Mental healthcare gaps persist in MD rural, urban areas

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Maryland’s mental healthcare system looks different depending on where you live. And in some corners of the state, it barely exists at all.

From the crowded corridors of Baltimore City to the rural stretches of the Eastern Shore and Western Maryland, the gap between those who can access behavioral healthcare and those who cannot is widening, shaped by geography, workforce shortages, insurance barriers and a system that advocates say has been underfunded for decades.

The Maryland Health Care Commission, the state agency that tracks provider supply and distribution, has documented the scope of the problem. According to Dr. Douglas Jacobs, the commission’s executive director, nearly every county in Maryland falls short. Every county, he said, except two, is designated as a partial or countywide shortage area. Baltimore City has the highest provider ratios, but Southern and Western Maryland face the most pronounced gaps.

The mental health commission’s 2024 workforce report found that Maryland’s behavioral health workforce needs to grow by 50% to meet current unmet need. Jacobs acknowledged the challenge is generational in scope.

“It cannot be fixed overnight and requires a coordinated approach,” he said. “With something like a workforce shortage, it takes time and effort and lots of different focus across the pipeline.”

Counties with the fewest providers include Prince George’s, Carroll, and Queen Anne’s. But Jacobs cautioned that raw provider counts don’t capture the full picture. “There are more micro issues. For example, there may not be the right mix of behavioral health specialties even where providers exist.”

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Kerry Graves, executive director of the National Alliance of Mental Illness Metro Baltimore, which serves Baltimore City, Baltimore County and Carroll County, hears from families across that spectrum every day. She says the barriers are real in every community, but the reasons differ.

“We are hearing folks are having a hard time getting appointments, whether in rural or urban communities,” Graves said. “There is a shortage overall.”

In urban areas like Baltimore, Graves said the challenge is as much about navigating a complex system as it is about provider scarcity.

“There’s confusion over how to access care because it’s just a confusing and difficult system to navigate,” she said. “Whether you have insurance or don’t. If you do have insurance, the waiting time can be extremely long. If you don’t have insurance, the costs can be too high to afford.”

The experience in rural Maryland is of a different kind. “In rural areas, we are talking about individuals traveling two times as far,” Graves said. “It can be extremely difficult. There’s not as much access to broadband, so there’s no access to telehealth.”

Telehealth has been held up as one solution to the rural access problem. Maryland permanently extended telehealth coverage in 2025 under the Preserve Telehealth Access Act. But Jacobs said the technology is not a complete answer.

“Telehealth is certainly helping,” he said, “but it’s not a full solution as there are people who lack access to digital and telehealth.”

The MHCC is conducting a telehealth needs assessment to identify where it is working and where gaps remain.

The types of mental health needs also differ by geography, Graves noted. Urban communities, she said, face higher rates of trauma and stigma, with a need for providers trained in culturally responsive care and equipped to address language barriers. Rural communities contend with isolation and physical labor that carries its own mental health toll.

“We are looking for providers that are well-versed in these specific areas,” she said.

Prior authorization, the process by which insurers approve care before it is provided, adds another layer of delay. Jacobs said the MHCC has proposed requiring electronic prior authorization to streamline the process, and that regulation is currently open for public comment in the Maryland Register.

“In behavioral health, if someone needs to be seen in an acute way and authorization is delayed, the consequences can be severe,” he said.

One area where both officials see potential is the integration of behavioral health into primary care settings. A law passed during the 2025 legislative session requires insurance coverage of the collaborative care model, in which a psychiatrist is embedded within a primary care practice.

“When they are integrated in this way, it can improve patient outcomes — inpatient outcomes go down,” Jacobs said.

The path forward, both say, requires more than any single fix. Jacobs pointed to the MHCC’s $6.3 million in rural health grants, which include a component for integrating behavioral health into primary care practices, as a starting point. But he acknowledged it is early. The organization is at the stage of receiving applications.

Graves put it plainly: “It has been broken for so long, and we are playing catch-up.”

She said the system needs robust, community-based outpatient services so that people can get help before they end up in an emergency room.

“The system is overwhelmed with needs,” she said. “Not everything needs to be done in the ER, which is where much of this care happens.”