Introduction: Access to Behavioral Health Services
According to the Kaiser Family Foundation (KFF), in 2021, approximately 40% of adults reported symptoms of anxiety and depression, and 57% of female and 29% of male high school students reported experiencing persistent feelings of hopelessness and sadness (an increase of 10% and 2%, respectively, compared with 2019). In 2022, there were more deaths by suicide than in any other year in the US and the highest rate since 1941. Overdose rates also increased by more than 10% between 2019 and 2021. Altogether, the demand for services in mental health and substance use care has grown, yet access remains elusive and limited in many ways. Disparities in access to behavioral health services remain a problem for many populations in need of care.
Access to Care
In 1993, the Institute of Medicine defined access to care as “having the timely use of personal health services to achieve the best health outcomes.” The Agency for Healthcare Research and Quality (AHRQ) described the four components that constitute access to care: 1) insurance coverage, 2) a usual source of health care services, 3) timeliness, and 4) capable, qualified, and culturally competent providers. Even President Biden’s 2023 Unity Agenda addressed the need for increasing access and connecting more Americans to mental health care and discussed ways to do so. As part of the 2024 series Connected and Strong: Strategies for Accessible and Effective Crisis and Mental Health Services,6 this technical assistance paper aims to highlight many ways that policymakers and program providers are thinking about enhancing services across the psychiatric continuum of care—increasing access to care is a critical theme.
Addressing each of the components proposed by AHRQ reveals the complexity of the problem of access. In the US healthcare system, for example, insurance coverage is a key component of access. Without insurance, individuals may delay or not seek care out of concern for the cost of services. In states with Medicaid expansion, a lack of insurance coverage has become less of a concern, though some people remain uninsured. Historically, there also has been a disparity in the way insurance covers physical health and behavioral health that has meant mental health and substance use disorder services have not always been covered. The federal government has enacted various laws addressing these inequities in coverage, and though access to care has improved, there are still barriers and ensuring the parity of behavioral health care coverage remains a challenge. The Behavioral Health Parity Playbook of the National Association of State Mental Health Program Directors (NASMHPD) and the Essential Aspects of Parity: A Training Tool for Policymakers by the Substance Abuse and Mental Health Services Administration (SAMHSA) offers a detailed analysis of parity and how behavioral health policymakers can foster parity compliance in their states.
The second component of access is a usual source of care, such as a Primary Care Provider (PCP). Without one, individuals are less likely to receive screening and prevention services. Screenings for depression, anxiety, and substance use are essential to early identification of behavioral health disorders. Many of these screenings are offered as part of routine care, which is why it is critical for individuals to be established with a health care provider. The KFF found that cost is often a barrier to routine care and that some people postpone care and forgo or delay purchasing prescription medication due to cost.
Timeliness of care is the third key component of access, but there is no standardized definition or metric of timeliness organizations can use to measure their provision of timely care. Healthy People 2020 defined timeliness as “the system’s capacity to provide care quickly after a need is recognized,” but “quickly” was not specifically defined. Organizations will often assess risk during a request for services, determining if the need for services is routine or urgent and responding with an appropriate level of timeliness. They may also promote open- or rapid-access scheduling, which supports timely access to care.
The fourth component of access involves the health care workforce. Health care service providers in any organization providing care need to be capable, qualified, and culturally competent; this is critical in creating opportunities for access to care for all, but especially for historically marginalized populations. Health care organizations must understand their communities and the populations that they serve. A lack of culturally competent staff may discourage people from accessing care due to concern that their identity or culture will not be understood or represented.
Although each of these elements is critical to ensuring access to care, timeliness is currently receiving more attention in the United States as many Americans have experienced increased behavioral health challenges since the onset of the COVID-19 pandemic. Between 2019 and 2020, Mental Health America (MHA) found that more than 50 million US adults (20%) experienced a mental health challenge, and more than a quarter of these adults (28%) were unable to receive care. Additionally, 15% of youth experienced a major depressive episode in the past year and more than 60% did not receive any mental health treatment. In 2020, the National Alliance on Mental Illness (NAMI) found that 17.7 million people experienced delays or cancellations for mental health appointments, and 4.9 million people were unable to access any mental health care.
Impact of Delayed/Not Received Health Care
When care is not provided promptly, outcomes worsen. People not receiving care in a timely manner can face a variety of negative outcomes, including not having important issues addressed (which can lead to nonadherence), relapsing on substances like opioids, running out of crucial medications like psychiatric medication, or even dying by suicide while waiting for care. Delayed access to treatment may also mean that, eventually, a higher level of care will be required from emergency departments, crisis services, or inpatient psychiatric services and more expenses will be incurred than if the condition had been treated in an outpatient setting. Untreated mental health or substance use disorders not only can cause poor health outcomes for the people not receiving care, they also can have negative impacts for the other people in their lives. In May 2022, the National Council for Mental Wellbeing released results from its Access to Care Survey indicating that when people did not get mental health or substance use care, they also experienced negative impacts in their personal and professional lives. Experiencing negative impacts in any of these areas can also exacerbate any mental health or substance use disorders, further contributing to negative health outcomes.