Policy Recommendations for Coordinated and Sustainable Growth of the Behavioral Health Workforce

Abstract

Policy Points.

• Demand for behavioral health services outpaces the capacity of the existing workforce, and the unmet need for behavioral health services is expected to grow.

• This paper summarizes research and policy evidence demonstrating that the long‐standing challenges that impede behavioral health workforce development and retention (i.e., low wages, high workloads, training gaps) are being replicated by growing efforts to expand the workforce through task‐sharing delivery to nonspecialist behavioral health providers (e.g., peer specialists, promotores de salud).

• In this paper, we describe policy opportunities to sustain behavioral health workforce growth to meet demand while supporting fair wages, labor protections, and rigorous training.

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 , ⁶ , ⁷ , ⁸ , 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.

What Are the Major Causes of the Behavioral Health Workforce Shortage Crisis Among Providers with Advanced Postsecondary Training?

Low reimbursement rates and wages, high service demands, and inadequate occupational supports are among the root causes of the nationwide behavioral health workforce shortage crisis among all behavioral health providers. In the following section, we review the evidence demonstrating how these factors contribute to workforce recruitment and retention challenges among behavioral health providers with advanced postsecondary training (e.g., psychiatrists, clinical psychologists, social workers, psychiatric nurses, mental health counselors, etc.) to demonstrate that merely adding NSPs to the workforce will not address these challenges and, therefore, will not address the behavioral health workforce shortage crisis.

Low reimbursement rates and wages

Inadequate provider compensation and low insurance reimbursement rates are among the major drivers of the behavioral health workforce shortage. For example, higher hourly wage rates are directly associated with the number of licensed psychologists in a region. ¹¹ Behavioral health providers’ wages have always been low relative to other health care professions, but low wages are an even greater barrier to entering the profession as postsecondary education costs have steadily risen in recent decades. ¹² , ¹³ It is well‐documented that medical student debt is associated with training physicians’ choices to pursue higher paying specialties, and psychiatry is among one of the lower‐paid specialties in the United States. ¹⁴ Clinical social workers, who represent most of the behavioral health workforce, earn a median hourly wage of $27, and over a third shoulder an average student debt of $38,500. ¹⁵ , ¹⁶ Behavioral health providers’ financial strain has led some to moonlight in the gig economy (e.g., driving for ridesharing platforms) or to see patients who can afford to pay for private behavioral health services out‐of‐pocket just to make ends meet. ¹⁷

In addition to facing low wages, many behavioral health providers (particularly master's‐level clinicians, who comprise the majority of the workforce) also face significant financial volatility and economic precarity. To cut costs, some behavioral health organizations have shifted business risks onto employees using independent contracting models: labor arrangements that allow organizations to flexibly hire and determine employee hours without offering salaries, benefits, or professional advancement opportunities. ¹⁸ A survey of Philadelphia's public behavioral health providers found that 44% of independent contractors wanted full‐time, salaried positions, and other research has shown that such labor arrangements lead to turnover. ¹⁷ , ¹⁹

Many behavioral health providers leave or do not participate in private and public insurance plan networks because reimbursement rates are too low. ¹ , ²⁰ A 2019 study reported that behavioral health providers were 5.7 times more likely to be out‐of‐network compared with physical health providers. ²¹ This is particularly true for psychiatrists, the majority of whom bill insurance for only a few patients annually. ²² Although behavioral health providers who see patients out‐of‐pocket can command relatively high wages, very few treatment‐seeking individuals can afford self‐pay behavioral health services. ²³ Thus, solving the behavioral health workforce shortage crisis will necessarily involve addressing the pervasive issue of low wages and reimbursement rates. Indeed, a review of state task forces and commissions evaluating behavioral health workforce challenges concluded the following: “Improving provider wages and reimbursement is the sine qua non [the essential condition] of workforce development.” ²⁴

High work demands and low occupational support

Behavioral health providers also face significant workplace demands and receive little occupational support, which has been tied to turnover. Study after study has documented how burdensome documentation and administrative tasks, large caseloads, burnout, declining work autonomy, chronic traumatization, inadequate training, and low supervisory support are all related to workforce turnover. ¹⁷ , ²⁵ , ²⁶ , ²⁷ , ²⁸ Behavioral health providers (particularly those in the public sector serving underresourced populations) describe feeling like they are “underpaid and overworked” and are treated like “cogs in a wheel” to serve health systems’ needs to get patients “in and out.” ²⁹ , ³⁰ The coronavirus pandemic exacerbated these workplace challenges. Many behavioral health providers experienced unprecedent burnout during the pandemic, leading many to leave the workforce. ³¹ , ³² Behavioral health workforce turnover also begets further turnover as the remaining providers in an organization are asked to see more patients and take on additional responsibilities with less staff support.

