A 2016 report of the Health Resources and Services Administration (HRSA) offered a bleak depiction of the current and future state of the nation’s behavioral health services workforce. Nearly half the American population resides in a designated Mental Health Professional Shortage Area (HPSA), and its plight is expected to worsen in coming decades. A majority of individuals with behavioral health conditions is currently unable to access appropriate care, and by 2025 a projected shortage of approximately 250,000 health professionals will relegate behavioral healthcare to the realm of luxury (Health Resources and Services Administration, 2016). Tragically, it is poised to become a rare commodity to be consumed only by the privileged few.
The HRSA report and its discouraging predictions were issued long before the Coronavirus visited our shores and wrought unspeakable havoc on the economy. Our national workforce is in disarray to a degree unseen in decades, and the behavioral health sector is more vulnerable to the vicissitudes of the job market than many others. In short, the COVID-19 pandemic produced a confluence of exceptional challenges that compounded existing trends. A precipitous rise in the incidence of serious mental health and substance use issues during the past 18 months threatens to unravel what is left of a strained safety net. Between November of 2020 and May of 2021, the proportion of adult New Yorkers who experienced symptoms of anxiety or depression and reported they were unable to access specialized mental health treatment steadily increased (New York State Health Foundation, 2021). An epidemic of adolescent suicidality, especially among girls, has assailed emergency departments and hospitals as their personnel struggle to contain the causalities of the Coronavirus (Centers for Disease Control and Prevention, 2021). In addition, a well-documented rise in drug overdose deaths, attributed largely to widespread opioid misuse and abuse, peaked in 2020 with more than 93,000 fatalities. This is 30% more than were reported in 2019 (Chatterjee, 2021). All of this occurs as behavioral health providers face unprecedented challenges in retaining what is left of an enervated workforce and prospective recipients encounter innumerable obstacles to accessing what few opportunities for care remain. (Many individuals have found themselves newly unemployed during the pandemic and without employer-sponsored health insurance coverage needed to access care.)
The imbalance between the supply of behavioral healthcare and growing demand for it is surely stark, and nothing less than a seismic shift in political will is needed to address it. Nevertheless, there have been some auspicious developments, if only on the margins. The American Rescue Plan Act (ARPA) and Coronavirus Response and Relief Supplemental Appropriations Act (CRRSAA), two federal laws enacted in 2021 to address economic and public health exigencies associated with the pandemic, recognized the role of the health and behavioral health workforce in responding to the public health emergency and provided supplemental funding to the Community Mental Health Services Block Grant (MHBG) on which states rely to bolster their behavioral health services infrastructures. The federal government is also offering additional support through enhanced Federal Medical Assistance Percentage (FMAP) funding (i.e., increases to the federal share of Medicaid funding available for certain reimbursable services). The means through which these funds will be expended is described in a report the New York State Office of Mental Health (OMH) recently prepared for the State Legislature pursuant to its regulatory authority, overarching goals of MHBG funding, and specific purposes of these one-time enhancements. Supplemental appropriations for the state’s share of MHBG funding include approximately $46 million and $80 million under the CRRSAA and ARPA, respectively, and the OMH report identifies workforce investment and the associated expansion of the behavioral health system’s capacity as priorities to which newly awarded funds should be committed (New York State Office of Mental Health, 2021). Such investments might rectify longstanding deficiencies in the state’s behavioral health workforce, some of which have been compounded by the pandemic, but they are unlikely to achieve their intended goals absent other measures that would enhance the system’s capacity to prevent and to proactively respond to emergent needs, thereby diverting individuals from more costly and extended care our system is ill-equipped to provide. “Upstream” interventions such as crisis prevention and response services and First Episode Psychosis (FEP) programs (e.g., OnTrackNY) promise to reduce long-term demand for behavioral healthcare and to alleviate the strain on our service infrastructure. Both are priorities for investment as described in the OMH spending plan. Service delivery via telephone and videoconference (i.e., telemental health) has become a mainstay during the pandemic, and it has received considerable approbation from providers and recipients alike for its role in ensuring public health and safety. It has also effectively served as a “staff extender” by enabling providers to meet recipients’ needs more efficiently than is generally possible through conventional methods of service delivery. Expansion of providers’ telemental health capacity is another priority identified in the spending plan.
Another state-sponsored initiative was recently announced that promises to build on the successes of the Delivery System Reform Incentive Payment (DSRIP) program and to strengthen the health and human services workforce. The DSRIP program was an ambitious undertaking that authorized the state to invest approximately $8 million in savings realized through Medicaid payment reforms into transformative initiatives intended to reduce service recipients’ reliance on costly (and often suboptimal) emergency department and institutional care services. It was largely successful in achieving its overarching goals, and the state Department of Health (DOH) recently signaled its intention to pursue a comparable initiative in a concept paper submitted to the Centers for Medicare & Medicaid Services (CMS). Section 1115 of the Social Security Act authorizes the Secretary of Health and Human Services (HHS) to approve pilot or demonstration projects that would promote the objectives of the Medicaid program. Known as “1115 Waiver” projects (inasmuch as they are exempt from certain requirements customarily applicable to Medicaid-funded programs), these have figured prominently in the advancement of various innovations designed to improve the health or welfare of Medicaid recipients and the service delivery system on which they depend. The DOH Concept Paper enumerates several goals to be accomplished through an 1115 Waiver request, some of which would address deficiencies in the health and social welfare infrastructure that have been exposed or worsened during the pandemic. This includes a commitment to augment the state’s healthcare workforce through investments that would enhance the existing Workforce Investment Organization (WIO) infrastructure. (WIOs were authorized in a previous 1115 Waiver and promoted the retraining, recruitment, and retention of direct service personnel in select capacities.) It also includes commitments to address Social Determinants of Health (SDoH) and racial inequities that continue to abound in our society, of which our health and social welfare system (and its workforce) is a prominent component (Scott, 2021).
Should the foregoing initiatives achieve their intended aims, the dedicated and compassionate individuals who commit themselves to serving the most vulnerable among us might finally find some of the support they need to sustain themselves and their careers at an extraordinarily challenging time. They deserve nothing less.