State Policy Strategies for the Workforce Emergency in Behavioral Health

Several states have created organizations to strengthen the behavioral health workforce. Common responsibilities of these entities include workforce assessment; strategic planning; and the funding, implementation, and evaluation of workforce interventions. Some of these organizations have successfully leveraged initial state funding by securing federal and foundation grants to further develop the workforce. These were often established as permanent structures, with the rationale that continuous efforts are necessary to build and sustain a workforce of sufficient size, diversity, and skill to meet current and future needs.

As a prime example, the Behavioral Health Education Center of Nebraska (BHECN; https://www.unmc.edu/bhecn) was established in 2009 at the University of Nebraska Medical Center and serves as the state’s behavioral health workforce development entity. Its initiatives to strengthen this workforce are implemented in high schools, colleges, professional schools, residency programs, postdoctoral fellowships, and the community of practicing providers. The center has three extension sites that were created to develop, train, and support a culturally diverse workforce in the more diverse rural areas of the state. Initially funded at $1 million annually, its FY24 budget was $5 million. The Nebraska legislature recently allocated an additional $25.5 million in American Rescue Plan Act (ARPA) funds to BHECN that it has competitively awarded to others within the state (www.unmc.edu/bhecn/arpa/index.html). These awards focus on education and training, supervision of provisionally licensed providers, behavioral telehealth in rural areas, and COVID-19–related workforce projects.

This strategy assumes that effective workforce development requires a thorough, cross-agency, multistakeholder strategic plan that addresses initial training and education, licensing, recruitment, retention, and continued professional development. Such plans have been mandated by governors and legislatures in many states.

In Colorado, for example, Legislative Bill SB22-181 (www.leg.colorado.gov/bills/sb22-181) required the state’s behavioral health administration to develop and implement a behavioral health care provider workforce plan, which was released in 2022 (9). Legislative requirements included a focus on workforce diversity, preparation for public sector service, recruitment and education of state residents in professional shortage areas, expansion of the peer workforce, expanded portability of credentials, and reduction of administrative burden on workers.

The underlying logic of this strategy is that increasing Medicaid rates and grant funding will improve worker compensation, recruitment, and retention. In a survey by the Kaiser Family Foundation (10), nearly two-thirds of responding states indicated that they were using fee-for-service rate increases to attract or retain behavioral health providers in their Medicaid programs.

For example, the Office of MaineCare Services, Maine’s Medicaid authority, was honored by the National Association of Medicaid Directors for transforming its rate-setting system to improve both member health and provider sustainability (www.maine.gov/dhhs/blog/mainecare-recognized-national-leader-medicaid-innovation-rate-system-reform-2022-11-14). The goal of this change was to create a system that offers rates consistent with the cost of delivering services and that keeps pace with inflation. Effective January 1, 2023, the median percentage increase in selected MaineCare behavioral health rates included community support services (59.2%), behavioral health services (22.0%), and behavioral health home services (43.0%) (www.maine.gov/dhhs/blog/maine-dhhs-announces-historic-payment-reforms-behavioral-health-2023-01-11).

In contrast to indirect efforts to strengthen the workforce, this focused strategy involves payments to agencies to immediately and directly address urgent worker recruitment and retention needs. Such awards have generally been time limited.

As a prominent example, Oregon workforce stability grants (www.oregon.gov/oha/HSD/AMH/Pages/Workforce-Stability-Grants.aspx) totaling $132 million were awarded to 159 provider agencies, which predominantly were serving the uninsured or those enrolled in Medicaid or Medicare. A minimum of 75% of each award had to be spent on employee compensation and the remainder on other recruitment and retention strategies. To supplement this initiative, the state allocated $60 million to develop a diverse behavioral health workforce, with “diversity” defined as people of color, tribal members, and rural residents (www.oregon.gov/oha/HSD/AMH/Pages/Workforce-Initiative.aspx).

This policy option involves financial support for behavioral health education programs, internships, continuing education, and training in evidence-based practices. It is designed to increase the number of individuals entering the field, help workers maintain their licensure and certification, promote advancement, and increase effectiveness of the services that workers provide.

In 2023, the State of Maryland House Bill 418 established a nonlapsing behavioral health workforce investment fund. The legislation required that the Maryland Health Commission, in collaboration with numerous state departments and stakeholder groups, recommend the level of funding and priorities for use of the funds. The Maryland Department of Health is required to report each year the number and race and ethnicity of behavioral health professionals and paraprofessionals who were educated, trained, recruited, certified, placed, or retained through use of expenditures from the fund (https://mgaleg.maryland.gov/2023RS/Chapters_noln/CH_287_hb0418t.pdf).

This strategy involves providing financial support to individuals being trained in behavioral health and to those who carry educational loans related to such training. This support is generally linked to service commitments in underserved communities. Many states have implemented and recently expanded loan repayment and tuition reimbursement programs.

CT Health Horizons (https://www.ct.edu/cthealth) is a recent example. It is a 3-year, $35 million, ARPA-funded program, which offers tuition assistance of up to $10,000 per student to grow Connecticut’s graduate-degree social work and undergraduate- and graduate-degree nursing workforce, including psychiatric nurse practitioners. The collaboration involves more than 30 public and private colleges and universities. Eligibility criteria for students in participating master of social work programs include, for example, having a current salary below the state’s living wage, and awards are prioritized for bilingual students and students of color.

This strategy broadens the workforce beyond individual professions. It strives to expand and build competencies among workers in the direct support, paraprofessional workforce and to increase the number of persons in recovery and family members offering peer support and advocacy.

California, for instance, has promoted such work through its behavioral health workforce development initiative (https://www.workforce.buildingcalhhs.com). It has offered peer workforce investment grants of up to $750,000 for peer-run, nonprofit behavioral health agencies to increase the number of peer support workers, expand their training, increase their rates of certification, and improve their competence and ability to work with other types of providers. The grants prioritize recruitment and training of peer staff who are bilingual or Black, Indigenous, or people of color (https://www.workforce.buildingcalhhs.com/grant-programs/peer-workforce-investment-grant).

For the first time in generations, the workforce challenges in behavioral health have the focused attention of legislative and executive branch leaders in many states. There is an immediate and probably time-limited opportunity to build on the interest of these leaders and on the current availability of federal funds. States should seize this moment to learn from each other’s policy decisions, strengthen their workforces, and share with each other the outcomes of implementation efforts. The strategies and examples described above and in the online supplement suggest multiple paths forward.

Federally supported research and multistate workforce learning collaboratives would help accelerate progress. Additional strategies are needed to increase the workforce pipeline, bringing new workers into the field and strengthening the competence of all health and social services workers to respond effectively to behavioral health needs. Moreover, as pandemic-related federal support of states declines, researchers and clinicians must urge state policy makers to sustain and expand their efforts. The opportunity is now. Time is of the essence.