Nita Sweeney, an author and former attorney, has seen many different therapists over the years to help manage her bipolar disorder and chronic depression that she’s lost count. Her treatment has also required hospitalization, medication, and neurofeedback — all of which she was able to afford.
“I am forever grateful to have both excellent health insurance and the disposable income to afford the expensive health care [I need] in order for me to simply stay on the planet. As a result, I have benefits many others lack. Life is better, but I still rely heavily on mental health professionals to keep me alive.”
But not everyone is as fortunate. Sweeney says that many of her friends also battle a mental illness and continue to suffer because, unlike her, they cannot afford to seek treatment.
Limited Insurance Prevents Mental Health Treatment
“One friend in particular is a sexual abuse survivor so traumatized by her father that she cannot see male health care providers of any type, especially therapists or psychiatrists.”
Limited insurance can also limit individuals who are seeking help for their mental health.
“Unable to work, she relies on Medicaid for insurance. She has missed medicine doses, gone off her medications altogether, wound up in the psych ward, and come close to suicide more than once because she could not find a female psychiatrist or counselor on her very limited government health plan. It infuriates me that I can see (nearly) any doctor I want while my friend suffers.”
Dr. Joe Parks, MD and Medical Director at the National Council for Behavioral Health, says inappropriately low rates paid in Medicaid and Medicare programs are a major reason for the lack of availability of mental health services. As a result, a high proportion of psychologists and psychiatrists are cash-only because the going cash market pays two to three times the rate insurance companies offer.
People Don’t Seek Help Because of High Costs
Isabella W. has battled anxiety and depression her whole life and decided to seek out a therapist when she got a full-time job that offered insurance. She didn’t connect with either of them, so she stopped going. She saw a third therapist who wasn’t covered by insurance, but the cost was simply too high. She was forced to quit.
“I have been [out of] therapy way longer than I have been [in it]. It’s too much money,” she said. “I just try and deal with my problems myself, which obviously creates a lot of spinning. I have always managed to overcome my depression, but I also think, one day it could be so bad I just can’t get out. Therapy should not be so costly; it causes more stress.”
Poor insurance coverage
According to the National Council for Behavioral Health, 42% of the population see cost and poor insurance coverage as the top barriers for accessing mental health care. One in four Americans reported having to choose between getting mental health treatment and paying for daily necessities.
Kathy K. has been dealing with severe depression and chronic suicidal ideations for months and no longer has insurance after losing her job. Due to these barriers, she can’t afford to see a therapist or a doctor to discuss medication options.
She spent a few days in the hospital after a neighbor called the police out of fear she would hurt herself. The stay “helped a little, but without [something long-term], it is very difficult to control this chronic depression.”
Kathy is not alone in needing help but not being able to find it. While there are numerous low-cost therapy options, including community mental health centers, therapists who offer a sliding-scale, university psychology departments, in truth, most low-income clinics have long waitlists.
Finding the right therapist in your insurance network
Alexa C. moved to a small town in Wisconsin for a reporting job when she graduated college. She decided to seek out therapy after dealing with anxiety due to the stress of her job and moving to a new place where she didn’t know anyone.
“It was difficult to find which doctors were in my insurance network, which doctors had appointments available (many were booked out for months), and who the right therapist would be for me,” says Alexa.
She saw someone over the course of a few months but stopped going due to time constraints and cost.
“I was lucky that I wasn’t depressed — just anxious — and I was very determined to try and [find someone]. But I kept thinking, if you were suffering from lack of motivation with depression, this would be impossible.”
A quick search on an insurance website usually brings up a list of mental health providers, but in reality, many of these lists are outdated or inaccurate or both.
According to Dr. Park, “Most state departments of insurance assess access by requiring a certain ratio of contracted providers per covered life. However, if you call up the list of behavioral health providers on any insurance providers’ website and go down the list asking for a routine, urgent new appointment, you will rapidly find out the majority of them are not actually accepting new patients.”
The Challenge of Out-of-Network Benefits
In an effort to expand options, some therapists offer out-of-network (OON) reimbursement, but this requires the client to pay out-of-pocket up front to later receive reimbursement from their insurance company.
Using OON for therapy can offer more flexibility such as the ability to see someone who offers a certain specialty or a greater selection of providers.
