32 minute read 14 July 2022

A human-centered vision for improving the mental health care ecosystem

Five basic shifts in the care ecosystem could change how those who need it most can access timely, affordable, effective, and equitable mental health care.

Alison Muckle Egizi

Alison Muckle Egizi

United States

Gwen Blasco

Gwen Blasco

United States

Helen Collins

Helen Collins

United States

Angela Gray

Angela Gray

United States

Executive summary

“When you are raised to view mental health care as a luxury, that’s all it's ever going to feel like—even if you know logically that it’s a need,” an individual seeking mental health care shared with us during an interview. Millions of US adults are not receiving the mental health treatment they need, and they face significant obstacles in finding it. The three basic problems are:

  1. Unequal access to mental health care providers
  2. An outdated and fragmented care ecosystem
  3. High out-of-pocket costs

Inadequate access to mental health care has consequences not only for individuals experiencing mental illness and their caregivers, but also governments and economies. As global mental illness rates continue to rise, world leaders are increasingly calling for actions to improve the mental health care situation. In the United States, the Biden Administration’s recent spotlight on mental health represents an important step in the direction of a more accessible, equitable mental health care system.

To assess potential avenues for improving access to care, we reviewed relevant literature and conducted 15 interviews with persons experiencing mental illness, mental health innovators, and providers, along with a workshop of 40 participants from local and state health departments, community groups, health systems, providers, and caregivers.

We synthesized the findings to develop a human-centered vision for the mental health ecosystem, reinforced by the efforts already underway by state, local, and federal health leaders. This vision hinges upon five major shifts for better mental health care access:

  1. Expand the mental health workforce by augmenting loan repayment programs and other incentives to inspire professionals to serve in areas where there is a provider shortage while investing in community mental health training programs, encouraging greater workforce diversity, and exploring engaging retiring providers as resources.
  2. Transform the user navigation experience to meet people where they are, building upon shared data systems for tracking local mental health needs, creating archetypes of individuals’ mental health journeys as models for design-thinking, developing a digital mental health crisis support platform, funding ecosystem care navigators, and bringing human-centered design to mental health care insurance coverage.
  3. Catalyze the development of recognized, innovative models, such as integrated behavioral and primary care models, clubhouses, mobile and home-based care, and in-community services like library-based social workers.
  4. Increase public and private insurance coverage by continuing to refine the regulatory framework, remedying exclusionary policies, expanding Medicare and Medicaid telemedicine coverage for adults, and incentivizing more providers to accept Medicaid coverage.
  5. Reform payment systems by working with insurers to reduce burden of excessive paperwork on providers, supporting alternative payment models, and making it easy for providers to serve individuals seeking care across state lines.

With these shifts, a new mental health care ecosystem is imaginable, a coordinated system in which all actors work in tandem to offer compassionate care in an easy-to-navigate, affordable, equitable, and nonstigmatizing system.

Policymakers, federal health agencies, state, local, and community authorities and providers can collaborate to build the infrastructure and support necessary to meet people where they are with the services they need.

Together with investments in prevention and early intervention, these proposed shifts can help create a nation in which every American has the opportunity to thrive.

The current mental health situation

Rates of mental illness across the globe are climbing, prompting a global call to action to strengthen mental health care.1 According to the World Health Organization (WHO), the worldwide incidence of mental illness and substance abuse disorders rose by 13% between 2007 and 2017.2 The situation has only been exacerbated by the pandemic, economic dislocation, and strife over the years since.3 Over the first year of the pandemic, there was a 25% increase in the prevalence of anxiety and depression globally.4

Nearly 50 million adults in the United States experienced some form of mental illness in 2022, and more than half of them received no treatment for their conditions.5 In 2020, there was a 30% increase in emergency department visits for mental health amongst 12–17-year-olds.6 Mental illness among the youth has risen to the extent that it is considered by many mental health care professionals to be a national emergency. Yet only 20% of teens with mental health needs have received mental health care.7

The current mental health situation in the United States and other countries grew from decades of public stigma, government inertia, and a broken care ecosystem.8 Navigating our mental health system can require a level of patience and persistence that can be difficult to muster when one is in distress or crisis. Further, individuals with severe mental illness who are also experiencing housing insecurity can find themselves in near-constant transition between group homes, psychiatric wards, emergency rooms—and the street.9 It can be challenging to secure stable support.

