Data & rankings

Adults with SUD who needed but did not receive treatment

In 2022-2023 combined data, over three-quarters (77.09%) of all adults with a substance use disorder (SUD) did not receive the treatment they needed. Over 80.00% of adults who needed care did not receive it in California, Georgia, and Illinois, the three lowest-ranked states.

Most adults with SUD who sought or considered treatment in 2023 but did not ultimately receive it said it was because they thought they should have been able to handle their drug or alcohol use on their own (74.10%), they weren’t ready to start treatment (65.60%), and/or they were not ready to stop or cut back using alcohol or drugs (60.10%).⁸ To best support individuals who may need treatment for SUD but are not ready to stop using substances, states must continue to invest in services to reduce overdose rates, such as distribution of opioid overdose reversal treatments and fentanyl test strips. These services are critical to keep individuals safe and save lives while expanding access to treatment and lasting recovery.

There were significant improvements in reducing other barriers to substance use care from 2022 to 2023. The percentage of people reporting they did not receive SUD treatment because they did not know how or where to get it decreased by 11.80%, from 48.90% in 2022 to 37.10% in 2023. The percentage of people reporting their health insurance did not cover alcohol or drug use treatment also decreased, from 40.10% in 2022 to 28.60% in 2023.⁹

These reductions are likely due to large state and federal investments in substance use awareness and increasing access to treatment providers and programs in 2022 and 2023. However, the significant cuts to Medicaid passed in 2025 threaten improvements in access to substance use care.10 At the state level, Medicaid funding must be protected to maintain progress in expanding access to substance use treatment.

Adults with AMI who are uninsured

In 2022-2023, 9.20% of adults with any mental illness (AMI) in the U.S. were uninsured, totaling over 5 million people. Nine of the states with the highest rates of uninsured adults were in the southern U.S. In Texas (ranked 51) nearly 1 in 5 adults with AMI did not have health insurance.

Medicaid is the largest payer for behavioral health care in the U.S. In 2023, 26% of all adults with a mental illness or substance use disorder were covered by Medicaid, totaling 22 million adults.¹¹

In 2025, Congress passed the H.R. 1, the One Big Beautiful Bill Act, which included significant cuts to Medicaid and coverage through the Affordable Care Act (ACA) marketplace.¹² According to the Congressional Budget Office (CBO), these provisions will cause about 15 million people to lose their current health coverage. This includes 10 million people who are estimated to become uninsured due to Medicaid and ACA marketplace cuts, and 4.2 million who will lose coverage due to cuts to premium tax credit enhancements that lower the cost of health insurance.¹³ People who are uninsured are more likely to forgo needed mental and physical health care, leading to worse outcomes over time.¹⁴

Individuals with mental health and substance use conditions are exempt from work requirements and will not have to pay copays for mental health services under H.R. 1. However, these cuts are still likely to significantly limit access to health care for adults with behavioral health conditions and result in worsening outcomes. Nearly 70% of Medicaid enrollees with a mental illness also have at least one chronic health condition.¹⁵ While mental health services are exempt from copays under H.R. 1, many physical health services are not, so people with mental health conditions may be forced to forgo care for their chronic conditions due to cost. H.R. 1 also limits states’ ability to raise or implement provider taxes and reduces existing provider taxes in expansion states. The CBO estimates that this change alone could cut $191 billion in federal spending cuts over the next 10 years, likely forcing states to cut reimbursement and available services, including behavioral health services.¹⁶

Adults reporting 14+ mentally unhealthy days a month who could not see a doctor due to costs

In 2023, 26.58% of adults who reported experiencing 14 or more mentally unhealthy days each month were not able to see a doctor due to costs. This was a 2% increase over 2022 and a 4% increase over 2021.

In Texas (ranked 49), more than 4 in 10 people with frequent mental distress could not afford to see a doctor in 2023. Most of the states with the least access to affordable health care were located in the southeastern U.S.

Cost is one of the main reasons people forgo needed mental health care. In 2023, over half (59.80%) of adults with a mental illness who sought or thought they needed mental health care said the reason they did not receive it was because they thought it would cost too much.¹⁷ Further, a 2025 poll by the Kaiser Family Foundation found that 18.00% of adults who delayed or skipped care reported that their health got worse as a result.¹⁸ To reduce rates of mental health crises and ensure the best outcomes for recovery, states must combat the rising costs of health care. This requires both short-term solutions, such as financial assistance for residents, and long-term solutions, such as limiting payer and provider costs through legislation and regulatory processes.¹⁹

Adults with AMI reporting an unmet need for treatment

In 2022-2023 combined data, 1 in 4 adults with any mental illness (AMI) in the U.S. reported an unmet need for mental health treatment in the past year. Unmet need is defined as seeking treatment or thinking they should receive treatment but not receiving it.

