Renewed energy to address Maine’s ‘broken’ mental health care system in upcoming session

Maine’s mental health care system is fractured and scattered, with chronic underfunding and gaps in services that prevent many from accessing the care they need. 

That’s what providers, advocates and lawmakers pushing for change say. And although progress has been made during the Mills administration to begin rectifying these issues, they say much more is needed to stabilize the system.

“Our system is broken, and that’s not any different than I’ve been saying the entire time I’ve been in the legislature,” said state Rep. Colleen Madigan, a fourth-term Democrat from Waterville who has worked in the behavioral health field for over 25 years. 

With a short session of the legislature set to begin later this year, advocates say there are potential solutions that could start to address these problems, including a series of bills that lawmakers have already passed but that haven’t been funded by the budget committee.

And indeed there may be renewed political momentum to take action on the issue of behavioral health, as well as gun safety, following a deadly mass shooting in Lewiston last month in which the shooter had easy access to weapons and a history of mental health problems. While advocates emphasize that those with mental health disorders are far more likely to be the victims of violence than the purveyors of it, they said they welcome a conversation about how to strengthen the behavioral health care system in the wake of the tragedy.   

“We need a system of care that’s providing the supports people need,” said Malory Shaughnessy, executive director of the Alliance for Addiction and Mental Health Services of Maine. 

What are the issues?

The problems with Maine’s mental health care system are multifaceted but interconnected. Ultimately, though, they boil down to a lack of access to services — an issue caused by persistent underfunding and a shortage of workers. 

Waitlists for mental health services are common across the state. Joe Everett, president and CEO of the Opportunity Alliance, which provides behavioral health care in southern Maine, said the organization has waitlists for every single one of its programs. And state Rep. Lydia Crafts, a Democrat from Newcastle and a social worker, said she has heard local mental health providers across the state talk about waitlists in the thousands and has found a similar situation in her job.

“Just generally, there are not enough providers,” Crafts said. “It’s hard to find people.” 

Crafts said one of the culprits is low reimbursement rates from MaineCare, the state’s Medicaid program. Because of this, some providers may not accept patients covered by Medicaid, which primarily serves those with low-incomes, because it’s not economically viable. 

“That puts poor folks on the losing end of accessing mental health,” Crafts said. 

The state has provided some funding to increase reimbursement rates, but lawmakers and providers say the issue is still a significant hurdle. 

Private insurance can also be part of the problem, Everett said. While many plans cover some mental health treatment, insurance providers often put limits on the number of times someone can see a therapist or get help from a social worker.

“It’s hard if you have a persistent mental illness and you only get 20 sessions a year,” Everett said. 

Another huge drag on the mental health care system: a workforce shortage. 

Everett said the Opportunity Alliance has around 500 total employees but about 50 vacancies. And statewide, he said there are only around 290 licensed psychiatrists, a severe shortfall when considering Maine has a total population of around 1.3 million people. 

Low pay for behavioral health practitioners is one reason behind the worker shortage, Everett said. Others include the increased cost of living in Maine amid an affordable housing crisis and the price of higher education, which saddles far too many prospective behavioral health workers with large amounts of debt. 

Everett added that with reimbursement rates still not keeping up with costs, it’s difficult for agencies to raise salaries because they too are only just scraping by. 

Debra Jacques, director of marketing and development at Aroostook Mental Health Services (AMHC), said the situation in that region is similar, although The County’s rural nature makes attracting workers even more difficult. 

The problem has resulted in a waitlist for the organization’s mental health therapy services, Jacques said. 

Madigan warned that the workforce shortage and the resulting lack of access to services has potentially dangerous repercussions. 

“A lot of community-based [mental health] services are not available in some of our rural areas and so what happens is if someone needs them in those areas and they’re not available, many folks become more and more acute until there’s crisis services needed and our crisis services aren’t in great shape either,” she said.

Maine’s mental health care system wasn’t always so broken, as the state was once considered a leader on the issue in the 1990s and early 2000s, advocates said. However, Shaughnessy said the state’s system started to deteriorate around the economic downturn in 2008 and 2009 following steep cuts made under the administration of then-Gov. John Baldacci and further reductions during former Gov. Paul LePage’s time in office in the 2010s. 

“We’ve seen cuts and cuts and cuts over the last decade or so,” she said.

In recent years, Gov. Janet Mills’ administration has worked with advocates and providers to make progress on addressing some issues, including adjusting MaineCare reimbursement rates.

