Rural behavioral health in New Mexico: why the money doesn’t become care

I’ve spent much of my career trying to close the gap between New Mexico’s cities and its rural counties — the gap that decides whether a family in Gallup or Chama gets the same shot at health as one in Albuquerque. As CEO of the Center for Health Innovation-Public Health Institute (CHI-PHI), an independent partner working to connect state agencies, legislators and communities around public health, I spend a lot of time in the Roundhouse making the case that where you live in this state still determines, in large part, whether you can get care. Nowhere is that clearer right now than in behavioral health.

Here’s the part that should stop us cold: New Mexico is not short on money. Our sovereign wealth fund has grown to roughly $75 billion and is on track to become the largest in the country by 2030. We’ve received over $920 million in opioid settlement funds. We have a state behavioral health trust fund, an early childhood fund, and Medicaid expansion. Few states have more resource wealth per resident.

And yet, as of mid-2025, local governments had spent only $15 million of the $110 million in opioid settlement funds sent their way — 13%. Fifteen of 33 counties and seven of 12 municipalities had spent nothing at all. Those counties were overwhelmingly rural. Albuquerque and Bernalillo County alone accounted for two-thirds of everything spent statewide.

This isn’t a story about missing or mismanaged money, or ill intent. The State Auditor’s own report says the barrier is a lack of qualified behavioral health providers and programs in rural counties to spend the money through. Roosevelt County has $390,000 sitting untouched — not because anyone’s blocking it, but because there’s no one to hire. A five-county plan to open a regional behavioral health facility in Clovis has stalled for the same reason. Having a building isn’t the problem. The workforce is.

New Mexico doesn’t have a resource problem. It has an absorption problem — capital and workforce infrastructure concentrated in Albuquerque and Santa Fe, trying to deliver care in places where neither one exists.

We’re not alone in this. Alaska is the only state with a comparable resource base — a massive permanent fund, decades of oil wealth, and severe frontier geography. Its suicide rate is more than double the national average, and rural substance use disorder is nearly double urban rates. When Alaska recently received $272 million in federal rural health funding, legislators there watched it start flowing to whichever vendors could move fastest — an out-of-state startup, a Massachusetts telehealth company, hospital systems already established in Anchorage. The lesson isn’t that rural health is unsolvable. It’s that money without deliberate, place-based workforce design defaults to wherever capacity already exists. Wealth doesn’t autocorrect for geography. Only design does.

Alaska also built the country’s strongest counterexample: the Behavioral Health Aide program, which trains people who already live in remote villages, through tiered certification, with Medicaid reimbursement built in from the start. It doesn’t try to parachute credentialed strangers into communities of a hundred people. It grows the workforce in place.

New Mexico doesn’t need to import a model like Camden Coalition’s urban complex-care system wholesale — but its relationship-first, root-cause approach is sound, but it was built for dense, urban New Jersey, not Catron County. What we need is that same relationship-first logic, delivered through an Alaska-style embedded workforce: people already living in the community, trained and certified where they are, rather than credentialed elsewhere and sent into a place they don’t know and won’t stay.

None of this happens by accident, and it won’t happen through another allocation dropped at a door with no one behind it. It requires outpatient capacity between crisis and nothing, grow-your-own training pipelines, technical support so rural counties can actually spend what they’re allocated, and funding rules that don’t quietly favor whoever already has the infrastructure to move fast.

New Mexico does not lack the resources to fix this. What it lacks is the delivery system rural communities actually need. Rather than waiting for money to find a way in on its own — because It won’t — we have to build the way in.