The Cost Of An Underfunded Mental Health System

Fighting to end mental health stigma has been a career goal for the last twenty years, so why does it feel bad as we progress? In 2020, 20.3% of adults sought professional mental health care rather than suffering in silence (Source). The progress in 2020 with adults seeking professional mental health support would feel much sweeter if it was not at the expense of tearing a hole in our already vulnerable safety net mental health programs. This statement is the conclusion rather than the starting point, so I invite you to understand how our mental health system arrived here and why we collectively need to take action to solve it before even fewer people can access mental health services when they need it.

In simplest terms, therapists are a commodity and not immune to supply and demand issues. The stigma to seek care, the proverbial Scarlett A, that kept many from accessing treatment served as a tamping mechanism for demand. However, in 2022 finding a good therapist with availability is just as hard as finding two-ply toilet paper was at the beginning of the pandemic. The emotional tolls of the Covid-19 pandemic were coupled with a pandemic of racial unrest. These two crises were layered with well-intended leniency of telehealth policies that allowed increased access and privacy. In total, greater demand was created that far outpaced availability. The desire for mental health treatment continues to grow, but the capacity has not been able to match. The culmination was that one study found that 41% of professionals said they could not meet demand, and the same survey reported that 46% of professionals felt burnt out (Source). This news is troubling, but it is not the end of the story, nor is it the whole reason you should be alarmed.

In true economic fashion, the scarcity of therapists has resulted in rather predictable outcomes for the trained eye. Before the pandemic, most newly minted therapists would hone their craft in community mental health centers. This afforded our safety net providers a rather steady labor workforce, albeit often green. These therapists would eventually migrate to a boutique private practice once they had established a reputation that would warrant the self-pay individuals. With increased demand, many therapists are skipping this step and jumping straight to the high dollar private pay individual in today’s market. These therapists should not be demonized as they are finally being paid a wage commensurate with education and service. The mass exodus of therapists from the Medicaid system has left workforce shortages that cannot be combatted on the razor-thin margins that these organizations survive. The National Council for Behavioral Health reports that 77 percent of counties across the country have severe shortages of behavioral health professionals (Source). Additionally, this means that many therapists now working in private practice come with less tenure than their peers from just a few years ago and often with a loftier price tag for an hour of therapy. As we face a shortage of therapists, the most marginalized and vulnerable individuals in our society are the ones going without. Those with means and access found toilet paper just like they can leverage their resources to find a therapist today. The child entering foster care needing a therapist to process the adjustment will wait. The mother needing substance use treatment will join a 100+ caseload. The individual being released from prison will sit in the walk-in center’s lobby for hours, waiting for a coveted appointment. This is the real price of therapy today.

Our mental health system is in crisis, and we are at an inflection point on what meaningful strategies are needed to create sustainable access for all. Our society has long treated individuals on Medicaid as disposable, and in our current state, we are causing them to bear the brunt of access issues. However, if you think this issue is only affecting those with Medicaid, I invite you to find a seasoned therapist still willing to accept your commercial insurance. Economic issues initially disproportionately are felt by those with fewer means; but left unchecked they continue to worsen until they are felt by the many. It will just be a few years before we only see private practice behavioral health professionals accepting cash clients at our current rate. As we envision a better system, we need to align our contributions to create meaningful population-level change. Our universities need to increase their pipeline of new professionals, and we need state and commercial insurance to pay rates that translate into livable wages. Our legislators need to prioritize upstream policy level actions and more significant funding, or this problem will only worsen. We need the voices of those receiving care to be at the table to envision a system that meets their needs. The ability to recognize that access to care for all only strengthens our communities. It is time that we abandon the false narrative of a scarcity of resources and allocate funding to the mental health system, which will allow us to help our neighbors effectively. After you squarely stare the problem in its face, my question is, will you take action? If you are ready to act, start by:

1. Speak with your state representatives about how we can increase the behavioral rates for Medicaid; they have not been raised in nearly a decade.

2. Ask your therapist friends and colleagues in private practice if they would do 1-3 sessions of pro bono or discounted rates for these individuals.

3. If you can donate, look to our community behavioral health providers and help them fundraise to offer retention and recruitment bonuses. Their margins are often too thin to afford these solutions.


Ryan Estes is the Chief of Clinical Innovation and Technology for Specialized Alternatives for Families and Youth (SAFY), a national leader in behavioral health, child welfare, and foster care programming. Ryan is charged with enhancing data-driven, equitable clinical outcomes by bridging the intersectionality of implementing evidence-based programming and adopting innovative technology. Ryan received his BA in Psychology from Wake Forest University, an MSW from University of North Carolina at Chapel Hill, and an MBA from UNC-Wilmington. Ryan has been in the behavioral health field for over twenty years as a clinician and director. Ryan holds licenses in North Carolina as a Licensed Clinical Social Worker and Licensed Clinical Addiction Specialist. Additionally, he is a Certified Clinical Supervisor with the NC Addiction Specialist Professional Practice Board. Ryan is the Vice Chair on the National Family Preservation Network board as well as the Treasurer for the NC Child Board of Directors. He additionally is the National Association of Social Worker’s National Board Treasurer and the former NASW-NC Chapter President. Ryan teaches part-time for the University of North Carolina at Wilmington in the College of Health and Human Services and is a current Annie E. Casey Foundation Child and Family Fellow.


Specialized Alternatives for Families and Youth (SAFY) of America is a national non-profit organization creating healthy youth and families through community-based solutions. Building upon our reputation as a leader in treatment foster care services, our comprehensive home- and community-based programs serve those with social service and behavioral health needs in seven states including Alabama, Colorado, Indiana, Kentucky, Nevada, Ohio and South Carolina. To learn more about our programs and services, call 800.532.7239 or visit www.SAFY. org.