In Wyoming (ranked 51), nearly 4 in 10 adults with AMI had an unmet need for mental health treatment in 2022-2023.

Each year, SAMHSA’s National Survey on Drug Use and Health (NSDUH) asks respondents who did not receive mental health treatment about their reasons for not receiving care. In 2023, the most common reason adults reported that they did not receive treatment was that they thought they should have been able to handle their mental health, emotions, or behavior on their own (70.50%). The second most common reason was that they thought treatment would cost too much (59.80%).²⁰

Many adults also reported a lack of access to or awareness of treatment providers. Nearly half (48.60%) of adults reported they did not know how or where to get treatment in 2023, and 40.70% reported they could not find a treatment program or a health care professional that they wanted to go to.²¹

Adults with AMI with private insurance that did not cover mental or emotional problems

In 2022-2023 combined data, 9.60% of adults with AMI had private health insurance that did not cover mental health treatment – totaling nearly 3 million people in the U.S.

The Mental Health Parity and Addiction Equity Act (MHPAEA) requires that insurance coverage of mental health and substance use disorder benefits be no more restrictive than coverage of benefits for medical or surgical care.²² However, people continue to have to pay more out-of-pocket for mental health care than physical health care. A 2021 study found that adults who were treated for depression or anxiety had almost twice the out-of-pocket spending as those who did not have a mental health condition.²³ In 2024, the Biden Administration finalized new rules to strengthen and incentivize enforcement of MHPAEA, which were a supplement to the original rules finalized in 2013.²⁴ However, in 2025, the Departments of Labor, Health and Human Services, and the Treasury announced that they would not be enforcing the new rules, and had plans to rescind or modify them, undermining access to behavioral health services for youth and adults across the U.S.²⁵ Without enforcement from the federal government, states bear the primary responsibility to enforce MHPAEA.

Youth with private insurance that did not cover mental or emotional problems

In 2022-2023 combined data, 8.60% of youth (ages 12-17) had private health insurance that did not cover mental health treatment – totaling over 1 million youth in the U.S.

The Mental Health Parity and Addiction Equity Act (MHPAEA) requires that insurance coverage of mental health and substance use disorder benefits be no more restrictive than coverage of benefits for medical or surgical care.²² However, people continue to have to pay more out-of-pocket for mental health care than physical health care. A 2021 study found that adults who were treated for depression or anxiety had almost twice the out-of-pocket spending as those who did not have a mental health condition.²³ In 2024, the Biden Administration finalized new rules to strengthen and incentivize enforcement of MHPAEA, which were a supplement to the original rules finalized in 2013.²⁴ However, in 2025, the Departments of Labor, Health and Human Services, and the Treasury announced that they would not be enforcing the new rules, and had plans to rescind or modify them, undermining access to behavioral health services for youth and adults across the U.S.²⁵ Without enforcement from the federal government, states bear the primary responsibility to enforce MHPAEA.

Youth with MDE who did not receive mental health services

In 2022-2023 combined data, over half (50.80%) of youth (ages 12-17) with a major depressive episode (MDE) did not receive any treatment or counseling for depression in the past year. That is a 5% improvement over 2021-2022 combined data. Still, over 2 million youth with depression are not receiving care. In Alabama (ranked 51) nearly two-thirds of youth with MDE did not receive treatment in 2022-2023.

In 2023, 85.30% of youth reported not receiving care because they felt they should have been able to handle their mental health on their own. Nearly 3 in 5 (58.90%) youth reported being worried what people would think or say if they got treatment, and 58.20% were worried that the information they shared would not be kept private.²⁶

Fear of involuntary treatment is also a major barrier to youth seeking mental health care. In 2023, nearly half (46.20%) of youth reported that they did not get treatment because they were afraid of being committed to a hospital or forced into treatment against their will.²⁷

Youth who have not had a preventive doctor’s visit in the past year

In 2022-2023 combined data, 28.60% of youth (ages 12-17) did not have a preventive health visit in the past year. That totaled over 7 million youth in the U.S. In Nevada (ranked 51), nearly 4 in 10 adolescents did not receive preventative care in 2023.

Despite being identified as a goal for improvement in Healthy People 2030, the percentage of adolescents who have never received preventive care has increased over time. In 2016-2017, the baseline years for measurement, 21.30% of adolescents had not received a preventive care visit.²⁸

Several expert organizations and agencies, including the National Academy of Medicine and the Department of Health and Human Services, recommend that all adolescents receive an annual preventive health care visit.^29,30 Preventive health care visits are especially critical during adolescence to promote wellness and identify physical and mental health problems as early as possible. Fifty percent of individuals with a mental health condition will show symptoms during their adolescent years.³¹ These preventive visits are often the only place adolescents receive necessary mental health screenings, including screenings for depression and substance use.

