At Des Moines University in early December, 12 Iowa gubernatorial candidates convened for a debate. It wasn’t about the typical policy issues of taxes or jobs or infrastructure. Rather, the candidates were there to talk specifically about Iowa’s mental health treatment system. All of the candidates -- ranging from liberal Democrats to conservative Republicans to Libertarians -- agreed on one thing: The state’s current system isn’t working, and the next governor needs to overhaul it.

Iowa’s struggles with mental health care reflect pressures felt across the country. But its problems were intensified two years ago when then-Gov. Terry Branstad closed two mental health institutions to save money. “They were relied on heavily by law enforcement,” says Peggy Huppert, executive director of the Iowa chapter of the National Alliance on Mental Illness. “Those institutions took the difficult patients.” Now the state has only 64 inpatient mental health beds, the country’s lowest number per capita.

Things got worse in 2016 when Branstad privatized the state’s Medicaid program, moving more than 600,000 Iowans into managed care plans. Iowa is hardly the only state to make that transition, but it happened over just four months; in most states, it takes years. The experiment has largely been considered a failure, with news reports of cuts in services for the most severely disabled and mentally ill. In a December survey, The Des Moines Register found 64 percent of Iowans unhappy with the shift. During the gubernatorial debate, all the candidates agreed that it needed to be reversed or heavily reworked.

Many of the problems Iowa and other states are experiencing were supposed to be addressed by the federal Mental Health Parity and Addiction Equity Act. The 2008 law’s goal was to make mental health care as accessible as primary care. But the law has been dismally enforced, and a November report by Milliman, a health-care consulting firm, found that mental health care is four to six times more likely to be out of network than other forms of care.

This can largely be attributed to lower reimbursement rates: A mental health professional, on average, receives 20 percent less than other providers. “A psychiatrist will receive a lower reimbursement for diagnosing a behavioral health issue that causes insomnia than a family doctor writing a prescription for insomnia medication,” Huppert says. As a result, many mental health providers opt out of insurance participation.

In addition, and perhaps partly because of the lower reimbursement rates, the supply of psychiatrists is not even close to that of other medical specialties. The National Institute of Mental Health reported in 2015 that more than half of U.S. counties had no mental health professionals at all. “It’s just not a specialty that’s as attractive to medical students,” says Stephen Melek, the lead researcher on the Milliman study.

To get more professionals into the pipeline, Melek says states can partner with local universities to strengthen mental and behavioral health training. But, he says, the reimbursement problem won’t get better until more states start “digging into what insurance companies are doing and push for more enforcement.”

Back in Iowa, Huppert is encouraged by the dialogue around mental health care. She attributes that openness to an easing of stigmas. “The willingness to discuss this, and for people throughout the state to talk about their personal experience, is incredible,” she says.