Access can be further reduced by limited availability of mental health providers in some areas of the country—along with high out-of-pocket costs. Access to mental health providers is uneven across the United States, with 37% of the country living in a mental health provider shortage area, which are areas with one or fewer mental health professionals per 30,000 residents.10 Two-thirds of those shortages occur in rural or partially rural areas. As of September 2021, 96.4% of Wisconsin residents and 80% of Mississippi residents live areas where there is a shortage in mental health providers.11 Conversely, only 4% of Massachusetts residents and 0% of Vermont residents live in such areas.12 Where available, mental health care is unaffordable for many. The Substance Abuse and Mental Health Services Administration reports that high costs prevented nearly 44% of Americans with any mental health issues and up to 52% of adults with serious mental illness from receiving treatment in 2019.13

Mental health care access has a direct impact not just on those experiencing mental illness and their families, but also on governments and the broader economy. Untreated mental illness can lead to diminished productivity, higher unemployment, foregone tax revenue, higher welfare expenditures, and an increase in physical ailments such as cardiovascular and metabolic disease.14

Still, addressing mental health challenges can yield substantial returns. According to the Lancet Global Health Journal, “for every US$1 invested in scaled-up treatment for depression and anxiety, there is a US$4 return in better health and productivity.”15 The Biden Administration’s prioritization of mental health marks a milestone toward an improved system that can provide enhanced access to those who need mental health care.16

Importantly, improved care access is just one component of a multipronged strategy to create a better mental health system. Mental health is shaped by who you are (such as biology, socioeconomic status, race, gender, marital status, and employment status), who you are with (such as peers, family, community members), and where you live. Factors such as neighborhood poverty, crime, racism, and housing quality can influence mental health, in addition to work and school conditions.17 Children who experience early trauma may have worsened mental health over their lives.18 Investment in protective factors—such as improved neighborhood conditions, affordable housing, job opportunities, safe spaces for community connection such as parks and churches, and wraparound early childhood supports—can go a long way toward improving the current mental health situation.19

In this report, we share findings from our research on the challenges and opportunities inherent in navigating our current mental health care ecosystem and propose five shifts to create a more accessible US mental health care system for all.

Our methodology

To assess the landscape of adult mental health treatment access in the United States and identify promising practices in other countries, we evaluated relevant peer-reviewed and technical literature, and used our findings to guide a half-day workshop with 40 participants (local and state health departments, community groups, health systems, providers, and caregivers), and a set of 15 interviews (6 persons experiencing mental illness, 4 providers, and 5 mental health innovators). The workshop and interviews were coded for themes. Findings were synthesized and are summarized below to identify potential avenues for improving access to care.

Navigating a fragmented, outdated mental health care ecosystem

Service providers, programs, advocates, and a support network of caregivers, employers, and community members are all part of the mental health care ecosystem. The ecosystem is complex, and individuals seeking care often struggle to access the resources they need. The recent explosion in digital offerings can add to participants’ confusion.

Those seeking a therapist may face challenges navigating a perplexing system of payments and insurance requirements. One interviewee told us, “When you’re at the end of your rope, it can be hard to go through the hoops of getting a counselor. Figuring out what counselors are in-network and … have openings, and then going out of pocket and fronting US$200 per appointment is exhausting when you’re severely depressed.”

Due to the fragmented nature of the ecosystem, many care seekers don’t know where to begin (see sidebar entitled “Illustrative example: Jamie’s search for mental health resources”). Should they see a primary care provider first and obtain a referral? Would it be easier to call the insurance company or visit the website? As one interviewee put it, “I wish everything in general was easier to navigate. The last thing I want to deal with is looking through insurance and figuring out if X, Y, and Z is covered.”

Illustrative example: Jamie’s search for mental health resources

Jamie is a young adult from an immigrant, low-income family who identifies as an LGBTQ+ individual. She recently graduated from community college, where discussions on mental health with her inner circle gradually helped her overcome the stigma associated with mental health, which was never a topic at home.