Will Current Efforts to Increase the Number of NSPs in the Workforce Sustainably Address the Major Causes of the Behavioral Health Workforce Shortage Crisis?

In the past several years, researchers and health policymakers have sought to extend the behavioral health workforce by increasing the number of NSPs in the workforce. ⁶ A survey of state Medicaid program officials found that, between 2022 and 2023, 82% of states had added peer and family recovery support specialists as providers that can bill for behavioral health services. ⁸ Many NSP promoters argue that they are a low‐cost solution to overcoming the prohibitive training barriers that delay clinical workforce expansion because NSPs are not required to hold postsecondary degrees in the behavioral health fields. ³³ Proponents assert that NSPs “may be a bargain” ³⁴ and are “affordable human resources.” ³⁵

Promoting NSPs on the basis that they can be paid low wages is economically exploitative. Furthermore, such proposals are short‐sighted and risk exacerbating current workforce shortages given that low reimbursement rates and wages are among the underlying causes of the current workforce crisis. Additionally, there is some evidence to suggest that relaxing occupational licensing regulations in other health sectors lowers earnings for clinicians with more extensive training requirements. ³⁶ Expanding NSPs on the grounds that they can be paid little thus risks driving down wages for the entire workforce. As Mental Health America, the United States’ leading mental health advocacy organization, has underscored: “Peer support should not be considered a cost‐saving service because it is ‘cheap labor.’” ³⁷

To be clear, NSPs play an important role in behavioral health care delivery. However, policies that focus on increasing the NSP workforce without addressing existing reimbursement, wage, occupational support, and training needs are likely to exacerbate problematic working conditions—the very conditions that have contributed to the current workforce shortage crisis. Recent evidence, summarized below, demonstrates that NSPs already incur these unsustainable working conditions—and even more profoundly than providers with advanced postsecondary training—revealing the need for new policy solutions to support and expand the entire behavioral health workforce.

Low reimbursement rates and wages

Mounting research reveals that US‐based NSPs are distressed by their poverty wages, if they are paid at all. ³⁸ Certified peer specialists in the United States, who must receive special certification credentials to serve in their roles, report receiving average hourly wages of around $16. ³⁹ , ⁴⁰ Wages are so low that many NSPs qualify for social service programs such as the Supplemental Nutrition Assistance Program (formerly known as food stamps). ⁴¹ However, many NSPs’ wages are often just barely above the threshold for many social service programs, leading NSPs to experience higher expenses with little assistance. ⁴²

Survey data suggest that 66% of peer support specialists are economically fragile, unable to generate emergency funds if necessary. ⁴³ Much of this financial fragility and volatility is attributable to the fact that many NSPs are often hired as part‐time workers. ⁴³ A survey of New York State's substance use treatment workforce found that 87% believed they were underpaid and that they wanted either 20% to 30% or 40% wage increases. ⁴⁴ Across studies, NSPs consistently report feeling devalued by their low wages: “We have not taken a vow of poverty, we need to get paid for our value.” ⁴² Worse still, some NSPs are unpaid volunteers. Promotores de salud—peer support specialists in Hispanic/Latine communities—perceive the lack of compensation to be unjust: “I think we have to validate all the work the promotora does, and also, we have to pay the promotora who does that job.” ⁴⁵

NSPs’ low wages cause turnover. In a study examining Medicaid stakeholder perceptions of substance use treatment, one state agency leader reported that NSPs flee to retail and food service jobs because of inadequate compensation: “You can go to Wal‐Mart or anywhere else and make more money. And, you know the work would be easier.” ⁴⁶ Thus, much like other behavioral health providers in the workforce, NSPs are likely to exit the workforce because of their low wages.