This flexibility however is unable to help individuals who cannot afford to pay upfront or may not have an insurance plan that offers reimbursement. There are also many reports of insurance companies making reimbursement difficult, which could mean you might not get your money back in a timely manner, or at all.
Lori E. decided to take advantage of her OON benefits, but has been in disagreement with her insurance company since August 2018 for the reimbursement of her sessions.
“I have literally talked to my therapist about the anxiety of having to deal with it, which is ironic. I had to pay upfront and although it is in black and white that my insurance would reimburse me a certain amount, they keep rejecting my claim. Dealing with it has been a mess.” she says.
Lori’s fight is, sadly, not an uncommon scenario. Dr. Carla Marie Manly, a psychotherapist in Santa Rosa, CA, has heard from many clients about the difficulties in obtaining reimbursement from their insurance company.
“As one client recently said, ‘They make a game out of it and hope I’ll give up.’ Several clients have, indeed, reported that their insurance companies found many excuses to delay, reduce, and refuse reimbursement. Many psychotherapists in my area have found that insurance company submissions are often declined and delayed for frivolous reasons.”
Going Into Debt for Therapy
Megan H. didn’t even think about trying to use insurance when she was encouraged by law enforcement to seek therapy after reporting a sexual assault. Instead, she went home and searched Google to find the best trauma therapist in her area. After doing an initial consult with a female therapist, Megan knew that she had found her fit. The downside? The therapist charged $180/hour.
“I didn’t realize at the time the frequency I would need therapy…I figured I would go once a month, so the cost didn’t seem too bad.”
But Megan quickly found that weekly sessions were necessary as she began to unpack her trauma. The costs added up quickly, but she says that she couldn’t imagine seeing anyone else.
“I very quickly went into debt — thousands and thousands of dollars — but I didn’t stop. I knew financially it was irresponsible, but I could just tell from the growth I was feeling that I needed to keep going.”
Megan made huge financial sacrifices to continue seeing her therapist. She stopped going out with friends, buying things that weren’t necessities, and surviving on what little food she could afford.
“You look in your checking account, and there’s like $10 in there, and you need to go to the grocery store, so you’re just like, ‘I’m going to get bread and eggs and live off of that.’”
Megan says her therapist has helped her get her life back and begin to heal. Though she doesn’t regret seeking help and is glad she found her current therapist, she does wish that she knew more about the time and financial commitment involved. She also says she probably would have tried using her insurance or looked into more affordable options.
While Megan feels incredibly grateful she found someone she connects with, she is just one of millions of Americans hobbled by debt while simply seeking to recover after trauma. According to a 2015 study done by Millman, a risk management and healthcare consulting company, behavioral care was four to six times more likely to be provided out-of-network than medical or surgical care.
Lack of frequency can prevent progress
As a single mother, Katie Tomaszewsi also went into debt as a result of seeing a therapist. She was treated for panic attacks, severe anxiety, depression, and anger after going through a divorce while trying to raise her daughter on her own. Since then, she’s had to take many breaks from therapy for financial reasons.
“I only have so many ‘self-care dollars’ and there have been times when I’ve had other needs that had to take priority. My therapist has been great and allowed me to see her every other week, sometimes less. Though, looking back, I do feel that every week is really needed for consistent progress.”
It’s tough to really get to the heart of issues when you only have 45 minutes to an hour twice a month to speak with a mental health professional. By the time you get your therapist up to speed on your life, the session is over, and it feels like no progress can be made.
The Bond Developed Between a Client and Therapist Makes It Hard to Switch When Insurance Changes
The client-therapist relationship is unlike any other relationship. The therapist ends up knowing everything about your life. They support you through the most difficult of times and are privy to the details you may not share with even your closest friends or loved ones. Because of this, many clients become incredibly attached to their therapist. Given how emotionally intimate the relationship can become with the right person, this makes sense. Whole Reddit threads exist for users to discuss the close relationship with their therapist.
My own therapist is one of the most important people in my life. I rely on her. I love how much better I feel when I leave her office. When I had to change insurance in late 2017, I had what I call a “mental breakdown.” I couldn’t afford the out-of-pocket cost of my therapist, the rate she charges to make a living.