Jamie is ready to see a mental health professional but is not successful in her search. She asks her primary care physician about therapy options and is told to check with her insurance to find out which therapists are covered. Navigating the insurance website and finding available in-network providers are challenging tasks. Jamie spends hours on the phone contacting providers listed as available on the insurer website, only to learn that the providers are neither accepting new patients nor are within the insurance network anymore—many providers she reaches out to do not respond at all. So far, none of the providers she has found in the insurance guide match her ethnicity, and none specialize in LGBTQ+ patients.

After weeks of diligent searching, Jamie receives a response from a therapist in her area, but the practice does not have an opening for the next six months. She starts to feel insignificant and hopeless. If no therapist can see her, Jamie wonders if her mental health is not important after all.

A year later, after having tried out several therapists, Jamie finally settles on an out-of-network therapist with whom she connected well during therapy sessions. However, Jamie finds that her insurance claims have been denied, deemed as “not medically necessary.” With Jamie’s tight budget, she begins to reconsider pursuing therapy. She thinks to herself, “maybe it is just a luxury that I can’t have.”

After deciding to pause therapy for now, Jamie is unsure of who else to turn to. She does not want to bring up her situation with her employer because she is worried it will affect her job security. Her cultural tradition does not support mental health treatment, so she cannot seek family support. But she is feeling worse than she did when she started this journey. Jamie decides that she will only seek help if her symptoms become unbearable. She has run out of time and energy to navigate finding affordable care and hopes she does not have a mental health crisis.

Navigation can be even more difficult when individuals with severe mental illness also need to cope with homelessness and unemployment (see sidebar entitled, “Illustrative example: Tyler’s journey through severe mental illness, homelessness, and incarceration”). All too often, they follow a winding path in and out of emergency rooms, group care settings, psychiatric wards, and incarceration.20

Illustrative example: Tyler’s journey through severe mental illness, homelessness, and incarceration

Tyler is a 35-year-old man, struggling with untreated paranoid schizophrenia. Unable to find a stable job, he receives an eviction notice and lives on the street on days when the homeless shelter is full.

When his mental health issues reach crisis levels, he begins misusing substances. Local emergency services are notified of a theft that Tyler committed in desperation for basic resources to survive, but instead of treating this incident as a mental health crisis, they take him to the county jail. Tyler's symptoms in jail worsen, and he is taken to the emergency department within the jail, where the level of care is suboptimal.

After some time, he is discharged, but is not given a plan for a follow-up or long-term treatment of his condition, nor is he connected to community resources to help him find a job or a permanent shelter. With no motivation to seek care and no way to navigate the complex system on his own, his mental health worsens again, and he eventually finds himself back in the cycle of incarceration.

What falls under mental health services and resources?

Mental health care services generally, but not always, include assessment, counseling, and medication. Providers can include both therapists (such as clinical psychologists, social workers, and marriage and family therapists) and medical providers who can prescribe psychiatric medicine (such as psychiatrists, psychiatric nurse practitioners, and physicians). Their services are usually provided through private therapy offices, health care systems, group homes, and psychiatric treatment centers—as well as via phone or video chat.

But the mental health care ecosystem involves other stakeholders as well. Some of these stakeholders include school systems, policymakers, insurance companies, families, and communities.

Improving the mental health journey requires mapping key players and relationships in the mental health ecosystem. Using material from our literature review, workshop, and interviews, we mapped the primary stakeholders who help shape a person’s mental health experience (figure 3). Each touchpoint in this ecosystem presents challenges and opportunities for improvement.

The US mental health care system is fragmented and characterized by inequities in access and high costs. Mental illness is a risk factor for homelessness, and persons experiencing homelessness or housing insecurity are less likely to recover from mental illness than members of the general population.21 According to many studies, Black, Latino, and people of color as well as LGBTQ+ adults face socioeconomic inequities that stem from historical, systemic discrimination in health care.22 How can the government continue to encourage innovations that promote equitable access and affordability in mental health?

