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September 2024 (Volume 102)
Quarterly Article
Briana S. Last
Erika L. Crable
Mental Health and Substance Use Challenges
December 2019
Back to The Milbank Quarterly
Policy Points:
Demand for behavioral health services in the United States far outpaced supply before the coronavirus pandemic, but the past several years have seen an acceleration of these trends. Since the pandemic began, many behavioral health organizations have seen their workforces shrink; for every 10 providers organizations hire, 13 providers leave.1 A historic shortage of around 250,000 licensed providers is expected by 2025.2 As a result of these shortages, less than half (and, in some shortage areas, only a quarter) of individuals in need of treatment can access care.3, 4
Task sharing, or delegating some care responsibilities to nonspecialist providers (NSPs), is a popular policy recommendation to augment the behavioral health workforce’s capacity.5-9 NSPs are individuals who are not required to undergo advanced postsecondary behavioral health training, and many of these providers share the behavioral health challenges or social positions of the people they serve.6 NSPs encompass a variety of roles, including peer support specialists, family recovery specialists, community health workers, behavioral health coaches, and promotores de salud. Although each NSP role has its unique historic roots and is regulated somewhat differently in the United States, behavioral health researchers and policymakers have proposed increasing all of these NSP provider types to expand the workforce. In fact, NSPs are among the fastest-growing group of workers in the behavioral health workforce.10
In this paper, we synthesize evidence suggesting that current efforts focused primarily on increasing NSPs will be unlikely to address the causes of the behavioral health provider shortage crisis and may even exacerbate them. In particular, we describe how the United States’ fragmented and underfunded behavioral health system leads all behavioral health providers to experience noncompetitive wages, growing work demands, and insufficient occupational support—all of which promote ongoing behavioral health workforce shortages. We review the growing evidence suggesting that NSPs disproportionately experience these occupational challenges as low-wage workers who are structurally disempowered in behavioral health service systems. We conclude with suggestions for federal and state policies to deliver financial and structural investments to workforce planning and support to provide economically secure opportunities for all behavioral health providers and to attract new providers to the system. Without coordinated, sustained, and multipronged investments in behavioral health workforce planning, efforts aimed at expanding the workforce by merely increasing NSPs risk shifting long-standing deleterious work conditions to highly exploited and vulnerable workers.