Americans Are Facing a Mental Health Crisis. Losing the Internet Won’t Help

Kenneth Sigler is about to have a difficult choice to make. For the past year, the 41-year-old small business owner from Hernando, Mississippi, has been using the Federal Communications Commission's Affordable Connectivity Program, which provides low-income households $30 a month for home internet or $70 for those living on tribal lands. One in five Americans with internet subscriptions currently use the program to help pay for internet.

As the agency has been warning for months, the FCC recently began notifying recipients that funds would likely run out in April, and their internet bills would soon increase. 

For Sigler, losing internet isn't an option, so he'll have to cut corners elsewhere. He relies on the internet for his business -- and just as critically, for his mental health, including online psychiatry appointments he'd already pared back from weekly to monthly sessions. 

Sigler is one of an estimated 59 million Americans who are enrolled in the ACP. He's also one of 31 million adults who receives mental health treatment online. "I'll be honest, this year I've already cut back on my doctor's appointments tremendously," Sigler said.

These are the ripple effects of the "digital divide," a term that refers to the gap between those who have access to -- and the means to afford -- a speedy broadband internet connection and those who don't. It's been around nearly as long as the internet itself; a 1995 report by the National Telecommunications and Information Administration referred to internet "have nots" in rural America. 

The looming end of the ACP, and the alarm it has triggered among dozens of experts I've talked to, reveals that this federal program is about much more than internet access. Amid a rising mental health crisis, limited access to broadband has been clearly linked with negative health outcomes for America's lowest-income communities. 

"It's really coming up quickly. I know we're all kind of scrambling, trying to find ways for our clients to continue working with us," Havi Hall, a therapist practicing in California, told CNET. "It's wonderful that it was there. When it gets to the end of something that's been so crucial for people, it becomes very scary."

So what does a $30-per-month subsidy mean for the mental health of America's lowest-income communities? As the ACP teeters on the brink, we may soon find out. I talked with therapists, researchers and users of the programs to learn how they're planning for life without the ACP, what effects it will have on America's mental health crisis and if there are any other alternatives.

ACP expiration coincides with growing mental health crisis

The ACP was initially a response to the COVID-19 pandemic, a period in which Americans' mental health, and the way we are treated for it, has been radically altered. 

"There's no question we're in a mental health crisis," said Mary Joye, a mental health counselor in Florida. "It became so glaringly obvious during COVID. Isolation causes all kinds of mental health disorders."

"We've definitely seen quite an uptick in the number of patients with anxiety, depression and substance use disorders," Dr. Chris Pagnani, a psychiatrist and medical director of Rittenhouse Psychiatric Associates, a treatment facility in Philadelphia, told CNET. "In the last few years, we've had quite a bit of stress related to the pandemic, quite a bit of political unease and controversy and conflict."

Around 4 in 10 adults reported symptoms of anxiety and depression in January 2021 -- almost four times as many as before the pandemic started. More than a quarter of young adults and 22% of essential workers reported suicidal thoughts.

But those trends started before the pandemic and have continued in its wake. The number of US adults with a mental illness has increased every year for nearly a decade, going from 43 million in 2015 to over 59 million in 2022, according to surveys conducted annually by the Substance Abuse and Mental Health Services Administration. 

While mental health issues have risen dramatically, so has treatment. Between 2019 and 2022, use of mental-health services jumped by almost 40% among US adults with commercial insurance, according to a recent study in JAMA Health Forum.

"There has been an improvement with the normalization of mental health and mental health treatment," Pagnani said. "You have more people reaching out to get help and feeling comfortable doing so."

But that normalization has put a strain on the country's mental health resources. As of March 2024, 122 million Americans live in areas with mental health professional shortages, and the US Health Resources and Services Administration estimates that over 6,000 more professionals are needed to ensure an adequate supply. But to those studying the industry, it may be impossible to fill so many slots.

"There will never be enough mental health providers to meet the demands," said Shannon Sauer-Zavala, a psychologist and assistant professor of Psychology at the University of Kentucky. "Every clinic you look at, whether it's telehealth or in-person, has a long wait list."