Five shifts to improve the ecosystem of care

States and counties can play a leadership role in driving ecosystem shifts for better mental health care access, including using modern, cross-sector data systems to evaluate and respond to mental health needs. As the nation’s largest financial supporter of mental health services, the US Centers for Medicare & Medicaid Services (CMS) is also well-positioned to influence US mental health care access.23 Federal policymakers can use this leverage to help model and support innovation so that all people who need mental health care can find it affordably. Our findings reinforce the importance of efforts in progress by state, local, and federal health leaders to make the following shifts for better mental health care access:

  1. Expand the mental health workforce
  2. Transform the user navigation experience
  3. Catalyze the development of recognized, innovative models
  4. Increase public and private insurance coverage
  5. Reform payment systems

1. Expand the mental health workforce

There is an acute shortage of mental health professionals in the United States and many other countries. According to the World Health Organization, the shortage is widespread globally, even among high-income countries that support a median of only 2.2 outpatient facilities per 100,000 people in 2020.24

As already noted, access to mental health care is unevenly distributed across the United States; roughly 122 million Americans live in areas with one or fewer mental health professionals per 30,000 residents.25 Many current mental health workers, moreover, are approaching retirement or considering leaving the field due to burnout or depression.26 One person experiencing mental illness told us that the largest challenge she faced in accessing mental health care is that in her experience, “most providers aren’t accepting new patients.”

Opportunities exist to expand the mental health workforce and thus ensure more equitable access to providers. For instance, community-based mental health training and resource networks can increase the system’s capacity while raising awareness of mental health services in underserved communities (see sidebar entitled, “Community partners in care”).

Community partners in care

In two Los Angeles neighborhoods, more than a dozen public and private mental health organizations have partnered to offer support for depression through integrated networks of advocates and responders. The group provided mental health training and resources to community members, including representatives of faith-based institutions, day care centers, women’s gyms, parks and recreation departments, and senior centers. The effort is credited with a 50% reduction in behavioral health hospitalizations, fewer outpatient visits to mental health clinics and hospitals, increased physical activity, and better mental health.27 Critically, the effort reduced the risk of homelessness in these two neighborhoods by 25%.28

The Biden administration has made strides toward boosting funding for mental health education and residency positions. The American Rescue Plan Act, signed into law in March 2021, set aside about US$4 billion to fund mental health care initiatives, including funds for behavioral health workforce education and training through the Health Resources and Services Administration (HRSA).29 The Resident Physician Shortage Reduction Act, pending right now, would authorize the creation of 14,000 new Medicare-supported medical residency positions over seven years starting in 2023. The following suggestions can build upon these promising steps to expand the workforce:

Augment training programs to inspire professionals to practice in underserved areas. One way to do this is by offering loan repayment programs to those who agree to serve in underserved areas, as with HRSA’s National Health Service Corps program. President Biden’s fiscal 2023 budget would invest US$700 million in multiple programs (such as the Behavioral Health Workforce Education and Training Program and the Minority Fellowship Program) to provide training, scholarships, and loan repayments for mental health clinicians who agree to work in underserved and rural communities.30 Increasing federal funding for hospital residency positions in behavioral and mental health and for mental health education and training for medical personnel can also drive workforce expansion.

Invest in community mental health training programs at colleges, universities, high schools, and community centers. This could help increase the workforce serving high-need, high-utilization populations and help break the vicious cycle of poverty, homelessness, and mental illness. Poverty can lead to mental illness, and mental illness is a risk factor for homelessness.31 Persons experiencing homelessness or housing insecurity are also less likely to recover from mental illness compared to those with reliable housing.32 Community-focused training programs can prepare students and lay behavioral health providers or provisionally licensed therapists to recognize mental illness needs in members of underserved communities. HRSA’s Behavioral Health Workforce Education and Training program is an example of one such investment.33

Encourage greater diversity in the workforce. Pairing persons seeking care with providers of the same race and ethnicity can result in better adherence to medications and fewer missed appointments.34 Central to the success of workforce expansion is using outreach and mentorship programs to increase the racial and ethnic diversity of mental health providers so that everyone can find therapists with whom they feel comfortable.

Increase community mental health support capacity. Embedding mental health literacy in other aspects of society can create more supportive communities for identifying and managing mental health concerns. For example, teachers are increasingly trained to recognize early signs of mental health distress. Similarly, employers and trusted community groups such as faith-based organizations and barber shops can be trained in mental health awareness. Mental health literacy programs show volunteers how to identify signs of mental illness and substance use. They can be embedded in school systems, community centers, and other major community organizations.35

Those who have successfully gone through the mental health treatment and recovery process—peer support specialists—can provide a network of understanding and empowerment for those with similar conditions. State health departments should continue to commission and implement training and certification programs to build networks of such specialists and connect them to community-based care centers. Peer support specialists can also help alleviate some of the impacts of workforce shortage through support for training, certifications, and their employment. The Biden administration is currently developing a national certification program for peer specialists that can help integrate them into the broader health care system.36

