Improving access to mental health services for youth in the United States.

IN THE WAKE OF THE RECENT SCHOOL SHOOTING IN Newtown, Connecticut, a public dialogue emerged about the accessibility of mental health care in the United States. Policy makers have called for a more critical examination of the mental health treatment system, and advocates are rallying around federal legislation that would strengthen community-based mental health services—especially for children and adolescents. Although the implementation of recent federal policies (ie, the Mental Health Parity and Addiction Equity Act and the Affordable Care Act) will expand insurance coverage for mental health disorders among many US children, these expansions will not improve access if communities lack a sufficient infrastructure to serve those in need of care. Mental health facilities that provide outpatient specialty services comprise a critical element of the treatment infrastructure for patients with mental health problems, especially for youth who are living in poverty, are uninsured, or are publicly insured. To inform the current dialogue, we report data from the 2008 National Survey of Mental Health Treatment Facilities and examine the extent to which gaps exist in this infrastructure. The survey is a national, facilitylevel survey of entities that provide specialty mental health services, such as psychiatric hospitals, residential treatment centers, freestanding outpatient clinics or partialcare facilities, and multiservice mental health facilities. A response rate of 74% was achieved from the 13 068 facilities surveyed. Findings based on restricting the sample of counties to those with complete facility-level data were similar to results presented in the FIGURE. Based on these survey data, only 63% of US counties have at least 1 mental health facility that provides outpatient treatment for children and adolescents, and fewer than half of US counties have a mental health facility with any special programs for youth with severe emotional disturbance (Figure). These gaps in infrastructure are especially pronounced in rural communities; fewer than half of rural counties have a mental health facility that provides outpatient treatment for children and adolescents, and only one-third have an outpatient facility with programs specially designed for youth with severe emotional disturbance. These data likely represent conservative estimates of the extent of the problem, because state funding for mental health services has been reduced since 2008. Between 2009 and 2012, states eliminated more than $1.6 billion in general funds from their state mental health agency budgets. These budgetary reductions have resulted in decreased services for children and adults with serious mental illness and closures of community mental health programs, especially in states that have consistently reduced their budgets since 2009. These gaps in the mental health facility infrastructure are part of a larger problem of geographic access to mental health services for persons with limited financial resources. Although some youth may seek treatment from mental health clinicians in solo or small group practices, the accessibility of these services is limited for youth who are either uninsured or publically insured. For example, only 3% to 8% of patients are covered by Medicaid for care provided by psychiatrists in solo or group practice, respectively. Although services delivered through school-based mental health programs could help address geographic and financial barriers to the mental health care system, many school systems have also faced substantial budgetary reductions since the economic downturn; these budgetary reductions have affected the availability of schoolbased mental health programs. Even if schools can offer mental health services, they may lack the resources and personnel necessary to provide comprehensive services for youth with severe emotional disturbance for whom medication, intensive psychotherapy services, or both may be indicated. One option for addressing these gaps in geographic accessibility for low-income youth is to expand the capacity of primary care safety-net facilities such as federally qualified health centers or rural health clinics to provide mental health services for youth. Nearly three-fourths of counties have at least 1 of these clinics, most of which offer some types of mental health services. Rural commu-