The thought of seeing someone new made me so depressed and anxious I felt like the world was ending. Fortunately, we were able to work out a price that I could afford. Anxiety over having to leave a therapist, someone you connect with deeply, due to financial or insurance issues is sadly common for many therapy goers.
Limited insurance creates a barrier in job mobility
Six years ago, Devon B. found a therapist she loves and who takes her insurance. She’s been considering new roles and new organizations, how she can advance her career, but the thought of dealing with new insurance stresses her out.
“I worry that if I switch, I won’t have insurance at another job that will cover it, which makes me really sad to think about because it’s taken me over six years to find a therapist I connect with on this level.”
Having to start over with a new therapist after sharing so much history with one’s current therapist can bring about or exacerbate anxiety and even depression. It’s also time consuming and exhausting to open up to someone new about the most personal details of your life. It can also be re-traumatizing to re-live painful events or memories.
This is why individuals like Megan were willing to go into debt simply to stick with their therapist. The therapeutic relationship is singular, and those that require the benefits of therapy are making major financial sacrifices simply to get the help they deserve.
Therapists Want Therapy To Be More Affordable
In some conversations, I’ve noticed an assumption that therapists are driven solely by profit, charging as much money as they can. While this may be true for a small minority, many therapists are struggling to offer affordable services while also making a living. In addition to the associated costs of licensure and schooling (nearly all therapists are required to have at least a master’s degree), there are also high costs of overhead while working in a private practice.
When my therapist revealed that she is reimbursed only $30/hour by my insurance provider, I was appalled. I considered this shockingly little for the services she provided and wondered if other clients were aware of this rate.
In addition, the amount of paperwork required for insurance reimbursement to ensure future sessions are covered, is significant. The hours therapists spend on paperwork are unpaid, further deterring them from becoming paneled on an insurance network. According to Dr. Park, 70% of their members report they actually lose money providing psychiatric services.
There is hope. Some providers are looking for new ways of structuring their practice to ensure they can provide services to low-income individuals, while still making a decent salary.
Low rates of reimbursement
When Dr. Shaun Wehle and his wife Amber relocated to a small town in Northwest Indiana from Los Angeles, they quickly found that many prospective clients — who worked hard for their insurance benefits and wanted to be able to use them — weren’t willing to pay out of pocket. Dr. Wehle tried to help these individuals find other resources, but these services typically had long wait times and some individuals went without help. Shaun said this broke his heart.
As a result, he and Amber decided to create Pillars of Wellness, a group practice that takes a number of different insurances and offers low-income therapy. The hope of Pillars is to leverage these insights to create a business model that allows clinicians the ability to easily move into a private practice, with Amber’s staff managing clerical and other duties. This way, the therapists can focus on providing high-quality service, while Amber and her team take care of financial aspects.
When asked about low rates of reimbursement, Amber says, “Some are low, and it’s arguably a disservice to the consumer. I go back and forth on pulling out of some insurance groups who are unwilling to recognize this imbalance. We once wrote to an insurer calculating the cost of running a practice and seeing only clients with their proposed rates. If a clinician only saw this agency’s clients full-time and had other costs of running a practice, they would be near the poverty line.”
It was this issue that caused Shaun and Amber to come up with a solution that satisfies both providers and clients.
“The more providers we have working together, the more we save on costs of doing business, and the more likely insurance agencies will work with us on rates. This was the hope, and I am pleased to say that it is working!”
Dr. Parks believes making therapy more accessible would be best achieved by more systematic and rigorous enforcement of network adequacy and mental health parity laws. This should be done through state departments of insurance, the federal agencies responsible for insurance regulation, and the Centers for Medicare and Medicaid Services (CMS).
He says that one of the most promising new rate methodologies is the prospective payment system being used by Certified Community Behavioral Health Centers in the eight-state demonstration implemented as part of the Excellence in Mental Health Act. The centers participating in this project have been able to generate a 25% increase in their caseloads, 46% can take someone in on the same date basis and another 46% can see someone within 10 days. Expanding Certified Community Behavioral Health Centers nationwide would significantly improve access to therapy.
Until major reform happens in this country, individuals are going to forgo help with their mental health or make major financial sacrifices in order to do so.
Dr. Parks says, “People should be able to receive mental health resources that are necessary for relief of their distress and maintenance of well-being, just as people should be able to get medical care as often as they need it.”