Explore engaging retiring providers as resources. Some providers in the mental health workforce are approaching retirement. These individuals may be willing to volunteer to support mental health treatment, offering an addition to the workforce at no or little cost to the employer. During our workshop, one participant expressed interest in volunteering after retiring, and this sentiment was echoed by other providers, health centers, and health departments, all with interest in a potential retirement service program. Logistical obstacles remain as retirees would need to maintain licensure and malpractice insurance to continue practicing. State and local leaders could explore partnerships to create a program supporting retirement volunteer service.

These steps can increase the mental health workforce serving the broader ecosystem (figure 4).

2. Transform the user navigation experience

While an individual suffering from a serious physical ailment may not hesitate to call a doctor, those most in need of mental health treatment often do not seek care.37 Any revision of the mental health care ecosystem should employ a human-centered design approach to make it simple, intuitive, and nonstigmatizing to obtain mental health care (see sidebar entitled, “Illustrative example: A human-centered mental health experience”).

Illustrative example: A human-centered mental health experience

Let’s revisit Tyler, the 35-year-old man who has been in and out of correctional facilities and continued to struggle with his mental health. As Tyler’s condition worsens, he texts the 988 hotline for help. Instead of involving law enforcement, the support team connects him to a care navigator who helps design a care plan for him based on his goals and needs.

His care navigator recommends that he join a local clubhouse, a community mental health recovery model that helps people experiencing mental illness to rejoin society and maintain their place in it, that is covered through a Medicaid waiver in his state and offers care and recovery at a low cost. The clubhouse treats Tyler with dignity and engages him in meaningful work. He feels a sense of belonging to a community of people focused not on what is wrong with him, but on what matters to him. The clubhouse offers not only resources for mental health, but also housing support and employment search services. His care navigator regularly connects with him to check on how his care plan is progressing and sets goals for the future. For the first time, he feels he has agency, purpose, and meaningful relationships. He even finds himself making jokes with new friends, and he realizes how much he has missed laughing.

Though there is still a possibility of another critical incident occurring in the future, the support of the 988 hotline and his care navigator can help ensure access to a supportive care environment if he needs inpatient care. His care navigator will serve as an advocate for Tyler as he continues to navigate the challenges of obtaining employment, housing, government benefits, and services.

Federal, state, and local health agency leaders can take the following steps to create a better mental health care navigational experience:

Create a shared data system for tracking local mental health needs. Anonymized data from social services systems can be linked with housing, police, incarceration, and health agency data to identify trends in mental health crises, cyclical patterns, and hot spots. Government agencies can create cross-sector data maps at the neighborhood level to identify environmental and social factors linked to higher rates of mental illness as well as protective factors that can reduce incidence of mental illness and use this data to inform prevention and response programs on the ground.

Build archetypes of mental health journeys as models for design thinking. Identify critical junctures and cyclical patterns in typical mental health journeys, as well as the stated goals and needs of those experiencing mental illness through available data and discussions with leading local mental health providers and, especially, persons experiencing mental illness. This data can help leaders understand and resolve for the biggest pain points in the navigational process, creating a more seamless—and less burdensome—experience.

Create a digital mental health crisis support platform. The US$105 million in SAMHSA grant funds for states to create a three-digit crisis hotline can be spent on a centralized, user-friendly system that can respond to mental health crises locally and regionally.38 State health leaders can consider whether to include chat or text capabilities to make it simple and approachable for individuals to receive a response when experiencing a crisis. A personable—“trusted friend”—chatbot can respond to mental health questions before connecting individuals with live help. Chatbots could be codesigned with local individuals with mental illness, based on their preferences.

Fund ecosystem care navigators to support individuals in crisis at critical junctures. Those experiencing a mental health crisis, as well as their caregivers, should have access to a care navigator who develops a care plan based on individual needs and goals and guides them through the mental health care ecosystem. While many hospitals offer care navigation support, there is typically no support to navigate the full continuum of care once an individual leaves the hospital. Leveraging 988 funds, states could work to offer digital care navigation services available via phone or computer, as well as in person. Housing should be a key part of any treatment plan, and care navigators can help secure connections with the right services and supports.39

Bring human-centered design to mental health care insurance coverage. CMS has made strides toward improving Medicare beneficiary health care experiences by describing coverage options and comparing hospital quality rankings to enable consumer choice.40 These efforts can help guide state and county health leaders in developing choice models that make it easier for consumers to find and compare available mental health providers.

