities of the country’s mental health care system raised challenges for the committee. To address this, the committee engaged in thorough discussions and deliberations on the research available in order to determine the essential information needed to inform its findings and conclusions. In conducting its research and formulating recommendations, the committee opted to craft findings, conclusions, and recommendations applicable across diverse types of care providers and policies. Therefore, this report attempts to offer a way forward to increase behavioral health care workforce participation in Medicare, Medicaid, and Marketplace plans in order to provide more access to behavioral health care services for these beneficiaries. Chapter 7 contains a complete summary of the committee’s recommendations.

COMMITTEE’S APPROACH

The committee met five times, either in person or virtually, between August 2023 and May 2024. It also held numerous online workgroup meetings and three public webinars. During these five meetings, the committee considered and discussed relevant research, heard from members of the public, and discussed the approach of how to engage more behavioral health care providers in U.S. public insurance programs.

The webinars provided real-life personal experiences from a range of people interacting with the behavioral health care system. Each webinar hosted two panels of up to three speakers. The two panels in the first webinar focused on capturing real-life experiences of those seeking adequate and competent mental health care through public insurance programs. Panel 1 focused on adults using the public insurance programs, while the second panel focused on caregivers to children who needed behavioral health care through public insurance. The second webinar centered on behavioral health care providers who interact with Medicare, Medicaid, and Marketplace insurance. Wanting to include a broad range of behavioral health care providers perspectives, the committee included a peer counselor, a licensed psychological associate, a psychiatrist, a primary care provider with experience in integrated care, a licensed mental health counselor, and a licensed registered art therapist.

For the third webinar, the committee wanted to center on a solution-focused approach and thus invited professionals who manage innovations to improve mental health and SUD treatment access in public insurance plans. This included professionals working in state insurance divisions, CMS’s Center for Medicare, the Blue Cross Blue Shield Association, and a state department of human services/Medicaid program. The proceedings in brief in Appendix D provides condensed talking points from each presenter and their bios.

The committee also completed an extensive examination of the peer-reviewed literature, ultimately considering more than 3,000 articles and targeting English-language, U.S.-focused articles published since 2010 concerning behavioral health care providers, delivery, and funding. In addition, the committee reviewed gray literature, including publications by private organizations and government, with a focus on strategies to improve access to quality behavioral health care. The committee also sought to gather more behavioral health provider perceptions of insurance participation in addition to what was discussed at the second webinar. To collect this additional input, a request for information (RFI) was created and released to a range of professional networks and working groups. This RFI included short questions aiming to supplement gaps in research and bolster the current research available through a literature review on the perceptions of behavioral health care providers. Aside from requesting basic demographic information, setting of provider and type of care provider, the RFI included two open-ended questions:

1.

As a provider, please share your experiences working with Medicare, Medicaid, and/or Marketplace insurance programs. Please be specific about program type in your response.

2.

If you do not participate in Medicare, Medicaid, and/or Marketplace programs, please indicate why. Please be specific about program type in your response.

The committee did not conduct a statistical analysis of the information the RFI produced. However, the report uses quotes for illustrative purposes to bolster the behavioral health care providers’ perspectives and aid in comprehending their engagement or non-engagement with these public insurance programs.

ORGANIZATION OF THE REPORT

The next two chapters in this report offer a comprehensive background on the behavioral health care system and the populations using the public insurance systems discussed. Chapter 4 addresses the need for workforce recruitment, expansion, and redistribution to increase the availability of a racially, ethnically, and linguistically diverse workforce. That chapter proposes strategies to integrate new behavioral health care providers into the networks of Medicare, Medicaid, and the Marketplace and sets the stage for Chapter 5, which concerns retaining and supporting the existing workforce. The chapter investigates the challenges faced by behavioral health care providers currently operating within the public and Marketplace insurance markets and explores factors contributing to behavioral health care provider attrition. Chapter 6 provides an overview of the current system infrastructure, taking a broad view of the levers that should be employed to establish a system that has fewer barriers and prioritizes patient-centered care. Chapter 7 contains the committee’s goals and recommendations as they relate to the study’s charge to improve the system.

The report’s appendices present supplemental information on conducting the study. Box 1-2 in this chapter provides the committee’s definitions of select terms that are used throughout the report. Appendix A provides committee and staff biographies. Appendix B provides information on the disclosure of an unavoidable conflict of interest. Appendix C contains supplemental tables and figures from Chapter 3. Appendix D lists panelists who spoke at the committee’s three public webinars. Appendix E contains the proceedings in brief for the webinars. Finally, Appendix F contains a crosswalk between the committee’s recommendations and conclusions from supporting chapters.

BOX 1-2

Committee Definitions of Select Terms.

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