I applaud Adrienne Washington for her recent Maine Monitor article (Feb. 16), where she thoughtfully laid out the dilemmas and contradictions between the increases in behavioral health licenses and reported critical behavioral health workforce shortages. I want to clarify this issue by diving deeper into the licensing numbers and providing further context, which includes dramatic shifts in our behavioral health care delivery and training systems over the last five years.

A further analysis of the licensing data shows that the increase in clinical social workers between 2019 and 2024 grew only 65% versus the reported 80% by eliminating the non-clinical social work licenses, such as case managers and masters-level community organizers, researchers and advocates.

Only 71% of social work licenses are clinical. Second, the percentage of behavioral health licensees residing out of state increased from 8% in 2019 to 19% in 2024, enabled by emergency licensing laws implemented during COVID-19. These measures made getting approval for licenses easier for persons out of state. The number of their in-state clients is typically a tiny fraction of their client panel.

Telehealth services grew dramatically during the pandemic and then dropped. The percentage of publicly insured children using tele-mental health visits increased from 2.74% pre-COVID to 35.9% in 2020. The Maine Quality Forum reports that tele-behavioral health services accounted for over 34.2% of commercial insurance and 19% of MaineCare behavioral health charges in 2022.

Tele-behavioral health improves access and makes it easier for clinicians to leave community agencies and move into private practice, where they can provide counseling on their own time and pick and choose clients with less severe behavioral health conditions. Furthermore, private practice clinicians benefit from the higher reimbursement rates of commercial insurers. They are more likely to have clients pay out-of-pocket, thus reducing public insurers’ lower rates, complicated billing processes and delayed reimbursements.

Agencies typically have the most reimbursements from MaineCare and Medicaid, whose current reimbursement rates typically do not adequately cover the cost of behavioral health services. The governor’s budget and current legislative environment threaten the MaineCare cost-of-living increases. The legislative disagreements about the budget will likely disrupt and lengthen payment delays, threatening the very existence of small agencies in particular.

Along with all of this, schools report drops in enrollment in behavioral health fields and shortages of placements in community agencies, whose bottom line is so tight that it is difficult to give time to train clinical students. New graduates are being enticed out of state, where incentives and loan repayments are as high as $50,000.

Recruitment and retention difficulties in community behavioral health and in-home agencies are dramatically widening the service gap between the “haves” and the “have-nots,” with our most vulnerable clients with the most severe illnesses losing out.

The Department of Justice (DOJ) lawsuit against the state of Maine contends that Maine is not providing adequate community- and home-based behavioral health care services for children and teens. The DOJ settlement has excellent plans, yet they are only aspirations if we don’t address factors contributing to our behavioral health workforce shortage. If Maine can’t meet the needs of youth and the settlement requirements, we risk our youth’s health and future, monetary fines and dragged-out court cases.

I urge all Mainers to talk to your legislators about supporting measures to address our critical behavioral health workforce shortage. Federal legislators need to know that the Executive Branch does not have “a mandate” to make decisions without Congress. Members of Congress need to vote against health care cuts or shifting costs to the states, placing undue burden on behavioral health agencies.

State legislators need to support increases in MaineCare reimbursement to cover the cost of services; ease behavioral health licensing restrictions; improve data reporting; provide scholarships, loan repayment and financial support to students and agencies for training; and provide recruitment and retaining incentives for our community agencies.

Mainers have much to lose if we don’t take swift and dramatic measures to address our behavioral health workforce shortages.