Mental Health Utilization Gap by Insurance Type Among US Adults With Chronic Pain

Importance: Chronic pain affects roughly 50 million US adults and often co-occurs with mental health conditions. Although mental health treatment can improve outcomes, little is known about how insurance type relates to utilization among adults with chronic pain. Objective: To examine how insurance type relates to mental health service utilization among adults with chronic pain, whether this association varies by mental health need, and cost-related barriers to care. Design, Setting, and Participants: This cross-sectional study analyzed data from the National Institutes of Health's All of Us Research Program Mental Health and Well-Being off-cycle survey. Survey responses spanned June 2018 through September 2023. Participants were adults aged 18 years or older at survey completion with a chronic pain diagnosis documented before survey completion. Data were analyzed in January 2026. Exposures: Insurance type: private only (reference), Medicare only, Medicare plus supplement, Medicaid only, dual eligible, military or Veterans Affairs (VA), and other. Main Outcomes and Measures: Self-reported mental health professional visit in the past 12 months (primary) and cost-related barrier to needed mental health care (secondary). The utilization gap was defined as the percentage of participants with mental health need who reported no utilization. Results: Among 36 275 adults with chronic pain (mean [SD] age, 57.2 [15.0] years; 68.0% female), 34.0% reported seeing a mental health professional in the past 12 months. Among 7305 with mental health need, the utilization gap was 34.2% (n = 2497). Gaps varied by insurance: military or VA, 18.7% (95% CI, 15.8%-21.7%); dual eligible, 25.9% (95% CI, 22.8%-29.0%); Medicaid, 34.8% (95% CI, 32.8%-36.7%); Medicare, 36.6% (95% CI, 33.7%-39.7%); private, 40.9% (95% CI, 38.8%-43.0%), a private vs military or VA difference of 22.2 (95% CI, 18.6-25.6) percentage points. Cost-related barriers were highest among the privately insured (532 of 2070 [25.7%]) and lowest among military or VA enrollees (50 of 626 [8.0%]; adjusted prevalence ratio, 0.42; 95% CI, 0.32-0.55). Conclusions and Relevance: In this cross-sectional study, among adults with chronic pain and mental health need, utilization gaps were more than double under private insurance vs military or VA coverage, and cost barriers were substantially more common among the privately insured. These patterns are consistent with a role for affordability and integrated care delivery, though cross-sectional data cannot distinguish insurance design from selection into coverage types.