This shortage has been exacerbated because many mental health providers aren't covered by their patient's insurance. A study in Health Affairs found that mental health services are up to six times more likely than general medical services to be delivered by an out-of-network provider.

"Provider networks are not there. They're full up, and they're not adding new providers at the rate that they need to to keep up with the demand," therapist Havi Hall said. "Demand for psychotherapy services far outstrips supply whether it's telehealth or in-person."

Online therapy is the default mental health treatment 

While telehealth can't fix the shortage issue, it has been effective in helping more people access mental health resources -- and for some patients outside the range of traditional health networks, access them at all.

"What telehealth has shown us is that you can still offer a wide variety of treatment services and it doesn't have to be face to face, which opens up patients to providers anywhere in the state they reside," John Grohol, a psychologist and founder of the mental health website Psych Central, told CNET. "But we're still short providers. It's helped somewhat, but it still hasn't alleviated the challenges of accessing services."

Fortunately, the mental health industry has broadly embraced telehealth services and is offering more every year. One study published by the American Medical Association found that 88% of mental health treatment facilities offered telehealth services in September 2022 compared with 39.4% of facilities in April 2019. In 2022, more than half of the 58 million Americans who sought mental health treatment did so online. 

"If we learned anything during the pandemic, it was that this technology really became a life raft for so many who needed services," Hall said.

"Telehealth just makes it so much easier to reach certain clients that don't have the ability to book that hour in-person and drive and park and find the office and sit in a waiting room and have their session and drive back."

The evidence points to online therapy being just as effective as face-to-face sessions. Multiple studies of clinical trials found that there is no difference in outcomes between telehealth and in-person therapy. 

"One of the misconceptions is that it still isn't as good as in-person therapy. And I think we have enough data and research to show that that's just not true," Grohol said. "You can have just as strong client-doctor bonds as you do with in-person therapy, and it can be just as effective if not more effective, because everybody feels like they're making better use of their time."

Rural and low-income people experience worse mental health outcomes

It may not seem like going online is a very healthy activity, but it has been consistently linked with better health outcomes. Organizations like the FCC and SAMHSA have even gone as far as to call broadband access as a "super-determinant" of health because of the impact it has on education, employment and health care access.

"The delivery of clinical services only contributes 20% to health outcomes. 40% is what we call socioeconomic status," said Carole Myers, a professor at the University of Tennessee in Knoxville who studies health care access and disparities. "It's things like your income level, your education level and the resources that are available in your community." 

While lack of subsidized internet may cut people off from telehealth services, it also isolates them from other opportunities that factor into mental health. Rural communities have a dearth of resources and jobs, Myers explained, and being connected can help alleviate people's financial and occupational issues.

"Broadband access is really important for telehealth, but it's important for economic development, for attracting businesses, it's important for education. And in turn those things drive health," Myers said.

According to a 2023 Pew Research Center survey, 72% of rural Americans subscribe to high-speed internet at home, compared with 77% in urban areas and 86% in suburban areas. In the survey, 95% of adults with an annual household income of at least $100,000 said they have a home internet subscription, compared with only 57% of adults in households that make less than $30,000 per year. 

Those are the same groups that need mental health care the most. Just over a quarter of rural Americans and 28.9% of those living below the poverty level had a mental illness in 2022, compared with 23.1% overall. And those numbers might be understating the disparity.

"If you look at low-income and diverse areas, there's massive under-diagnosis of behavioral health conditions and treatment of those conditions," said Shana Hoffman, CEO of Lucet, a behavioral health optimization company for health plans.

Stigma around mental health persists particularly in low-income and rural communities. One study involving interviews with Medicaid recipients found that patients often felt that their interactions with providers were demeaning, which had a significant impact on getting mental health needs met. 

"I felt like I was being judged for not having health insurance and for not taking care of me," one participant was quoted as saying in the study. "When I left there, I was just real sad. I was supposed to reschedule an appointment. But since he was rude to me, I didn't reschedule that appointment."