One reason that NSPs’ wages are so low is that behavioral health organizations’ face infrastructural and reimbursement constraints that do not cover the costs of providers and therefore limit their ability to raise providers’ wages, including NSPs. Although many NSPs are funded by grants in the United States, emerging research suggests that the billing codes being developed for NSP services are insufficient, much like they are for other behavioral health providers. Indeed, one study examining providers’ reasons for behavioral health workforce turnover found that peer support specialists can only use five Medicaid billing codes, which do not reflect the full range of services they provide. ²⁸

High work demands and low occupational support

Much like other behavioral health providers, NSPs report facing significant work demands and limited occupational support. ⁴² Like their colleagues with advanced behavioral health degrees, NSPs’ burnout is related to their intentions to leave their behavioral health organizations. ⁴⁷ Unlike trained behavioral health professionals, however, NSPs face unique challenges that make their work particularly demanding. One contributing factor to NSPs’ lack of occupational support and fair working conditions is that, unlike their colleagues with advanced postsecondary training, many NSPs currently lack strong national professional societies, guilds, or unions to advocate for fair working conditions and wages. In fact, NSPs are sometimes promoted as a way to “move beyond professional guilds” ⁴⁸ because these guilds advocate for state and federal regulations that protect their members’ labor standards.

Across studies, NSPs report feeling treated as “free, cheap subsidized labor.” ⁴⁹ NSPs are sometimes asked to work above their training credentials (e.g., intensive case management) without compensation equivalent to professional case managers or to complete menial tasks not within their job descriptions. Like other behavioral health providers, NSPs consistently report high caseloads and burnout, but they also report experiencing disrespect, mental health stigma, and workplace discrimination linked to their positions as low‐wage workers. Surveys of peer support specialists find that nearly 40% report that nonpeers at their workplaces are not supportive. ⁴³ NSP job dissatisfaction is associated with turnover. ⁴⁰ , ⁴⁴

NSPs often report receiving little clinical or other kinds of occupational support in their workplaces. NSPs who had only received five days of training and no ongoing clinical support expressed needing more opportunities to learn clinical techniques and practices. ⁴⁹ Some NSPs would like postsecondary education opportunities to further their clinical training but face economic barriers. In one study, 80% of New York State substance use disorder providers said they would pursue higher education if granted tuition reimbursement and 82% would complete a postsecondary degree if it resulted in higher wages. ⁴⁴ This suggests that many NSPs would pursue professional behavioral health training if they could afford it.

NSPs also consistently report barriers to professional advancement in their organizations. Only half of surveyed New York State's behavioral health administrators reported that they offered employees opportunities to rise the ranks beyond entry‐level positions. ⁴⁴ That may explain why 43% of NSPs intend to leave their roles in one to three years or “until something else comes along.” ⁴⁰ Although almost all states offer peer specialist credentials, because of the patchwork of financing mechanisms funding NSPs, these credentials have not reliably led to higher wages or professional advancement opportunities. Indeed, peer support specialists have shorter job tenure than other social service occupations. ³⁹

Altogether, growing evidence suggests that NSPs are not immune from the workforce challenges that lead to ongoing workforce shortages among US behavioral health providers with advanced postsecondary degrees. In fact, this research suggests that NSPs may experience these challenges more profoundly as low‐wage workers with few occupational protections. Thus, efforts to sustainably extend the workforce by increasing NSPs are unlikely to succeed without coordinated and sustained investments simultaneously delivered across the workforce to improve working conditions and wages for all providers. Continuing to add NSPs to the workforce without sustained investments risks passing on the system's deleterious conditions to even more vulnerable workers—many of whom are hired precisely because they share the minoritized social and lived behavioral health experiences of those they serve.

What Can Be Done to Support All Behavioral Health Providers and to Sustainably Expand the Workforce?

State and federal policymakers must invest in funding and coordination to increase and sustain behavioral health workforce growth across all provider types, including NSPs. In Table 1, we propose several state and federal policy recommendations that can sustainably increase the behavioral health workforce. ⁵⁰ , ⁵¹ , ⁵² , ⁵³ , ⁵⁴ , ⁵⁵ , ⁵⁶ , ⁵⁷ , ⁵⁸ , ⁵⁹ , ⁶⁰ , ⁶¹ These policies directly address the previously described root causes of the workforce shortage crisis without transferring existing workforce challenges to NSPs. Below, we briefly describe each policy recommendation we identified based on promising policy innovations at the state and federal level both within the behavioral health field and beyond.

Table 1.