3. Catalyze development of recognized, innovative models

One way to create user-friendly care pathways is through integrated care models, which integrate the services of primary care providers, care managers, behavioral health providers, and social workers in a single setting to provide holistic, person-centered medical and mental care. Primary care is often the entry point for mental health care. According to a 2014 American Psychological Association report, “As many as 70% of primary care visits are driven by patients’ psychological problems, such as anxiety, panic, depression, and stress. More than 80% of patients with medically unexplained symptoms receive psychosocial treatment in primary care by a physician.”41

The American Psychiatric Association estimates that a complete integration of mental health services with physical health care could generate annual savings of US$26–48 billion for the American health care system.42 Since the 2010s, noticeable progress has been made through legislative programs to integrate physical and mental health care services, including the Primary and Behavioral Health Care Integration program, the Center for Medicare and Medicaid Innovation’s Accountable Health Communities model, and more.43 Yet, substantial progress has yet to be made to support the widespread dissemination of models based on integrated, collaborative care.

While challenges around infrastructure costs, data collection models, and reimbursement and payment structures continue, several healthcare systems have adopted integrated mental and physical health care models. Cherokee Health Systems in Knoxville, Tennessee, colocated mental health professionals in primary-care settings, allowing them to conduct real-time mental health screenings and track high-need individuals for treatment adherence. Cherokee Health Systems reported that the arrangement reduced emergency department visits by 68%, hospital care by 37%, and overall costs by 22%, respectively.44

Case study: The United Kingdom’s Integrated Care Systems

Since 2016, the National Health Service (NHS) in England has been undergoing a strategic reorganization leading to the establishment of 42 geographically based Integrated Care Systems (ICSs). ICSs bring together providers and commissioners of NHS services with local authorities and other local partners to plan, coordinate, and commission health and care services. They are part of a fundamental shift in the way the health and care system is organized—away from competition and organizational autonomy and toward collaboration, with health and care organizations working together to integrate services and improve population health. The central aim of ICSs is to integrate care across different organizations and settings, joining up hospital and community-based services, physical and mental health, and health and social care.45 ICSs are allocated a budget by NHS England based on an assessment of need of the local populations and services provided therein.46 On April 28, 2022, the Health and Care Act was passed, and ICSs will become statutory bodies beginning in July 2022.47 The statutory ICS is led by an Integrated Care Board (ICB), supported by Integrated Care Partnerships (ICPs), and has four key purposes:

  • Improving outcomes in population health and health care
  • Tackling inequalities in outcomes, experience, and access
  • Enhancing productivity and value for money
  • Supporting broader social and economic development

Persons experiencing severe mental illness and housing insecurity often see providers of last resort, such as emergency department physicians, rather than primary care providers.48 For these hard-to-reach populations, models such as “clubhouses” (such as the one described in the sidebar entitled, “Illustrative example: A human-centered mental health experience”) can offer integrated care outside the health care system.

The nonprofit organization Clubhouses International has created 300 local clubhouses in more than 30 nations that offer voluntary, community-based opportunities for work, well-being, and social connections to help persons experiencing mental illness improve their lives. Members are connected with work that is intended to benefit the community and focus on their strengths and talents rather than their diagnoses. Clubhouses provide housing support, employment assistance, benefits assistance, educational opportunities, social and recreational events, and access to medication and psychiatrist visits, and empower members as decision-makers in their own clubhouses.49

A year of holistic recovery services through a clubhouse cost less than a two-month psychiatric hospital stay, and participation has been linked to reduced hospital stays, lower incarceration rates, stronger friendships, and better overall physical and mental health.50 Clubhouses International claims that its model offers returns of US$14 for every US$1 invested.51

Such models show the power and promise of holistic care focused on fostering a sense of belonging and purpose, which are key for mental wellness. Policymakers and regulators can play an influential role in creating the alignments and consensus needed to ensure that these innovative models succeed and spread.

