05 Oct The State of Mental Health in America 2020: Adult Prevalence and Access to Care
Part One in a Series
Enacted in 2010, the Patient Protection and Affordable Care Act (ACA) has expanded healthcare access and affordability for tens of millions of people in the United States. Part of the ACA is the Mental Health Parity and Addiction Equity Act (MHPAEA). The goal of this Act is to ensure that mental health and substance use disorders are treated as equally as any other physical health condition.
But how is it working? Ten years later, what do we know about the state of mental health in America before and after the enactment of the ACA? Mental Health America (MHA), a nonprofit mental health advocacy organization founded in 1909, set out to answer these questions in a comprehensive study called The State of Mental Health in America. This extensive project covers both adult and youth mental health, so we’ve chosen to break down the study into two parts. Here, we will take a look at the findings for adults.
- Adult mental health is relatively stable in the United States. It has not significantly worsened since the adoption of the ACA, but it has not significantly improved either.
- Suicidal ideation in adults is up slightly, from 3.77% to 4.19%.
- Substance use disorder, including both alcohol and drug abuse or dependency, declined in adults, from 8.46% to 7.68%
- Though insurance coverage has increased, more than 10 million adults still have an unmet need for mental health treatment. That number has not decreased since 2011.
- Insurance coverage is increasing but it’s not more comprehensive.
- The number of mental health providers has improved in nearly every state since the last report. However, projections from the Health Resources and Services Administration (HRSA) still indicate an immense shortage of mental health and substance use treatment providers to meet the demand for services in 2030.
Prevalence of Mental Illness
According to the study, 18.57% of adults in the United States, or roughly 45 million people, have some form of mental illness, while 7.68% have some type of substance use disorder. Severe mental illness is reported by 4.38% of American adults. It’s important to note that while the study did not break out the numbers, overlap between mental illness and substance use is common, so some percentage of American adults are coping with both simultaneously. Suicidal ideation is on the rise, with more than 10.3 million people reporting serious thoughts of suicide.
Access to Care
Shockingly, despite the best efforts of the ACA and mental health advocacy organizations, more than half of adults with mental illnesses, or 26 million people, are going without treatment. Nearly a quarter report that they have an unmet mental health need, a percentage that has not changed since the ACA took effect. In addition, 29.4% of adults living with a cognitive disability are unable to see a doctor.
Barriers to care include lack of availability of mental health professionals within the community, lack of insurance coverage, inability to access specific treatment types, insufficient funds to cover out of pocket expenses, and a disconnect between the primary healthcare system and the mental healthcare system.
Additionally, there is an unequal distribution of behavioral health providers throughout counties in the United States. In 2016, more than half the counties across the country had zero psychiatrists. While integrating primary care and behavioral health care is a necessary first step in reducing the impact of the shortage, primary care providers cannot solely fill the void created by a lack of psychiatrists. Expanding the use of telepsychiatry, and employing peer support specialists and other paraprofessionals as providers of care, are just some of the solutions that may help alleviate this shortage.
Variations by State
If the COVID-19 pandemic has taught us anything, it’s that the United States is not a monolith. Each state responds to public health crises based on many factors, ranging from the advice of local health officials to political pressure. When it comes to mental health and substance use, including both prevalence and access to care, the numbers vary dramatically according to where you live.
To better understand the rankings, it’s important to compare similar states. Factors to consider include geography and size. For example, California and New York are similar. Both are large states with densely populated cities and include cities that are larger than some smaller states. With that caveat, the percentage of adults with mental illnesses who are uninsured has dropped in 39 states since the adoption of the Affordable Care Act. The most dramatic drops in uninsured rates are in states like Louisiana, which previously had high levels of an uninsured population, but chose to expand Medicaid in accordance with the ACA. Today, uninsured percentages range from 2.7% in Massachusetts to 22.9% in Wyoming.
Interestingly, unmet mental health needs do not necessarily track with rates of uninsured adults. The percentage of people reporting an unmet mental health need ranges from 14.3% in Alabama to 31.2% in Utah, while the percentage of adults with untreated mental illness ranges from 40.7% in Vermont to 64.8% in California.
Putting It All Together
To account for these state disparities, Mental Health America has created a state by state ranking system. Overall Ranking is based on 15 factors for both adults and children that, when taken together, indicate lower prevalence of mental illness and better access to care. Pennsylvania takes top marks in Overall Ranking, followed by New York and Vermont, while the bottom three are Idaho, Oregon, and Nevada. When ranking solely for adults, the rankings shift. Hawaii, Iowa, and Minnesota are the top three in Adult Rankings, while Idaho, Utah, and Oregon receive the lowest marks.
The results show that the mental health support community will require more resources if they want to help those with mental illnesses and/or substance use disorders so people are able to access the care they need. Despite the progress made under the Affordable Care Act, too many adults are still unable to get proper treatment. Like anything else, much of this depends on the action of individual states. Those who live in states that have expanded Medicaid and taken active steps to ensure mental health parity tend to have better access and better outcomes than those living in states with other priorities. National data reflect the impact of legislation and policies. This data should be used to increase dialogue to help improve outcomes for individuals and families with mental health needs.