Another study of rural mental health care consumers determined that "close-knit social networks, conservative values, and a general lack of privacy makes it challenging for residents to seek mental health treatment." This was echoed in my conversations with therapists who work in rural areas.

"There's still a lot of stigma in these small communities," Sauer-Zavala said. "Everybody knows what your car looks like. You're at the mental health clinic and everybody knows."

One therapist I spoke with, Dawn Kufeld, works in rural Arizona. According to SAMHSA, Arizona has the lowest percent of needs met for mental health professionals of any state in the country. 

"With lower income and rural clients, it really helps them to be able to hop on a session when they need to from their home," she told CNET. "They don't have to travel somewhere because they're already strapped financially."

How the ACP helped close the gap

The ACP was an attempt to address the root cause of the digital divide: Most Americans who lack internet don't have it because they can't afford it, not because they can't access it.

"The digital divide is fundamentally tied to inequality," said Christopher Ali, professor of telecommunications at Penn State University. "We often think that it's an infrastructure issue, which is the case in rural and remote and indigenous communities. But the reason most people don't have internet is price."

According to a 2021 Pew Research Center survey, 20% of people who don't have a home internet subscription listed "too expensive" as the main reason -- the highest of any answer and more than twice the number who said service isn't available. That fit another study which found that "for every American without broadband service available, up to twice as many have service available but still don't subscribe."

These discoveries countered prevailing assumptions about internet access.

"For a long time, we've operated under a Field of Dreams-type of strategy when it came to closing the digital divide. If we build the network, they will come. It turns out that's not true," said Joel Thayer, president of the Digital Progress Institute. "Affordability is a part of that equation."

By the time the FCC froze new ACP enrollments in February, over 23 million households had signed up -- more than half of all eligible households and higher than the number enrolled in the Supplemental Nutrition Assistance Program, or SNAP, which subsidizes groceries and meals. The ACP accepted households at or below 200% of the federal poverty guidelines, or $60,000 for a family of four; SNAP's cutoff is 130%. One in four households participating in the ACP program are Black, one in four are Latino and nearly half are military families.

A big point of contention in broadband circles is whether the ACP actually helped connect people who wouldn't have had internet otherwise -- in other words, if it really helped narrow the digital divide. 

FCC Chairwoman Jessica Rosenworcel testified before Congress that between 20% and 22% of ACP subscribers didn't have broadband prior to the ACP; an earlier FCC survey published in January 2023 found that it was 16%. What we do know is that the number of Americans with broadband internet increased from 73% in 2019 to 80% in 2023. It's anyone's guess how these numbers will change once the ACP disappears.

"Once people have been on, are they really going to give it up? I don't know the answer," Blair Levin, a former FCC chief of staff and telecom industry analyst at New Street Research, told CNET. "But because the numbers are so large, we know that millions who currently have broadband will not have it and that there are additional millions who will have it inconsistently."

What's at stake if the ACP ends?

Both of the ACP recipients I spoke with said they expected to keep the internet plans they're currently on -- even with a $30 monthly price increase. Walter Durham, a Navy retiree who uses the internet for telehealth appointments, said he's planning to make trade-offs with his health if the ACP expires.

"If the ACP gets canceled, then I either don't use the internet anymore or I have to take money from other things I use," Durham told CNET. "Healthy eating is what my wife and I use that extra money for."

"Internet is pretty much one of the last things I would cut just because of how much it does," said Sigler, explaining that he'd have to weigh paying for rent, food, gas or something else. "If I had to cancel my internet, there's no way I could work. I'd have to stop going to school. It would basically shut down a source of my income. It's kind of a spiral effect."

A number of therapists I spoke with expressed alarm about what the end of the ACP could mean for America's ongoing mental health crisis. 

"I actually think that that would have a very large ripple effect on individuals -- not just with psychiatric telehealth visits, but all types of medical visits," Pagnani told CNET. "That really would put them at a disadvantage in terms of being able to get proper health care."

"Mental health is everybody's problem. Mental health costs a ton of money if we don't prevent it," Sauer-Zavala told CNET. "And outpatient therapy via telehealth is way, way, way cheaper than the cost of lost wages and mortality and things that the government cares about. It's way cheaper just to give people resources than it is to play catch up dealing with the ramifications of untreated mental health."

