The Geography of Behavioral Health: Why State-Level Data Should Shape Local Strategy

In Part One of this series, we looked at the national picture from the 2026 Pain in the Nation Report from Trust for America’s Health. The national data told us something important: the United States may be at a turning point. Deaths related to alcohol, drugs, and suicide declined in 2024, and that progress is meaningful. But national data only tells part of the story.

Behavioral health is experienced locally. It is shaped by the state someone lives in, the community they call home, the school their child attends, the health plan they are enrolled in, the provider network available to them, the crisis response system they can access, and whether prevention, treatment, harm reduction, and recovery supports are actually within reach. That is why the state-level data in the report matters so much.

A national trendline may point in one direction, but state-level data helps us understand where progress is taking hold, where risk remains stubbornly high, and where policy choices, funding decisions, and system design may be making a difference.

State Data Tells a More Complicated Story

The report shows that, in 2024, most states saw improvement in the combined age-adjusted rate of deaths from alcohol, drugs, and suicide. That is encouraging. But the details matter.

According to the report, 45 states and the District of Columbia had lower combined mortality rates in 2024 compared with 2023. Four states—Iowa, North Dakota, South Dakota, and Wyoming—had higher combined rates, while Nebraska stayed the same. The story becomes even more nuanced when the report separates alcohol-induced deaths, drug overdose deaths, and suicide deaths.

Alcohol-induced death rates declined in 32 states and the District of Columbia, but increased in 17 states. Drug overdose death rates declined in 49 states and the District of Columbia, with South Dakota as the only state showing an increase. Suicide death rates declined in 32 states and the District of Columbia, but increased in 16 states, while Colorado and Texas stayed the same. That is a lot to take in.

It also reinforces a simple but important point: state-level strategy matters. A state may be improving overall while still struggling with alcohol mortality. Another state may see a significant reduction in overdose deaths while suicide rates remain flat or increase. A third state may have strong crisis infrastructure but limited access to ongoing treatment or recovery supports. The data does not give us a single storyline. It gives us a map. And maps are meant to help us navigate.

Geography Should Inform Strategy

One of the report’s most useful contributions is that it helps us look at behavioral health geographically. The report shows that the highest combined rates of alcohol, drug, and suicide deaths in 2024 were in Alaska, New Mexico, and West Virginia. The lowest combined rates were in New Jersey, New York, and Nebraska.

When looking at specific causes of death, the variation is just as important. New Mexico, South Dakota, and Wyoming had the highest alcohol-induced mortality rates. West Virginia, Alaska, Washington state, and the District of Columbia had some of the highest drug overdose mortality rates. Alaska, Wyoming, and Montana had the highest suicide mortality rates.

These differences should matter to policymakers, payers, providers, associations, funders, and community coalitions. A state with high alcohol-induced mortality may need to ask different questions than a state with a rapidly changing stimulant or opioid pattern. A state with persistently high suicide rates may need to look closely at rural access, lethal means safety, social isolation, veteran supports, crisis response, and the availability of culturally responsive care. A state with high overdose mortality may need to examine naloxone access, medications for opioid use disorder, harm reduction, fentanyl and xylazine testing, recovery housing, and transitions from emergency departments, jails, residential treatment, and inpatient settings.

State-level data should not be used to rank states for the sake of ranking states. It should be used to ask better questions.

Data Without Context Can Mislead Us

A word of caution: data is powerful, but it is not perfect.

The report makes clear that mortality data has limitations. It does not fully capture nonfatal overdoses, suicide attempts, substance use disorders, untreated mental illness, community-level distress, or the lived experience of individuals and families navigating care. It also may not capture 2025 or 2026 trends, and reporting capacity can vary across states, tribal jurisdictions, territories, and local communities.

That matters because behavioral health systems can look better or worse depending on what is being measured. A state may show improvement in overdose mortality but still have serious gaps in treatment access. A state may have lower suicide mortality but increasing emergency department visits for suicidal ideation. A state may have a promising opioid settlement strategy but lack the workforce needed to implement it. A state may have strong policy language on prevention but limited funding to bring that work to scale.

This is why state-level data should be treated as a starting point, not the finish line. The real work is interpretation.

• What is the data telling us?

• What is it not telling us?

• Who is missing from the data?

• Which communities are being averaged out?

• Where do mortality trends, claims data, provider capacity, workforce shortages, Medicaid policy, and community experience point in the same direction?

Those are the questions that turn data into strategy.

State Policy Choices Matter

Behavioral health outcomes are influenced by federal policy, but many practical decisions are made at the state level. States influence Medicaid eligibility, reimbursement, benefit design, provider rates, crisis system financing, school-based mental health, opioid settlement governance, workforce development, public health surveillance, behavioral health integration, and the balance between prevention, treatment, harm reduction, and recovery supports.

That means state policy is not background noise. It is part of the intervention.

For example, the report highlights ongoing challenges and opportunities related to 988 implementation, mobile crisis response, suicide prevention programs, safe storage, red flag laws (tied to gun control), school mental health, opioid settlement funds, and Medicaid coverage. These are not isolated policy areas. They are pieces of a larger behavioral health infrastructure.