Additional models for improving care access for hard-to-reach populations can help to meet people where they are, including the following innovations:

  • Home-based care. Home-based care models in health care are becoming increasingly popular, particularly for early child and family support and older and mobility-limited adults. With no transportation burden, fewer missed appointments may be expected. Mental health providers conducting home care will be able to integrate with home health care more easily. They can be better-equipped to collaborate with home visitors to refer patients who need services and resources outside of mental health that may improve their mental health status, such as Supplementary Nutrition Assistance Program (SNAP) benefits.52 A rising number of home-visiting programs for new parents and young children are incorporating mental health providers into their visits.53
  • Mobile crisis response. In rural communities, as well as underserved urban neighborhoods, mobile crisis response vans can improve access where mental health provider availability is limited. Mental health leaders can leverage lessons learned from current mobile crisis response efforts and expand upon existing programs.
  • In-shelter care provision. In Minnesota, providers offer weekly appointments in local homeless shelters, as well as offering services to individuals living on the street by going to hot spots as a routine part of service.54 States can emulate this example to offer additional supports for those most in need.
  • Library-based services. Public libraries can play an important role in the care ecosystem. Social workers can be stationed in libraries as gateways to mental health services, housing, child care supports, and other resources, offering patrons connections to the kind of care they need.55

4. Increase public and private insurance coverage

Many individuals cannot find or receive mental health services due to insufficient insurance coverage or the challenges involved in obtaining insurance reimbursement. The Patient Protection and Affordable Care Act (ACA) made unprecedented improvements to US mental health coverage.56 Building upon this work, US policymakers can work across the full ecosystem to build consensus and ensure that individuals with the greatest mental health needs have coverage as part of an integrated system of care.

Congressional committees over the last several months have conducted hearings on the topic. Bipartisan legislation is reportedly in progress after a series of Congressional committee hearings in 2022 focused on mental health.57 At present, Chairwoman of the US Senate Committee on Health, Education, Labor, and Pensions (HELP), Senator Patty Murray (D-WA), expects to develop a draft bill focused on mental health issues in the United States, including difficulties accessing care over summer 2022.58

How can Congress and federal health agencies help shape an efficient regulatory framework to incentivize and expand private insurance coverage while setting an example in public health insurance?

Continue to refine the mental health regulatory framework. Uphold and enforce the 2008 Mental Health Parity Act by eliminating loopholes used to avoid coverage and holding insurance companies accountable when they fail to meet standards of care.

Remedy exclusionary policies. Certain policies, such as the “institutions for mental disease (IMD) exclusion,” and prior authorization requirements for inpatient psychiatric care and access to psychiatric medicines, can restrict coverage for medically necessary care.59 Due to the IMD exclusion, some hospitals limit the number of psychiatric beds available to ensure that Medicaid payments will be accepted, reducing access.60 Vermont uses a Medicaid 1115 waiver as a workaround to backstop coverage for inpatient behavioral health care.61 In the long run, federal policymakers should partner with states and insurers to reevaluate and update exclusionary policies. By striving to provide services along the full continuum of care, including inpatient and outpatient facilities, peer support, and community-based care, Medicaid can continue to increase rates of engagement, reduce emergency room usage, and improve access to care.

Expand Medicare and Medicaid telemedicine coverage for adults. Permanent federal action on telemedicine coverage for Medicare and Medicaid holders, many of whom are low-income or elderly adults, could provide therapy access to millions of people who cannot currently access it. Federal agencies should continue to evaluate how to improve tele mental health services for Medicaid recipients with limited access to digital services and reliable phone lines. Through a variety of partners including Walmart, the Veterans Health Administration offers 13 active locations for beneficiaries to access telemedicine in rural communities across the U.S.62 Such community-based service models offer promise for reaching more beneficiaries in rural areas.

Use incentives to encourage more providers to accept Medicaid coverage. The federal government could increase Medicaid coverage through incentives such as higher Medicaid reimbursement rates, grants for providers accepting Medicaid patients, and reduced regulatory burden on inpatient psychiatric facilities, thereby increasing mental health care options for covered beneficiaries. The federal government could also consider expanding coverage to providers such as family therapists and licensed professional counselors.

These actions can catalyze change in the insurance market, opening up access to those who need it most (figure 6).

