By David Mechanic More People Than Ever Before Are Receiving Behavioral Health Care In The United States, But Gaps And Challenges Remain ABSTRACT The high prevalence of mental illness and substance abuse disorders and their significant impact on disability, mortality, and other chronic diseases have encouraged new initiatives in mental health policy including important provisions of the Affordable Care Act and changes in Medicaid. This article examines the development and status of the behavioral health services system, gaps in access to and quality of care, and the challenges to implementing aspirations for improved behavioral and related medical services. Although many more people than ever before are receiving behavioral health services in the United States— predominantly pharmaceutical treatments—care is poorly allocated and rarely meets evidence-based standards, particularly in the primary care sector. Ideologies, finances, and pharmaceutical marketing have shaped the provision of services more than treatment advances or guidance from a growing evidence base. Among the many challenges to overcome are organizational and financial realignments and improved training of primary care physicians and the behavioral health workforce. W ith the passage and imple- mentation of federal mental health parity legislation in 2008 and the many support- ive provisions for behavioral health in the Affordable Care Act (ACA), there appears to be a turning point in the recognition of the centrality of mental health status and func- tion for the nation’s health. But many challenges remain in developing services responsive to the realistic needs of people with serious mental health and substance abuse disorders. Central to the challenge is timely access to services and needed referrals, appropriate organization and coordination of services, and greater com- mitment to providing evidence-based services of high quality. As the late John Eisenberg so appropriately challenged the field of medicine more generally: “We need to respect experience and expertise, but not accept the doctrines of those who would have physicians follow the lead of self-proclaimed experts and authorities, whose assertions often lack the strength of sci- entific evidence. We need to move away from ‘eminence-based’ medicine, and toward evi- dence-based medicine.” 1 In this article I review the damaging effects of serious behavioral disorders and the forces that shaped the evolution of the current system, in- cluding the disarray of services, the status of financing, and the essential role of Medicaid. I then examine pathways to evidence-based prac- tice, particularly for people with the most serious and incapacitating disorders. I conclude with the challenges of reform and discussion of imple- mentation of opportunities of the ACA and ex- tensions of Medicaid. The Costs Of Behavioral Disorders Behavioral health is a central aspect of health status, and serious behavioral disorders have doi: 10.1377/hlthaff.2014.0504 HEALTH AFFAIRS 33, NO. 8 (2014): 1416–1424 ©2014 Project HOPE— The People-to-People Health Foundation, Inc. David Mechanic (mechanic@ rci.rutgers.edu) is the René Dubos University Professor at the Institute for Health, Health Care Policy, and Aging Research at Rutgers University, in New Brunswick, New Jersey. 1416 Health Affairs August 2014 33:8 Mental Health Downloaded from HealthAffairs.org on June 15, 2020. Copyright Project HOPE—The People-to-People Health Foundation, Inc. For personal use only. All rights reserved. Reuse permissions at HealthAffairs.org.