Policy Recommendations to Address the Root Causes of the Behavioral Health Workforce Shortage and Support Nonspecialist Providers

Challenge Facing the Behavioral Health Workforce	Policy Recommendation	Real‐World Example of Policy Implementation
Prohibitive postsecondary education costs prevent workforce recruitment and development for all behavioral health worker types, including nonspecialist providers, particularly in high‐shortage and underserved areas	States and the federal government should create and expand grant programs such as the Health Resources & Services Administration's Behavioral Health Workforce Education and Training and the National Health Service Corps scholarship programs to subsidize behavioral health graduate training, particularly in high‐shortage areas.	In March 2024, President Joseph Biden proposed to invest $2.6 billion in training programs such as the National Health Service Corps, Behavioral Health Workforce Education and Training Program, and the Minority Fellowship Program—programs that train clinicians committed to serving in provider shortage areas. 50
	Invest in free public higher education to increase the number of individuals who can pursue behavioral health graduate training and to enhance the diversity and inclusivity of the behavioral health workforce.	New Mexico passed legislation to make their public higher education tuition‐free for all state residents, including immigrants regardless of their immigration status. 51
	Create alternative career pathway programs to make advanced, postsecondary behavioral health training more accessible and to create opportunities for career growth and professional development for nonspecialist providers.	New York City's “Teaching Fellows” program is one of the most well‐known, evidence‐based policy programs that has successfully created alternative career pathways and opportunities for professional growth to address teacher shortages in high‐need, underserved areas. 52
For many provider types, low reimbursement rates lead to unlivable behavioral health workforce wages	Policymakers must first conduct a needs assessment to evaluate what important clinical activities are not currently billable and what reimbursement rates should be to enhance organizations’ abilities to pay workers living wages.	In February 2022, Oregon released a report assessing the reasons for behavioral health workforce shortages with a focus on reimbursement challenges and how they contribute to low wages. 53
	Earmark taxes to support increased reimbursement rates for behavioral health services and support training and certification costs.	California and Washington have earmarked taxes to increase funding for their behavioral health systems. 54
	Increase Medicaid and private insurance reimbursement rates as well as minimum wages for behavioral health workers (especially nonspecialist providers) at rates that match both demand for services and the costs of living.	As of the fiscal year 2023, 32 states increased Medicaid fee‐for‐service reimbursement rates to attract or retain Medicaid behavioral health providers. 55
	To ensure immediate workforce growth to meet high service demands, create stimulus funds to generate initial signing and retention bonuses, especially in underresourced areas.	Enacted for the fiscal year of 2023, New York State implemented a signing bonus for behavioral health workers. 56
Inadequate job protections and overwork	Pass federal laws that would make it easier for workers to organize for better pay and work conditions; enhance funding to the National Labor Relations Board to increase federal oversight that would ensure just compensation and fair working conditions for all behavioral health workers.	The Richard L. Trumka Protecting the Right to Organize (PRO) Act would facilitate worker organization to ensure adequate job protections and safe staffing standards. 57
	The Occupational Safety and Health Administration, the HHS, and HHS's partner agencies (e.g., Substance Abuse and Mental Health Services Administration) should develop best practice guidelines for behavioral health organizations (e.g., caps on caseloads, peer support groups, clinical training, etc.) to reduce overwork and burnout and to increase providers’ sense of efficacy and resilience.	Some states, such as New York, have introduced legislation regulating caseloads for child welfare workers, modeling how this could be implemented for behavioral health workers. 58
High work demands and little occupational or clinical support cause burnout and diminished self‐efficacy among providers	Expand and increase funding for federal and state technical assistance centers to reduce providers’ administrative burdens. Technical assistance centers provide the necessary infrastructure to create collaborations with behavioral health providers, licensing boards, and payers to streamline documentation requirements and support providers in meeting documentation requirements.	In 2011, the New York State Office of Mental Health and Office of Addiction Services and Supports partnered with New York University to develop the Community Technical Assistance Center, which offers training and technical assistance to all New York State licensed behavioral health agencies. 59
	States and federal agencies should provide grants and funding opportunities to offer ongoing training and consultation to behavioral health providers in evidence‐based practices to support their clinical care. Providers should be compensated to attend training, and financial strategies should support clinicians’ use of evidence‐based practices. Providers should receive regular, high‐quality clinical supervision and should be supported in working in multidisciplinary teams.	Several states have trained clinicians in evidence‐based practices, and some states have experimented with providing clinicians with enhanced reimbursement rates to use evidence‐based practices. 60
	States should invest in developing the infrastructure for providers to engage in peer consultation and collaborative learning to enhance worker autonomy, self‐efficacy, and lifelong learning.	Several states, including South Carolina, have implemented learning collaborative models to increase the use of evidence‐based practices and enhance interprofessional collaboration. 61

HHS, Department of Health and Human Services.