5. Reform payment systems

Today’s payment systems often burden mental health providers with excessive paperwork, reducing the likelihood of insurance coverage. Fee-for-service payment models often incentivize volume over value. A few reforms could create a substantial shift in payment challenges and increase mental health access for all:

Work with insurers to reduce excessive paperwork burden on providers. Submitting a single insurance claim can require hours of paperwork, and follow-ups are often required to ensure claims are approved. Private insurance denies claims for mental health care twice as often as for physical care.63 Determining whether care is “medically necessary” is still a subjective process.64 One provider explained, “Insurance is still dictating therapy, as opposed to the therapist telling the insurance what the patient or client needs.” Leaders can take a human-centered design approach to simplify the claims process for providers, working with insurers to create standard claims process elements across payers. This could take the form of a “common app” for claims submission. Regulatory agents can also evaluate the claims and appeals process to identify bottlenecks and inefficiencies, while ensuring parity is upheld.

Support alternative payment models. Federal health agencies can support innovation in alternative payment models, as CMS is doing through its Innovation Center.65 CMS currently offers a voluntary form of integrated care through Accountable Care Organizations that shifts payment for mental health services away from the fee-for-service model to value-based reimbursement contracts that pay providers based on quality of care rather than the number of patients seen.66 These also offer opportunities for shared savings and shared risk.67 Such models can encourage collaborative care planning and follow-ups while improving patient outcomes and reducing costs.

Make it easy for providers to serve individuals seeking care across state lines. State licensing rules should be reformed to expand license reciprocity so that therapists and psychiatrists can serve populations across state lines, evening out the distribution of the mental health workforce. Likewise, allow mental health providers to offer telehealth services across state lines.

The HRSA-funded Psychology Interjurisdictional Compact (PSY-PACT) is an interstate agreement to allow both telehealth services and temporary authorization for in-person care across its member states, reducing regulatory barriers of practicing across state lines. At the time of writing this article, 28 states have joined the compact and more are expected to do so.68 Lessons learned from PSYPACT can inform the design of a license reciprocity program that could enable providers to serve across state lines more easily in the future.

With these five shifts to catalyze ecosystem change, a new mental health care ecosystem is imaginable: a coordinated, connected system in which all actors recognize the needs and goals of individuals seeking care and work in tandem to offer compassionate care in an easy-to-navigate, affordable, equitable, and nonstigmatizing system (figure 7).

Final thoughts: A new mental health care ecosystem

Many Americans find it difficult to obtain mental health care. Despite progress in health care reform and new models of care, many individuals seeking care still are excluded from the mental health care ecosystem.69 Mental health care delivery has grown and morphed over time: disruptive technologies, such as guided mental health care apps, have tremendous potential to make mental health care more appropriate, affordable, and scalable. Incentivizing innovations in the digital mental health space will continue to bring mental health care into the 21st century, yet while this shift has brought mental health into the digital age, the ecosystem itself, also needs to be restructured.70

By understanding the challenges faced by those attempting to access mental health care, policymakers at the federal, state, and local levels, working with community providers, can build the infrastructure and support necessary to meet people where they are with the services they need.

The proposed ecosystem shifts outlined in this paper can make mental health care more affordable and accessible—and build the bridges so many desperately need to help individuals receive the care they deserve. Alongside investments in prevention and early intervention as part of a multisector, multilayered approach to improve the mental health system, these changes can help create a nation in which “every person realizes their desired emotional, psychological, and social potential.”71

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The authors would like to acknowledge the many individuals who contributed to this research, including Kimberly Pratt, William Eggers, Hudson Harris, Daniel Pelton, Meaghan LeMay, Erin Healy, Lynda Boggs, David Rabinowitz, Jennifer Caspari, Paul El-Meouchy, John McInerney, Ellyn Seestedt, Penny Brierley-Bowers, Sako Maki-Thompson, Lydia Murray, Jessica Nadler, Wendy Gerhardt, Brandi Dentice, Sarah Cunningham, Phong Khanh Huynh, and Julie Brown.

We are also grateful to workshop and interview participants, whose candid and thoughtful reflections and ideas were paramount to both our understanding of the challenges and recommendations. Finally, we appreciate the support of Shruthi K. in developing graphics for this article.

Cover image by: Steffanie Lorig

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