When those pieces work together, people are more likely to receive the right support at the right time. When those pieces remain disconnected, people fall through the cracks.

A person in crisis may call 988, but if there is no mobile crisis response, no crisis stabilization option, no follow-up care, and no accessible outpatient provider, the system has not truly responded. A person leaving jail or residential treatment may receive a discharge plan, but without coverage, medication continuity, housing stability, and recovery support, the risk of relapse, overdose, or crisis remains high. A young person may be identified as struggling in school, but if there is no school-based mental health infrastructure or community provider capacity, early identification may not lead to early intervention.

State policy decisions either strengthen those connections or leave them to chance.

Opioid Settlement Funds Are a Test of State and Local Priorities

The report also reminds us that opioid settlement funds represent a major and time-limited opportunity. Across the country, states and localities are receiving approximately $50 billion through opioid litigation settlements. These funds are intended to address the harms caused by the opioid epidemic and support opioid abatement and remediation. The opportunity is significant. So is the responsibility.

Settlement funds should not simply backfill existing budgets or support disconnected one-time projects. They should be used to build durable infrastructure: prevention, harm reduction, treatment access, recovery supports, family education, peer services, data systems, workforce development, and community-based strategies that reflect local need. This is especially important because the overdose crisis continues to evolve. Opioids remain a major driver, but stimulant use, polysubstance use, fentanyl, xylazine, and other emerging substances require flexible and data-informed responses.

States and localities should be asking: Are settlement dollars being invested in ways that will still matter five or ten years from now? That question should be front and center.

Questions We Should Be Asking

As we move from national data to state-level action, several questions stand out:

• Are state leaders using mortality data alongside claims data, workforce data, community feedback, and provider capacity data?

• Are opioid settlement funds being invested in prevention, treatment, harm reduction, and recovery infrastructure that will last?

• Are Medicaid policies supporting access to behavioral health care, or creating new administrative barriers for people already struggling?

• Are crisis systems being built as a true continuum, or are 988, mobile crisis, stabilization, outpatient care, and follow-up services still operating in silos?

• Are rural communities, tribal communities, communities of color, veterans, youth, families, and people in recovery centered in state strategy?

• Are providers being asked to produce better outcomes without the reimbursement, workforce, data tools, and operational support needed to deliver them?

• Are state agencies, payers, providers, schools, public health leaders, and community organizations working from the same roadmap?

These questions are not easy. But they are necessary.

What This Means for State and Community Leaders

For state agencies, provider associations, advocacy organizations, funders, and coalitions, the report should be read as both a warning and an invitation.

The warning is that progress can be uneven and fragile. A statewide improvement can mask local crisis. A reduction in one mortality category can distract from worsening trends in another. A policy victory can fail to produce meaningful change if implementation is underfunded, fragmented, or disconnected from community need. The invitation is to use state-level data as a planning tool.

That means moving beyond broad statements of concern and toward practical system design. It means asking where investments are most likely to reduce harm, improve access, and strengthen long-term community well-being. It means identifying gaps in the continuum and creating strategies that connect prevention, crisis response, treatment, recovery, and social supports. It also means being honest about sustainability.

Many states and communities are trying to solve behavioral health problems with short-term grants, limited workforce, outdated payment models, and fragmented data systems. That is not a stable foundation. If states want better outcomes, they need financing strategies that support the full continuum of care and the infrastructure required to manage it.

How NorthStar Behavioral Health Advisory Can Help

At NorthStar Behavioral Health Advisory, we believe that state-level data should become more than a set of charts in a report. It should become a roadmap for action.

NSBHA helps organizations interpret behavioral health trends and translate them into practical strategy. For state agencies, associations, advocacy organizations, funders, and community coalitions, this can include support with environmental scans, stakeholder engagement, opioid settlement strategy, payer/provider alignment, policy analysis, service gap assessments, and implementation planning.

We bring a perspective shaped by clinical experience, managed care, data analytics, policy engagement, payment innovation, and lived recovery experience. That combination matters because state-level behavioral health challenges rarely sit neatly in one lane. They sit at the intersection of public policy, Medicaid, commercial insurance, provider operations, workforce, community need, data, and trust.

NSBHA can help organizations navigate that intersection with a practical roadmap grounded in mission, sustainability, and measurable impact.

A Final Thought

The state-level data in the 2026 Pain in the Nation Report should remind us that geography matters. Where someone lives can shape whether they receive prevention, whether they can access treatment, whether crisis care is available, whether recovery support is sustained, and whether community conditions promote health or deepen risk. That should concern us. It should also motivate us.

Because state-level systems can be changed. Policies can be improved. Investments can be aligned. Data can be used more effectively. Communities can be engaged more meaningfully. Providers can be supported more sustainably.

The map is in front of us. The question is whether we are willing to use it.

--If you or someone you know is struggling or in crisis, call or text 988 or chat at 988lifeline.org for free, confidential support 24 hours a day, 7 days a week.--

In Part Three of this series, which will be released next week, we will shift from state-level strategy to the provider perspective: what behavioral health organizations can do now to strengthen sustainability, payer partnerships, data capacity, and community impact.