Out‑of‑Pocket and Out of Reach

welcome to Mental Health Evolution, a podcast about what's changing in mental health and why it matters. I'm your host, Rachel Harrison, inviting you into honest conversations with people from all perspectives in the field. Clinicians, tech founders, investors, insurance companies, and all the folks in between. Let's explore what's working, what's not, and what's next.

Welcome back everyone, to the Mental Health Evolution Podcast, where we explore changes happening in the mental health industry and discuss topics from multiple perspectives. More and more, I am finding the need to be able to set the stage and talk through some various dynamics in the industry as a solo episode. And that's what we're going to do today. I want to share some insights and some information on a topic I've been thinking about and exploring, which is how rising out of pocket healthcare costs are impacting people's ability to stay in therapy as well as access mental health support. In this episode, I'll walk through some of the forces behind these changes, including deductibles, co pays and marketplace shifts, and explore what those trends may mean for clients, clinicians and the broader mental health system. So let's start with a few articles here to set the stage. We wanted to find current information and so you will see at least one here that is a 2026 article and that's important because many of these shifts that are being seen and reported by providers and clients alike are more recent really, starting early this year in 2026 and some at the end of 2025 as insurance plans and deductibles have reset for the year. But let's go over some of these articles in brief to get you an idea of what has been happening. The first one I want to highlight here is called the High Costs of Mental Health A Barrier, a Burden, and a Call to Action. This one from the Access Institute that helps to create access for people that have a barrier, and they report on how cost remains a major barrier to accessing therapy as demand continues to grow while provider supply and affordability lag behind. So we're going to dig into some of those pieces. The next article that I want to look at is called Insurance Design Can Create Copay Barriers to Mental Health Care. This one is a research review from RWJF and many insurance plans, they have found, do charge higher co pays for mental health visits compared with primary care. That is not necessarily new, but it does reduce utilization, especially for older adults in Medicare Advantage plans. But I think across the board. I know that most of you probably realize realize that if you are accessing mental health care, usually you're paying at least the specialty provider rate and sometimes an even higher rate when you are accessing mental health care. And this is one of the barriers that we will talk about more and more Next article Just to go over this briefly, the APA services this is the 2026 summary which I found very helpful. I do highly recommend taking a look at it saying new policies affecting access to mental health care and this article is discussing how policy decisions are limiting affordable access, including things like cost sharing, funding cuts and barriers that have been disproportionately affecting people who need care. This article also offers some suggestions of what can be done and I'm going to highlight that a little bit later in the episode as well. And the last the PMC report. This is from 2024, so a little further back, but the article is called High out of Pocket Cost Burden for Mental Health Care and again, research showing that a subset of patients spends a large percentage of income on out of pocket mental health care costs and highlighting those affordability challenges. So with that setting the stage, I'd like to talk about some broader themes and and some anecdotal scenarios that are going on because I want to highlight conversations that I have been hearing about personally and professionally and what people are reaching out to tell the podcast. I'm also seeing from other providers what they are expressing either personally or on a public forum such as social media. And the bottom line is that everyone is reporting a change. I would say it like this. Things are different in 2026. We are seeing a shift. I talked to a colleague recently and have changed any identifying data so it's not easily identify this person. She's a group practice owner and she has a practice that accepts commercial insurance. She is saying a couple things. First she is saying it's harder to get referrals As a local practitioner. I have heard this echoed throughout different forums online. I've also heard this from multiple solo providers. People are struggling to get referrals. Local practitioners who used to feel like they couldn't see enough people, there were too much demand, are now really looking for clients. So that's just an interesting trend that is shifting. And 2 some clients are terminating services due to higher costs and they have insurance. So these are not people saying the cost of out of pocket mental health care or practitioners who you don't take insurances too much. These are people saying I have insurance and I can't afford mental health care. And that represents a big shift too in our industry. And I want to dig through that a little bit more and kind of unpack that because as I process and as we process on the pod, these two things I sat with some of the things I've been hearing as trends and I want to highlight each one here how it impacts clients, clinicians and businesses in this space. First, we're going to talk about changes being seen in commercial and employer provided insurance plans. Number one, the cost of insurance plans has skyrocketed. This has been all over social media. I'm sure you've seen it. But there are things happening here where even people with employer plans are having to pay more just to have insurance. So the price of entry is has gone up exponentially. I know people that are paying double and triple the amount to have their monthly pay rate just to have insurance. Medical insurance also covers mental health care. Typically these people are seeing higher rates required just to have insurance. And as you can imagine, that creates a significant financial burden. That means there's less cash available in that person's budget for other things such as maybe deductibles or copays. So even for providers that are in network, this