Michigan State beat Ole Miss in the Sweet 16 round of March Madness on Friday in Atlanta. The sheer number of games to bet on in a short time makes the NCAA tournament popular with legal sportsbook games.
Grant Halverson/NCAA Photos via Getty Images
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Grant Halverson/NCAA Photos via Getty Images
Gambling — online and in person — is more widely accessible in the U.S. than it’s ever been, and the industry has the revenue to show for it. The total U.S. commercial gaming revenue profit last year was over $70 billion, according to the American Gaming Association.
Americans are expected to wager an estimated $3.1 billion in legal bets on the NCAA March Madness tournament alone this year. That’s even more than was bet on the February, 2025 Super Bowl, which was $1.39 billion.
After a 2018 Supreme Court decision allowed for legal sports wagering outside of Nevada, dozens of states adopted the practice. It is now legal in 38 states plus the District of Columbia.
Online gambling and sports betting platforms proliferated in the wake of that decision, and mental health experts say research around addiction and gambling — and treatment for problem gambling — has not kept up with the changes to the industry.
“It’s just so easy.”
“On your phone, money’s not real,” says Jen, a woman who struggled with gambling for years and now has more than $100,000 of debt. She asked NPR not to use her last name for fear of professional repercussions. “It’s not tangible. And so you lose sight of the fact that you’ve just gambled away all this real money.”
She and others interviewed for this article say platforms that facilitate legal sports betting and online casinos feel like video games.
“I could wake up in the middle of the night and gamble,” says Jen. “I could do it from bed. It’s just so easy.”
Jen has also struggled with a substance use disorder. She says the primary difference for her between that and gambling is that gambling is worse.
“The urges come out of nowhere and the distance between you and the action is so minimal,” she says. “I don’t have to call up a shady dealer to ask him to deliver something. I don’t have to ingest anything. It’s really just a matter of picking up my phone.”
Legal versus illegal gambling
Industry representatives say society is in better hands with legal gambling than illegal gambling, and that too much regulation will drive people with gambling disorder to illegal markets.
“There is a vast predatory and pervasive illegal market sitting there as a digital storefront right next door to legal operators,” says Joe Maloney, a senior vice president for strategic communications for the American Gaming Association. That association represents the many online sportsbook companies that have sprung up as well as casinos.
The illegal markets “do not invest in responsible gaming measures,” Maloney says.
Guardrails for legal online gambling include things like forced breaks, self-exclusion options, or limiting people who have lost too much money from continuing to play, Maloney says.
A black hole of data
Part of the reason researchers say they do not have a good handle on the breadth of problem gambling in the U.S. is that no one is measuring it. “The last time a large national study was really accepted as the prevalence rate was in 1999,” says Michelle Malkin, Director of the Gambling Research and Policy Initiative at East Carolina University, “which is nothing close to what we see happening in the United States or the world today.”
That study pinned the number of problem gamblers at less than 1%. Malkin is working to use existing state datasets and modeling to update these data; though she has not arrived at an exact figure, she says her research indicates the national prevalence rate of problem gambling is significantly higher.
Other research has provided clues about the impact of gambling on the public.
“When you look at adult males in their early 30s you see that the legalization of gambling is related to worse mental health and more reported days of poor mental health,” says Stephen Wu, a researcher at Hamilton College who measured mental well-being among different demographics in states before and after gambling was legalized.
Other studies looking at the impact of legalization show an increase in searches for phrases that include the words “gambling,” and “addiction,” and a link between legal gambling and domestic violence.
“A business model based on addiction”
Neuroscience shows that much like substance-use disorders, gambling addictions can change the brain over time. “ You see the response is remarkably similar,” says Kristin Scaplen, who studies psychology and addiction at Bryant University in Rhode Island. She points to research that suggests gambling wins deliver the same kind of dopamine reward as consumption of substances like alcohol. “You see this kind of remodeling in the brain,” she says.
Advocates for gambling restrictions say this kind of disordered thinking and behavior is what delivers profits for gambling companies. “There’s no revenue without the addicted gambler,” says Les Bernal, who runs an advocacy group, Stop Predatory Gambling.
Bernal points to an investigation from the Wall Street Journal that showed that 70 percent of the profits from one online gambling company came from less than one percent of the users. He says states partnering with this industry set up inherent conflict of interests.
“Those are the business practices that make all the money for the state,” says Bernal.
Ben Yew has experienced this firsthand.
