The Unseen Realities Behind Mental Healthcare in Schools

More mental health professionals in schools risks worsening shortages elsewhere.

May is mental health month so this is the first in a series of posts delving into the causes and consequences of the mental health crisis we find ourselves in in the U.S. today. The opioid epidemic is one well-known aspect. More broadly, one in five Americans met criteria for mental illness even before the pandemic, and almost a third of those report not being able to receive the treatment they need. How we got here and what policy levers could get us out are certain to remain hotly contested questions.

As with any crisis people will use it to promote the policies they already favor. Commentators on the left will say “it’s clear the mental health crisis shows we should expand Medicaid! After all, don't you know the Oregon experiment famously showed Medicaid reduces depression?”

Commentators on the right might say the mental health crisis shows the effects of pandemic-era school closures, but beyond that I’m not so sure what they would say, and to be honest, I consulted Google to come up with that. As my Mercatus colleague Kofi Ampaabeng has alluded to, opposing school closures or particular aspects of the Affordable Care Act is a far cry from a coherent, unified vision of market-based healthcare policy, let alone for mental health policy.

I’ll save my take on what that vision ought to be for another day, but I will give you my perspective on what the Biden administration describes as “bold action to make it easier for schools to provide critical health care services, especially mental health services, for millions of students across the nation."

Broadly speaking, the goal is described as providing healthcare services to more children while they’re in school — after all, this is where kids spend the majority of their waking hours, so why not reach them where they are? It’s the kind of vision that at first glance is hard to oppose, evoking memories from the time you hurt yourself during recess or maybe fell out with a friend, but got through it all through the warm embrace of the school nurse.

Nostalgia aside, there sure are worse things the government could do than to streamline billing procedures if it leads to more school nurses or therapists helping kids with disabilities. 

But see, not a single nurse or therapist was created in the process of writing the 184-page document showing schools how to get paid. If the plan succeeds in bringing more nurses and therapists to schools, those are professionals who would have been elsewhere, caring for someone else. Without significant expansions to the mental health workforce, we run the risk of merely redistributing available providers, prioritizing their presence in schools while neglecting the needs of others.

Some 150 million Americans already live in mental health provider shortage areas, and when those services, almost by definition, revolve closely around interpersonal relationships, I worry about the impacts, especially in the short term, of moving scarce providers from one group to another. 

To make a dent in the crisis, we must think beyond shifting providers from one group to another, and start addressing the critical supply factors that led to the shortages in the mental health profession, including reforming barriers to entry such as licensing, scope of practice, and certificate-of-need laws. But we must also look at the broader causes of how we got here, why so many Americans are struggling, and how to prevent that from happening in the first place.