Western North Carolina's Mental Health Crisis: Why Access to Care Still Falls Short
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Western North Carolina is facing a sustained mental health and substance use crisis. Across Buncombe County and the surrounding region, demand for behavioral health services continues to rise while workforce shortages, financial barriers, and fragmented systems make it difficult for many residents to access the care they need.
According to the WNC Health Network, reported poor mental health in the region has increased by 39% since 2012. Substance use also remains a significant public health concern, affecting individuals, families, employers, schools, and communities throughout Western North Carolina.
During a recent conversation with Lissa Carter—a clinician whose work spans recovery services, clinical supervision, education, and behavioral health leadership—we explored not only the challenges facing our region, but also the opportunities to strengthen the systems that support mental health. One message emerged clearly: improving behavioral health access and outcomes will require more than simply increasing the number of providers. It will require building a system that enables clinicians to stay in community practice, supports patients in accessing timely care, and aligns incentives with long-term health outcomes.
🎤 Listen to the full podcast interview with Lissa Carter here.
Rethinking Mental Health
One of the most important themes from our discussion was how we define mental health itself.
Mental health is often viewed as a simple distinction between being "well" or "ill." In reality, it exists on a continuum. It reflects our ability to adapt to stress, navigate adversity, build relationships, and function in daily life. From this perspective, treatment is not solely about reducing symptoms—it is also about strengthening resilience, increasing support, and helping people develop the skills and resources needed to thrive.
This broader understanding has important implications for public policy.
If we measure community mental health only by the number of hospital beds or licensed providers, we miss many of the factors that influence wellbeing. Stable housing, reliable transportation, food security, employment, education, social connectedness, and involvement with the criminal justice system all shape mental health outcomes. Effective policy should recognize these connections and evaluate behavioral health within the broader context of community wellbeing.
Building on Regional Strengths
While the challenges are significant, Western North Carolina also has many strengths to build upon.
Across the region, dedicated clinicians, nonprofit organizations, healthcare systems, educators, and community partners continue to develop innovative approaches to behavioral health care. These include:
Strong peer support, harm reduction and recovery programs
Clinical education and workforce training partnerships
Growing recognition of mobile crisis and alternative response models
Passionate professionals committed to improving community health
These assets provide a strong foundation for future progress. The opportunity now is to strengthen and expand what is already working.
The Workforce Challenge Is About More Than Numbers
Behavioral health workforce shortages receive considerable attention, but the issue extends beyond simply producing more licensed clinicians.
Many early-career professionals begin their careers in community mental health settings where salaries are relatively low, educational debt is high, and supervision requirements create additional demands. This means that after completing their required clinical hours, many providers transition to private practice, where compensation is often higher, administrative burdens are lower, and greater flexibility is available.
The result is an unintended mismatch between workforce experience and community need.
Community mental health organizations, which often serve individuals with the most complex behavioral health needs, end up relying on newer, less experienced clinicians while more experienced providers leave for practice settings that are financially more sustainable. It also means that new clinicians face higher risks of burnout (especially in settings with fewer experienced clinicians to consult or work alongside), experienced mentors become less available, and patients requiring intensive care experience greater challenges accessing experienced providers.
The lesson is an important one: increasing the size of the workforce without addressing the underlying incentives may do little to improve access for those who need care most.
Just as building more housing does not necessarily create more affordable housing, expanding the behavioral health workforce alone may not create more accessible behavioral health care.
Medicaid Plays a Critical Role
Medicaid is the single largest payer for mental health services in the United States, and one of the most important drivers of behavioral health access in North Carolina.
However, low reimbursement rates can discourage providers from participating in Medicaid networks, while administrative requirements add additional barriers to serving publicly insured patients—a situation that is only going to get worse as new reporting, enrollment and tracking requirements come online to comply with new Medicaid policies set out in the Trump administration’s HR1, aka “The One Big Beautiful Bill.” As a result, low-income, indigent, medically-frail and other individuals in vulnerable populations may have health insurance but still struggle to find providers who are accepting new patients or who participate in their insurance plan.