piece is is the first layer of complexity. The next layer is that deductibles across the board seem to be increasing. Again, this is not every single plan and it doesn't reflect everything, but it is a pattern seen by providers are reporting this all across the country. These deductibles often create a financial burden that is not sustainable for a client to pay 8 or $10,000 of their mental health care costs out of pocket before being able to access a benefit. And as you can imagine, that's another layer to this barrier of getting care even for clients that have insurance. And third, co pays are increasing. Again, not every plan, but we are seeing this more and more. A large number of commercial plans are seeing an increase in copay costs for outpatient mental health care. I believe inpatient as well, although I haven't heard as much about that. And this means that a client who is already paying more for their insurance plan may also have a higher deductible and now has a higher copay once the deductible is met. So the multiplication effect is pretty significant. The cost of receiving care may double, triple, quadruple. For people that have been utilizing mental health care, they're saying can I still afford this? So I think it's worth us taking a look at that pattern and how it is impacting the industry as a whole. The other factor is Medicaid cuts. This is well known and we have talked about this some on the pod. But as one of the articles referenced, the Medicaid cuts mean that 11.8 million individuals, 11.8 million, if you can just think about that for a moment, will no longer have access to Medicaid benefits. According to the APA article that I referenced above, these are individuals often who have an acute need for mental health care. So cuts here mean that there are more people who cannot afford care. When I look at this data and clients or patients who are no longer able to afford mental health services, I just wonder to myself, where do they go? What happens next? At the same time, providers are often saying that they can no longer afford to accept Medicaid, Medicare and even some commercial insurances due to the low reimbursement rates and the rising costs to remain in practice. So by my assessment, this means that our gap continues to widen. We have providers who cannot afford to provide care through insurance that we have, and we have clients and patients who cannot afford out of network care and sometimes cannot even afford care with their commercial insurance and with Medicaid cuts may not even be covered anymore. My question is this. I'm curious who stands to gain with these trends and I'm just going to leave that there. While these data points don't present a great picture for the mental health industry, I think there are a few points to consider and some of these also come from the APA recommendations. First, I want to say if you currently have a reasonable copay for mental health services, please use it, enjoy it, count yourself as fortunate. This is a good thing and we're glad for it. Secondly, I encourage any client or provider to look into local resources that might be able to fill a gap. This could be a mental health association, this could be a grant that supports with co pays. There are some resources out there though they can be hard to find. And if we can do things to help bridge the gap for a client to be able to afford care, I think we should. Whether that means in our communities there's a resource or whether that means that we ourselves are able to be that resource. And thirdly, I really like the APA's recommendation in their article of documenting what is happening. Let's really look at this, let's write down when we have a client that terminates because they can't afford their copay, let's document that, let's make a note of that and let's share this information with Colleagues who are also providers and patients. Gathering collective data helps us all to see trends and patterns and come up with collective solutions to the barriers we are seeing. It also helps us if we are going to talk to policymakers about changes that we would like to see. So talk to your friends and colleagues. Unity for local providers I think is going to be a necessity with all of the market changes that we are facing. And lastly, I want to inspire some creative and out of the box thinking. This is for clients seeking care as well as providers. I don't have all the answers, but the question to ask is what can be done to make this work? Maybe it's a client can come for fewer sessions but not stop entirely. Maybe there are some creative financial solutions that can help. Maybe providers can create programs, look for grants, other ways to fund services. I am not sure, but I know we need to think about this differently. I know that as an industry we have providers and business owners that care deeply and I am hopeful that we can find a way to help support client and patient needs while confronting these changes. If you are someone that has found a way to get creative here, to find resources to do unique things, I would love to hear from you. I'd love to have you on the pod. I would love to hear about how we are looking at creative solutions and for clients too. If you have found a way, if you have figured out how do we budget this, how do we look at our yearly medical budget and make a way like what kind of creative ideas are there out there for that? I think that's great too. The bottom line is that mental wellness and mental health care continue to be important to all of us. They're important for our communities and I hope that as things are changing and things are getting more expensive and financial stresses are really becoming something that people have to think about day to day. Some people have always thought about that day to day. Let's be real. I hope that we can find a way to continue to make mental health care accessible. With that, thank you for listening to today's solo episode. We will continue to build upon this trend with other guests and data so we can look at what is happening and make the best decisions for client care, clinician well being and business health in our industry. If this topic resonates with you, whether you're a clinician, a practice owner or someone trying to navigate mental health care, we would love to hear your thoughts. We'll be back in the next episode to explore more issues relevant to the mental health care community. Thank you for listening and bye for now.