The Community Preventive Services Task Force for Healthy People 2030 recommends creating school-based health centers to increase access to preventive health services and meet youth with care where they are, especially in communities where access to primary care may be limited.³² Mental health screenings can also be implemented in schools in health classes, or as part of a ubiquitous mental health screening and education protocol outside of clinical settings.³³ A 2025 survey of K-12 principals found that nearly one-third of U.S. public schools mandate mental health screenings for students, but many reported a lack of resources as a barrier to connecting students to care.³⁴ Consistent state and federal funding for school mental health services is critical to ensure all youth have access to early identification and intervention for their mental health.

Students identified with emotional disturbance for an individualized education program (IEP)

In the 2023-2024 school year, only 0.663% of students are identified as having an emotional disturbance (ED) for an individualized education program (IEP). Under the Individuals with Disabilities Education Act (IDEA), ED is one of the disability categories that can make a student eligible for special education services and an IEP. This number is critically low compared to the prevalence of severe mental health concerns among youth. For example, in 2023, 3.4 million youth reported experiencing MDE with severe impairment, compared to only 317,641 who were identified with ED for an IEP.

IEPs are critical for ensuring that youth with disabilities can receive the individualized services, supports, and accommodations to succeed in a school setting. However, schools continue to report problems with adequate funding and staffing to meet the behavioral health needs of their students. A 2024 survey of schools from the National Center for Education Statistics found that less than half (48%) of schools reported they could effectively provide mental health services to students who needed them. That was a 10% decrease from data collected during the 2021-2022 school year. Over half of schools reported that they were unable to meet students’ mental health needs due to a lack of staffing (55%) and funding (54%) in 2023.³⁵ Despite emergency school funding following the COVID-19 pandemic and increased efforts to eliminate the teacher shortage in special education, there were still about 8 students with disabilities for every one certified or qualified teacher or paraprofessional in the U.S. in 2022. ³⁶

Efforts by the Trump administration to dismantle the Department of Education and limit access to school mental health funds are jeopardizing schools’ ability to serve their students with mental health needs. While states are responsible for decisions regarding how they implement the Individuals with Disabilities Education Act (IDEA) and use funding, the Department of Education is responsible for IDEA enforcement and distribution of that funding to states. If states are not adequately providing students with disabilities with the supports or accommodations they need, the Department of Education can withhold federal funds.³⁷ States already differ significantly in how they provide special education services, but without an agency to enforce IDEA compliance, those disparities will likely widen as states make difficult decisions about where to cut funding. Further, the federal government contributes about 12% of special education funding to states.³⁸ If the federal government dismantles the Department of Education, it should assign enforcement of IDEA to another agency and continue providing funding for school mental health services. As states are given more jurisdiction over education policies, they must continue to invest in accommodations and supports for students with disabilities.

Mental health workforce availability

In 2024, there were 320 individuals for every one mental health provider in the U.S.

While the ratio of mental health providers has improved each year, it has not kept pace with the number of people in the U.S. who need behavioral health care. As of August 2024, over one-third of the U.S. population (122 million people) lived in a mental health workforce shortage area.³⁹ Reflecting this strain, a 2022 survey by the American Psychological Association (APA) found that 6 in 10 psychologists were not accepting new patients, leaving many without the ability to receive care.⁴⁰

States must continue to invest in training programs, tuition reimbursement, and loan forgiveness for people entering the behavioral health workforce – especially in rural and underserved communities. Several states have invested additional funds into these programs to address their workforce shortages in recent years. Maryland (ranked 20), for example, passed a law in 2023 that established a Mental Health Workforce Development Fund to help cover the cost of educating, training recruiting, and retaining behavioral health professionals and paraprofessionals.⁴¹

Low reimbursement rates are one of the primary barriers to recruiting and retaining the behavioral health workforce, including the peer support workforce.   Medicaid, Medicare, and commercial insurers often reimburse so little for mental health services that providers stop accepting insurance, forcing patients to pay out-of-pocket and limiting access to care. Low reimbursement can also deter new providers from choosing to join the behavioral health workforce. States can use their authority to improve Medicaid reimbursement rates for providers. In Oregon (ranked 4), for example, the state Medicaid authority increased the Medicaid reimbursement rate up to 30% for behavioral health providers in 2023.⁴² The CY 2026 Physician Fee Schedule proposed rule includes changes that help to rebalance primary and behavioral health care payment rates with specialty care under Medicare, which can help to recruit new behavioral health providers and/or retain the current behavioral health workforce.⁴³ However, states must now make decisions about where to cut costs in Medicaid due to changes passed in H.R. 1, the One Big Beautiful Bill Act,⁴⁴ which may cause some to further reduce Medicaid provider reimbursement rates.