This is especially true in more rural areas of Western North Carolina where the number of Medicaid-enrolled providers can be very low…or in some counties, even zero. In a report by the Cecil G. Sheps Center for Health Services Research on mental health workforce, researchers found that “15 NC counties with no [Mental Health/Substance Use] prescribers, 25 counties without a MH/SU physician, 50 counties without a MH/SU [Physicians Assistant], and 23 counties without a MH/SU [Nurse Practitioner].” All 18 counties in WNC are federally designated as Mental Health Professional Shortage Areas (HPSAs)
Sue to Medicaid’s outsized impact on mental health care access, improving reimbursement, reducing unnecessary administrative burden, and building in supports community-based providers could help create stronger incentives for experienced clinicians to remain in settings where they are most needed.
Opportunities for Policy and Practice
Improving behavioral health in Western North Carolina will require coordinated action across state government, local organizations, healthcare systems, and community partners.
Several policy questions deserve continued discussion.
State Policy Opportunities
Can Medicaid reimbursement for behavioral health services better reflect the true cost of providing care to increase access and incentives for providers?
How can the state strengthen financial support for clinical supervision to expand the workforce while improving retention?
How can we ensure that licensed clinicians to have the final say in insurance coverage of treatment plans to ensure clinical best practices are supported?
Are there opportunities to reduce administrative requirements that discourage providers from participating in Medicaid?
How can behavioral health outcomes be measured alongside housing, food security, transportation, and other social drivers of health?
What additional opportunities exist to strengthen coordination between behavioral health and the criminal justice system?
Local Opportunities
Regional organizations and healthcare providers also have opportunities to strengthen behavioral health through collaboration.
Potential strategies include:
Increasing public awareness of available behavioral health services and how to access them
Helping residents better understand the roles of different behavioral health professionals
Expanding peer consultation and peer supervision networks to support workforce retention and professional development, reduce burnout, and improve quality of care?
Continuing to invest in peer support specialists and mobile crisis response programs
Creating workplace cultures that support retention of providers with better supervision, culture, and opportunities to support their own mental health?
Looking Ahead
Western North Carolina has no shortage of committed professionals working to improve behavioral health. The region's challenge is not a lack of dedication. Rather, it is ensuring that our systems support the people providing care as effectively as they support the people receiving it.
Addressing behavioral health will require more than expanding services. It will require aligning payment, workforce development, community resources, and public policy so that experienced clinicians can remain in community care, patients can access timely treatment regardless of insurance status, and communities can invest in prevention as well as treatment.
The conversation is no longer simply about increasing capacity. It is about building a behavioral health system that is sustainable, equitable, and designed to improve long-term health for everyone in Western North Carolina.
Resources:
Sustaining our Mental Healthcare Workforce w/Lissa Carter - WNC Health Policy Podcast Ep. 27
“The social determinants of mental health and disorder: evidence, prevention and recommendations.” (Kirkbride et al., World Psychiatry. 2024 Jan 12;23(1):58–90)
“State of the Behavioral Health Workforce, 2025,” Health Resources & Services Administration (HRSA)
Medicaid Behavioral Health Services info page
NCDHHS Medicaid is Changing info page
“State of North Carolina's Mental Health and Substance Use Services Workforce: Need, Supply, and Distribution Landscape Assessment” info page, NC Center on the Workforce for Health
HRSA Mental Health Professional Shortage Areas map
WHC Health Network Resources
If you or someone you know needs support
The SAMHSA’s National Helpline at 1-800-662-HELP (4357) is a free, confidential, 24/7, 365-day-a-year treatment referral and information service (in English and Spanish) for individuals and families facing mental and/or substance use disorders.
NAMI Western Carolina’s website offers many ways to find support, learn more or get engaged in your community, including information and resources on mental health, support groups, and opportunities for advocacy that can you can support.
Disclaimer
This content was developed by the WNC Health Policy Initiative in consultation with people and organizations with connections to the health of people of Western North Carolina. Individual or organizational opinions, findings, conclusions, or recommendations are those of the relevant author(s)/interviewee(s) and do not necessarily reflect the view of the WNC Health Policy Initiative or its host institutions of the University of North Carolina Asheville (UNCA), Mountain Area Health Education Center (MAHEC) or our funders.State of North Carolina's Mental Health and Substance Use Services Workforce: Need, Supply, and Distribution Landscape Assessment