“ There are whales and then there are just casual gamblers,” says Yew, referring to the slang term for gamblers who bet, win and lose large sums of money. He says he personally handed over close to $1 million to gambling companies of all kinds — legal, illegal, online, brick and mortar casinos — over many years of struggling with problem gambling. Much of the money he lost was stolen from family members.
Legal betting on sports used to be limited to places like the Westgate Las Vegas Resort & Casino, pictured here. But a 2018 Supreme Court case opened the door to phone apps that can be used for betting.
Ethan Miller/Getty Images/Getty Images North America
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Ethan Miller/Getty Images/Getty Images North America
Among other things, he says, gambling cost him his first marriage and his relationship with his two daughters.
“ My moral center and any values that I had —anytime I was in active addiction — they are completely eschewed. They sink to the deepest, dark, darkest depths of your soul,” says Yew. “You don’t retrieve those when you’re trying to chase the next win.”
After spending time incarcerated for theft, Yew is in recovery. He’s hopeful he might someday reconcile with his daughters. “ I don’t blame them for hating me or not wanting to speak with me,” he says. “I do love them now and forever.”
What treatment works?
“ It’s not bad that we have legalized gambling,” says Malkin, the professor and researcher who studies gambling. “Most people can gamble in a healthy way, but we need to be taking care of and focused on the person who can’t.”
Malkin and other experts say society — and the gambling industry — have failed to acknowledge the extent of this need, develop a widely available treatment for problem gambling, or adequately roll out prevention programs.
Experts who treat those struggling with problem gambling say part of the work is helping individuals adopt a new mindset. “The currency can be the ego boost,” says Eric Webber, an addictions counselor at Caron Treatment Centers in Pennsylvania. Webber says even without money, people in active addiction often look for small ways to “win,” throughout the day, such as beating a stoplight or guessing a number correctly.
Webber came to the work after personal experience with gambling, and says he’s grateful he wasn’t actively gambling when it became widely legal. “Since the 2018 legalization of gambling, we’ve just seen sort of this tidal wave of issues,” he says.
Many centers like his treat gambling disorders in outpatient settings along with substance use disorders. Patients often suffer from both. Inpatient facilities that specialize in gambling are rare – fewer than five exist in the country by some estimates. In part, therapists say, that is because insurance companies are reluctant to cover inpatient treatment.
But many therapists who work with those struggling with gambling point out a need for specialized treatment that differs from treating other kinds of compulsive behavior.
“You don’t ingest anything,” says Jody Bechtold, a clinician who treats gambling disorders. “You don’t just pass out because you had too much.” Access to finances is an important consideration, says Bechtold. “You really have to target, do they have access to money? Do they have blocking software? Do you make sure you don’t have any access to your own money and your family member manages all of it so that you can’t just go to an ATM and go to the casino?”
Bechtold says until insurance companies start covering inpatient treatment, it will likely be out of reach for many. “ It’s kind of an oxymoron,” she says. “Your finances are so devastated, but do you have $10,000 to go to rehab?”
Malkin says treatment for people who have already wrecked their lives and drained their bank accounts is not enough. Gambling is a growing problem on college campuses, she warns, which can set people up for a lifetime of struggle. “We need to be doing the outreach and education early,” she cautions.
Who pays for treatment
Industry advocates and those who seek more resources for intervention and prevention agree on one thing: without legalized gambling, there is no revenue stream for treatment.
What they don’t agree on is who should pay for these services, and how much should be invested.
Representatives from the industry point out that states already set aside money from gambling revenue for treatment and intervention. Maloney, with the American Gaming Association, says the industry contributes $130 million for “problem gambling services, preventions and treatments.”
Maloney asserts that gambling brings revenue “for critical priorities.” States, he says, can funnel as much money as they choose back into treatment.
But national advocates warn treatment is underfunded, especially compared to the billions of dollars of investment that the federal government puts into resources for addiction to alcohol, tobacco and other substances.
“There’s no federal funding for gambling addiction,” says Cait Huble, spokesperson for the National Council on Problem Gambling. The group estimates the cost to society of problem gambling is $14 billion annually. “It is several decades behind it in terms of public opinion and recognition of it as a mental health condition,” says Huble.
Her group has been advocating for legislation that would create a federal funding stream for treatment and intervention, syphoning millions from the profits of the gambling industry.
Jen, the woman with more than $100,000 of debt – says none of the guardrails made a difference for her. She says she played on both legal and illegal sites, often switching between platforms.
She’s still working on putting her life back together, but it’s complicated by the necessity of a smartphone in modern life. “My last relapse was in December – less than three months ago,” she says. “I don’t trust myself.”
