Medicaid spent $1,294.71 per enrollee on behavioral health services in the District of Columbia in 2023. West Virginia, which has among the highest rates of substance use disorder in the country, spent $392.71. That 3.3-to-1 ratio is not a rounding error. It is a structural feature of how Medicaid behavioral health dollars flow across state lines.

The Gap at the Top and Bottom Is Not Close

Twenty jurisdictions appear in this dataset. The spread between them is wide enough to suggest that "Medicaid behavioral health coverage" means something fundamentally different depending on where a patient lives.

DC, Maine, and New Jersey all cleared $1,000 per enrollee. The bottom four in the dataset, Ohio, West Virginia, Colorado, and Massachusetts, all came in below $465. For a Medicaid enrollee with a serious mental illness or substance use disorder, that difference translates directly into what services are available, how often they can be seen, and whether their provider gets reimbursed enough to stay in the network.

Large States Are Not Spending Their Way to Parity

Size does not explain the gap. Ohio enrolled 3,238,723 Medicaid beneficiaries in 2023, the largest enrollment in the dataset, and spent $397.44 per enrollee. Pennsylvania enrolled even more, 3,365,651 people, and spent $497.24 per enrollee. New Jersey, with 2,161,698 enrollees, spent $1,078.37 per enrollee and posted the largest total behavioral health spend in the dataset at $2,331,114,632. The per-enrollee gap between New Jersey and Ohio is $680.93. That is not a marginal difference in reimbursement rates. It represents a fundamentally different level of covered service intensity.

Alaska, with only 192,745 enrollees, spent $815.50 per enrollee, more than double West Virginia's rate despite operating in a state with notoriously high healthcare delivery costs. The implication is that enrollment size and geography are not the binding constraints. State policy choices about which services to cover, at what rates, and through which delivery models are doing most of the work.

The States That Need It Most Are Spending the Least

West Virginia's position at the bottom of this dataset is the finding that demands the most scrutiny. The state consistently ranks among the worst in the country for overdose deaths and substance use disorder prevalence. Its Medicaid program covered 585,714 enrollees in 2023 and spent a total of $230,017,224 on behavioral health, which works out to $392.71 per person. Maine, with 373,893 enrollees and a smaller total population, spent $412,320,685 on behavioral health, nearly double West Virginia's total outlay for fewer people.

Kentucky, another Appalachian state with high substance use burden, spent $479.57 per enrollee across 1,491,534 enrollees. That is 22% more than West Virginia but still less than half of what DC, Maine, or New Jersey spent. The pattern across the bottom of this dataset is not random. States with the highest documented need for behavioral health services are consistently the ones where Medicaid is spending the least to meet it.

Whether West Virginia's $392.71 figure reflects low utilization driven by provider shortages, reimbursement rates too low to sustain a behavioral health workforce, gaps in covered services, or some combination of all three, the data cannot resolve. What it does resolve is the outcome: a Medicaid enrollee in West Virginia has access to roughly 30 cents of behavioral health spending for every dollar available to an enrollee in DC. For a program that is supposed to guarantee a floor of coverage regardless of state of residence, that floor is not level.