Make professional behavioral health training more accessible

Postsecondary education costs are prohibitive, particularly for individuals from underserved and minoritized social positions. These costs prevent people—i.e., potential behavioral health providers and NSPs—from pursuing postsecondary behavioral health training or from working in underserved, high‐shortage areas after graduating because they often elect to see private or self‐pay patients to recuperate lost earnings and debt incurred during graduate training. A recent scoping review revealed that federal scholarship programs are likely more effective than loan repayment programs at recruiting behavioral health providers to high‐shortage areas—particularly underresourced and diverse providers—because scholarship programs minimize the upfront costs of pursuing postsecondary behavioral health training, making graduate training more accessible. ⁶² Thus, state and federal policymakers must invest in scholarship programs and in making state universities affordable (if not free) to enable individuals to enter the behavioral health workforce and serve in high‐shortage areas. ⁵⁰ , ⁵¹

Create alternative pathways for professional advancement and growth

Many NSPs report wanting to pursue graduate behavioral health training, but they cannot do so because of the steep financial barriers to entry to postsecondary institutions. ⁴⁴ NSPs, like all behavioral health providers, deserve pathways for career growth as their expertise grows. In addition to investing in traditional pathways to professional behavioral health training, state and federal policymakers can develop alternative pathways to traditional behavioral health roles (e.g., clinical social workers, mental health counselors). Behavioral health policymakers can learn from other fields that have successfully implemented these alternative career pathway programs. For example, to address widespread teacher shortages in high‐need, underserved school districts, New York City implemented “The NYC Teaching Fellows Program,” which is an intensive program available to individuals without the required education requirements. The program places individuals in high‐need school districts and pairs on‐the‐job training and supervision with free, expedited, public university coursework to support them in achieving their teaching licenses. This program has been shown to improve student achievement among underresourced students. ⁵² Developing alternative behavioral health career pathway programs at the state and federal level will not only make advanced behavioral health credentials more accessible—supporting workforce recruitment—but it will also provide a pathway for NSPs to develop their professional expertise and to develop in their careers, supporting workforce retention.

Increase reimbursement rates and provider wages

Low reimbursement rates and wages are key reasons that individuals do not enter the behavioral health workforce. ⁵³ Federal and state policymakers should increase public reimbursement rates, expand the number of clinical activities that are billable, and set minimum wage standards for behavioral health providers. Increasing wages for all provider types is necessary to ensuring that individuals will be attracted to and remain in the workforce. States have innovated strategies to increase public reimbursement rates and provider wages. ⁸ , ⁵⁴ , ⁵⁵ In addition, states have also developed strategies to immediately increase the number of providers working in underserved areas through sign‐on and retention bonuses. ⁵⁶

Establish job protections to make behavioral health work attractive and sustainable

Behavioral health providers consistently describe overwork and few job protections, which lead to significant turnover and ongoing shortages. Federal and state policymakers should establish occupational health and safety standards (e.g., caseload caps, safe staffing ratios) for behavioral health work and ensure that behavioral health organizations meet these occupational standards. ⁵⁷ , ⁵⁸ Federal and state policymakers can also pass laws that make it easier for workers to collectively organize to protect their health and safety. ⁵⁷

Enhance clinical and occupational support to increase providers’ preparedness and self‐efficacy

Behavioral health providers consistently describe feeling unsupported to meet the demands of their work. Providers face onerous administrative burdens due to reporting requirements from state and federal agencies as well as from insurers. In addition to reducing administrative burdens, state and federal policymakers should provide enhanced support and technical assistance to behavioral health organizations to ease these burdens. ⁵⁹ Behavioral health providers, particularly NSPs, describe feeling like they do not receive sufficient clinical training to meet the needs of their patients. There is a significant shortage of providers trained in supporting specific clinical populations (e.g., individuals with serious mental illness, children and youth, individuals with substance use disorders). Providing ongoing clinical training and support to providers will increase their clinical preparedness and meet population behavioral health needs. ⁶⁰ , ⁶¹

Conclusions

To address current behavioral health workforce shortages sustainably and equitably, large‐scale and coordinated financial investments—not labor cost‐cutting measures— that support all behavioral health providers are needed. NSPs are critical to the behavioral health care system, but policies that focus on simply increasing the NSP workforce fail to address the myriad financial and labor protection issues that derail behavioral health worker recruitment and retention efforts. The United States must instead make sustainable investments to address these problems and ensure timely access to a variety of qualified behavioral health provider types. We propose several policy recommendations with real‐world examples for states and the federal government to scale up to meaningfully address the behavioral health workforce crisis while advancing NSPs’ vital role in promoting quality behavioral health care.