In an emailed statement, Maine Department of Health and Human Services spokesperson Jackie Farwell noted that the Mills administration invested $230 million in behavioral health services in 2022 and 2023 alone. That money was meant to improve accessibility and quality of care and provide better funding for practitioners through improved reimbursement rates, she said. 

Furthermore, she noted that DHHS in 2022 launched the 988 Suicide and Crisis Lifeline, created the first comprehensive emergency crisis center in Portland, and enhanced mobile crisis services. Farwell added that over 4,000 people are either enrolled in or have completed health care workforce programs, including those related to behavioral health training, at free or reduced costs as part of a Mills administration program.    

Solutions

While the steps taken thus far by the state represent progress, advocates say more must be done. 

“We have some good bones, we have some new investments, but we still have many gaps and transitional gaps between levels of care,” Shaughnessy said, using the example of someone who comes to the emergency room to receive mental health treatment and is stuck there because there is no space available in residential or community-based programs. 

Shaughnessy said a significant first step would be for policymakers to fund bills already passed by the legislature that are pending before the Appropriations and Financial Affairs Committee, which makes decisions on measures that cost the state money. 

One such bill would mandate that the state apply for a waiver from the federal government for Medicaid-funded services for patients who are in mental health facilities with more than 16 beds, a proposal Shaughnessy said is needed to spur more access to in-patient services. 

Other pending bills that Shaughnessy is calling for lawmakers to fund include: legislation to provide support services for people with emotional dysregulation disorders, a bill to reduce barriers to addiction recovery by increasing case management services, a measure to create more peer-based centers for mental health treatment, a proposal to better meet the needs of people with severe mental health diagnoses through additional programmatic funding, and a bill to increase children’s mental health services in rural Maine. 

Shaughnessy also wants lawmakers to fund measures meant to entice workers to join the behavioral health field by changing some education requirements and providing educational vouchers, as well as a bill to study current barriers to parity within the mental health system. 

All told, Shaughnessy said funding these proposals would cost between $10 to $15 million, which she argued is doable with the proper political will. 

“That’s a drop in the bucket” when compared to Maine’s overall state budget of $9.8 billion over two years, she said. 

And while funding those bills wouldn’t completely resolve the longstanding issues with the mental health system, Shaughnessy said they would help the state build toward a much more comprehensive, effective apparatus of care over the next several years. 

Advocates and practitioners are also calling for additional action to attract workers to mental health care positions. Such efforts need to start with higher pay, they said. 

“People need to earn a livable wage in this sector and even more than a livable wage to actually have housing here,” Everett said. 

Further rate adjustments from MaineCare are one way the state could raise pay and prevent turnover as people leave the industry for more lucrative professions, Crafts said.   

Everett said the state should also focus on recruiting people nationally to come to Maine to work in behavioral health by implementing signing bonuses and student loan relief programs. Crafts said there is a bill to revamp a student debt forgiveness program for social workers that has been carried over to the upcoming legislative session.  

Madigan added that further investment in creating Certified Community Behavioral Health Clinics would help. Such centers, which have received federal support from the Biden administration, are meant to provide coordinated access to care for those with mental health issues and are required to serve those in need, regardless of their ability to pay. 

Earlier this year, Maine DHHS was awarded a $1 million grant to build on efforts to create such a model in the state. However, Madigan said additional funding is needed to accelerate that process. 

“The state having more of a buy-in for that model [would be] a big thing,” she said.

Along with those proposals, in the wake of the Lewiston shooting, state Rep. Laurel Libby, a Republican from Auburn, said she would be proposing emergency legislation to repeal Certificate of Need (CON) requirements for inpatient and outpatient facilities in the state. CONs require certain health care providers to get state approval before making major changes such as pursuing a merger or an acquisition, developing new facilities, making substantial capital investments, or shifting access to services. 

“We have a chronic, systemic shortage of mental healthcare in Maine. We saw the effect of that shortage last week during the tragic events that took place in Lewiston,” Libby said in an October news release. 

“Repealing CON is the first step in eliminating those obstacles,” she continued. “Time and again, states that have repealed CON have demonstrated an increased ability to respond to the needs of their communities.” 

However, Madigan is not convinced that repealing certificate of need requirements would actually solve the problems with the state’s system. She said CONs are not the hurdle preventing agencies from increasing services, but rather financial viability is what’s holding the expansion of services back.

Whatever direction lawmakers go this session, Shaughnessy emphasized that concrete action is needed, arguing that the consequences of not addressing the issues with the mental health care system are vast. 

“It costs us in humanity and dollars every day for not investing fully in the system of care,” she said.