"If the program were to go away, I think that a lot of families are really going to feel that impact and be in situations where they're not sure how to access mental health services," said Kufeld, the therapist in rural Arizona. 

Could the ACP be extended?

For months, there have been efforts from advocacy groups and government agencies to re-fund the Affordable Connectivity Program. President Joe Biden requested an additional $6 billion in funding from Congress in October -- enough to carry the ACP through the end of 2024 -- and a bipartisan group of legislators introduced a bill in January that would provide $7 billion. In the first week of March, more than 140 additional members of Congress joined the bill as co-sponsors. 

Still, industry insiders I spoke with were split on the bill's prospects. One senior NTIA official told CNET that they're hopeful about an ACP extension at some point, but said it's unlikely to happen before the existing funds are exhausted in April.

"I would say I'm pessimistic," Levin, the telecom industry analyst, told CNET in late February. "A month ago, I was very pessimistic. Now I'm really pessimistic."

The program is widely popular among voters. According to polling from Public Opinion Strategies and RG Strategies, 78% support continuing the ACP, including 64% of Republicans, 70% of independents and 95% of Democrats.

"You're seeing Democrats and Republicans make almost categorical admissions that the ACP is a good thing and is one of the better products in terms of government subsidy programs," Joel Thayer, president of the Digital Progress Institute, told me. "You also are seeing very valid concerns out of Congress and the FCC itself."

Those concerns include the programs broad eligibility requirements -- former FCC Commissioner Michael O'Rielly estimated that up to 40% of Americans qualify -- as well as accusations of waste and fraud. A Wall Street Journal investigation in January found that Charter had received $3.01 billion of the ACP's total $12.82 billion -- nearly three times higher than any other recipient. 

Resources for affordable internet

Though there's still a chance the ACP could be extended -- the National Digital Inclusion Alliance has a helpful list of resources for advocates -- it's a good idea to start planning for a world without it. Here are some other resources available that can help you pay for internet:

• State and local resources: Some cities and states provide their own internet assistance programs. Maryland, for example, offers a $15 monthly discount for low-income households in addition to the ACP. Most cities and states have a website set up for internet resources; you can usually find it by Googling "[location] internet subsidy." 
• Nonprofit organizations: Nonprofits like EveryoneOn, Education Superhighway and Human-I-T provide affordable internet service and devices.
• Low-income programs from internet providers: Some internet service providers have their own programs in place for low-income households, with AT&T, Cox, Mediacom, Optimum, Spectrum, WOW and Xfinity all offering discounted service for low-income households. You can see which providers are available in your area by entering your address on the FCC's broadband map.
• Discounted internet for seniors: Seniors make up about 4 million of the ACP's 23 million households, and many ISPs have discounts they can use. Access from AT&T, Optimum Advantage Internet, Spectrum Internet Assist and Verizon Lifeline are all available to seniors, with varying requirements. 
• Lifeline: Lifeline is a federal program that provides a $9.25 monthly discount for phone, internet or bundled services. Its eligibility requirements are slightly more restrictive than the ACP's -- household income must be at or below 135% of federal poverty guidelines -- but the program has been permanently funded since 1984, so there's not as much risk that it will run out of funding. 
• Buy your own equipment: It usually costs around $15 to rent a modem and router from your internet provider. You can save money in the long run by purchasing your own equipment, particularly if you buy refurbished gear. You can typically get everything you need for about $100, but you'll need to make sure your modem is compatible with your ISP before you make a purchase.
• Explore other internet options: If your internet bill is too pricey without the ACP discount, you can explore what other options are available at your address. Most internet providers offer plans under $50 monthly. Many also offer discounts for things like bundling with a cellphone plan or committing to a long-term contract.

More advice

• Affordable Connectivity Program Ending This Month: How You Can Keep Internet Costs Low
• Best Mental Health Apps of 2024
• Can't Get Therapy? 4 Ways to Boost Your Mental Health Right Now for Free