A recent analysis of 2021 data conducted by Milliman, a renowned actuary and technology consulting company, has revealed a troubling truth: only one-third of Americans with a behavioral health condition received treatment within a year of their diagnosis. The research, commissioned by the nonprofit organization Inseparable, paints a sobering picture of the state of access to behavioral health care in the U.S., exposing significant gaps in treatment and highlighting the stark disparities that exist across different regions and insurance types.
The findings of this report emphasize that, while certain populations or regions may have better access to behavioral health services, none are receiving care at the levels needed. As the report states, “While access to behavioral health care is a complex topic and involves additional considerations beyond those included in this report, many metrics for which data are available point to aspects of access that could potentially be improved.” This highlights the deep systemic issues that contribute to the lack of sufficient treatment for those who need it most. For individuals with mental health and substance use conditions, this means that too many are left to navigate their challenges without the support and care they desperately require.
The Disparities Across Payer Types
One of the most glaring aspects of the report is the significant disparity in access to behavioral health care depending on the type of insurance a person has. Medicaid members had the highest rate of receiving behavioral health care post-diagnosis, with 44% of Medicaid beneficiaries accessing treatment in 2021. This is notably higher than the 31% of people with commercial health insurance who received care, and far above the 16% of individuals with traditional Medicare (fee-for-service) who sought care. This stark contrast underscores the impact that insurance types have on a person’s ability to receive access to behavioral health care.
However, even those with Medicaid, which offered the best access in this study, still faced barriers. For instance, despite the relatively higher access to behavioral health care, the report also noted that many individuals diagnosed with behavioral health conditions did not receive specialized treatment from a behavioral health provider. Instead, some individuals may have received care from primary care doctors or other non-specialist providers. While this can sometimes be appropriate, the fact that so many are not receiving care from trained behavioral health professionals indicates a serious gap in the system.
In general, there is a significant underutilization of access to behavioral health care across the U.S. The most concerning aspect of this underutilization is the stark difference in treatment rates between different payer types. Medicaid, for example, offers more comprehensive access to care, yet even within this population, only 44% received treatment, suggesting that even in systems designed to provide care, barriers still remain. Meanwhile, those with traditional Medicare or commercial insurance are even less likely to receive the care they need. This shows that while having insurance is important, the quality and accessibility of that insurance plays a critical role in determining who actually receives access to behavioral health care.
The Role of Geographic Disparities and Provider Shortages
The report also highlights another critical factor in access to behavioral health care: geographic location. According to the data, most Americans live in areas that are classified as “behavioral health professional shortage areas.” These are regions where there are not enough trained behavioral health providers to meet the needs of the population. As a result, residents in these areas often have limited access to care, with some states experiencing a more severe lack of available services than others.
For example, Florida—one of the states with the lowest behavioral health provider supply ratios—illustrates the devastating impact of these shortages. Individuals in Florida received only 22.7% of the number of therapy visits that residents in areas with the highest provider supply received in 2021. This is a massive gap in access to behavioral health care that has significant consequences for the mental and emotional well-being of individuals living in underserved regions.
The issue of provider shortages isn’t just limited to certain states—it is a nationwide problem. The report found that in many states, residents face incredibly long wait times for treatment, or in some cases, they may have to travel long distances to find a provider. These barriers often deter people from seeking care altogether or force them to delay treatment until their conditions worsen. This chronic shortage of behavioral health professionals further exacerbates the disparity between those who need care and those who receive access to behavioral health care.
Financial Barriers: The High Cost of Treatment
In addition to the shortage of providers, the report also found that the financial burden of receiving access to behavioral health care can be prohibitively high for many people. While Medicaid beneficiaries generally face minimal out-of-pocket costs, individuals with private insurance or those paying out of pocket for services often face steep fees. For example, a 60-minute psychotherapy visit for someone without insurance or with self-pay costs an average of $174.46. This amount varies widely by state, with Louisiana having the highest average at $286.89, and South Carolina at the lowest with $93.92.
Even individuals with commercial insurance aren’t spared from high costs, particularly when they need to go out-of-network for care. The report found that out-of-network care for commercially insured patients results in out-of-pocket costs that are more than double—around 2.3 times—those associated with in-network care. This financial burden makes it difficult for many people to afford ongoing treatment, leading some to abandon their search for care entirely. Unfortunately, these high costs are not always transparent, and many people may not even be aware of the significant cost differences between in-network and out-of-network providers.
The Impact of Out-of-Network Care
The issue of out-of-network care is another critical concern for many individuals seeking access to behavioral health care. According to the report, approximately 16% of all behavioral health costs come from out-of-network services. This is particularly problematic because out-of-network care often involves higher patient cost-sharing requirements, which can be a significant financial burden for individuals already struggling with their mental health or addiction.
Some states see a much higher proportion of behavioral health costs coming from out-of-network care. New Jersey, for example, saw about 50% of behavioral health costs coming from out-of-network services, while other states like Hawai’i and South Dakota saw much lower figures. This disparity reflects the adequacy of commercial insurance networks in providing patients with access to in-network care. If networks are insufficient, patients are often forced to seek care outside of their insurance network, leading to significantly higher costs.
Furthermore, out-of-network providers often require additional steps for insurance coverage approval, which can be a time-consuming and frustrating process. These hurdles often make it even harder for individuals to access the care they need, and may discourage them from pursuing treatment altogether.
The Need for Comprehensive Reform
The report’s findings paint a bleak picture of the current state of access to behavioral health care in America. There is a glaring gap between the number of people who need care and the number of people who actually receive it. While some progress has been made, particularly for Medicaid beneficiaries, the overall picture reveals that the system is far from adequate. To address these challenges, there needs to be a comprehensive reform of the behavioral health system.
This reform should focus on increasing the number of trained behavioral health providers, particularly in underserved regions, and expanding access to affordable care through insurance reforms. Additionally, steps should be taken to reduce the financial burden of care by making in-network options more accessible and reducing the reliance on out-of-network services.
In conclusion, addressing the behavioral health crisis in the U.S. will require a multifaceted approach that includes better access to care, reduced financial barriers, and an expansion of the behavioral health workforce. Without these changes, many individuals will continue to face insurmountable obstacles to receiving the care they need. The current system leaves far too many people without the support they deserve, and it is time for real change to ensure that everyone who needs access to behavioral health care can receive it.
