The Coverage Gap Is a Policy Problem with Cara Cheevers

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 to the Mental Health Evolution podcast where we talk about how the landscape is rapidly evolving in the mental health industry. Today we are joined by Kara Cheevers, vice President of Coverage Policy, at Inseparable. Inseparable is a national mental health advocacy organization on a mission to win better mental health care for everyone in this country country. And they do that by research and data into real policy change at the state and federal level, championing lawmakers, closing coverage gaps, and building the kind of political will it takes to fix a system that has been falling short for a long time. Cara leads their coverage policy work focused on the structural and financial barriers that keep people from getting mental health care, including reimbursement, disparities, provider shortages, and the ways insurance systems fail both patients and providers. And today we're going to talk about what Inseparable does, what the data tells us about the mental health workforce crisis and what clinicians can actually do about it as Always before we talk to our guests, we're going to talk about a little bit of articles and give you some data about what's going on around this topic today. These may be helpful for listeners who want to learn more about this topic and dive deeper. And of course we will have everything in the show notes if this is something that you want to take a deeper dive into the first article is from the Health Resource Services Administration and it's called the State of Behavioral Healthcare Workforce. This is a 2025 article and it gives us a national snapshot of where the behavioral health workforce stands right now. It finds that 40% of Americans, which is around 137 million people, live in a mental health professional shortage area, and it projects major shortfalls in counselors, social workers and psychiatrists through the year 2038. Beyond the supply and demand numbers, it also highlights that low reimbursement, burnout and limited scopes of practice are pushing providers out of the field or keeping them from taking insurance at all, which is definitely a theme that we have touched on podcasts that we've recorded before. The second article from Pew Charitable Trusts is called State Policies Can Help Address the Mental Health Care Workforce Shortages and this is from April 2026. Pretty recent article and it looks at what states are actually doing to strengthen the mental health workforce. It highlights pipeline programs, streamlined licensing, and other state level strategies that are helping recruit retain behavioral health providers with real examples from states that are starting to move the needle. It is a useful reminder that while federal policy gets most of the attention, states have meaningful tools available to them right now. And then lastly, this article is from the organization that Kara represents, Inseparable the Workforce Report Bridging the Mental Health Care Gap. And this is from March 2026, so also very recent data. And this report that we will be discussing today assesses all 50 states and the District of Columbia on how well they are meeting their mental health workforce needs. And the findings are striking. Only four states meet more than half of their population's demand for mental health services, and nearly half of all states meet 25% or less. The report also found that in many states the therapists earn significantly less per session than comparable medical providers, which helps explain why so many providers are choosing not to accept insurance. It lays out three areas where state policy can make a real difference. Number one building a workforce pipeline, number two supporting the people already in the field and number three modernizing data and technology. Each of these pieces point to the same underlying problem, which is a system that asks mental health Providers to do more with less, pays them less than their medical counterparts and gives patients fewer in network options than they have for other kinds of care. Kara Achievers has spent her career trying to change that and today we're going to dig into how. So thank you Kara for being here for this conversation.

Thank you so much for having me.

I'd like to start with you and a little bit about how you got into this type of work. What inspired you to be an advocate here?

That's a great question. I'm a social worker by training from West Michigan and got my bachelor's degree in social work and then eventually got my master's in social work as well. I'm not a clinician, I don't do micro level social work, but I really enjoyed the classwork and the framework of the social work program and have used it to do systems level change my entire career. I've really focused on policymaking, systems reform and grant making more broadly. And so with each kind of chapter of my career, it's brought me a little bit closer and closer to mental health system reform more broadly. With each step, you know, we look at this is a problem for this subpopulation of people and that also impacts everybody. And so I've just gotten a little bit closer and closer and closer to the root problem. That is how our mental health system is not designed with people's and patients best interests and needs at heart. I'm also a patient of the mental health system. I have my own mental health conditions and despite the training, despite the privilege and despite the access I have, I've in my life really struggled to get the care that I need when I need it. And my story is no different than others, you know, accruing significant financial harm and debt to get the mental health care that I needed because I didn't understand or wasn't able to find a therapist with my own insurance that I paid a lot of money for. My story is no different than any other person's in my community, probably on my same block in which I live and so have been really motivated to fix the system to make sure that others don't experience what I've experienced. And that way we can really continue to mitigate the harm that is caused by our unfortunately dysfunctional mental health system.

Yeah, I agree. And, and I mean, I know we have visited this issue too. It's, it's difficult for providers to take insurance for a lot of reasons. Reimbursement being one of them, barriers to getting sessions approved that they need being another all kinds of things. And so understandably, going out and not taking insurance, and then that does put the burden then back on the clients and patients.

And.

And it's definitely something I've been in this field for 28 years. It's something I've seen since that whole time. Right. It's not something that's changed or really evolved. It's sort of been the better the provider, the more likely it is they don't take insurance, unfortunately.

You know, that's a really interesting point, and I've heard that kind of discussion point a lot where if it's a good provider, they don't take insurance. And that's something I've pushed back on for a long time because there's so many incredible providers that do. And what I think about, prior to joining Inseparable, I had the opportunity to serve at the Colorado Division of Insurance, where I led this, Colorado's mental health parity enforcement work. And when I was at the division, my kind of euphemism or moniker that I would use when thinking about the enforcement work we were doing was to say, you know, I can't require a provider to take insurance. That's not my job. That's not my role. But what I can do is understand and solve for and fix the problems that disincentivize them or make it impossible to accept commercial insurance. And then from there, the market will do what it needs to do, or providers can make their own decisions. However, we know, especially in the commercial insurance market, it is really hard to take commercial insurance, or it has been known to be really hard because of reasons like administrative burden, reimbursement rates being too low, submitting an application to join an insurance network, but then never hearing back from an insurance company, or not hearing back for months and months and months while you're still seeing a patient wait list grow because there are people experiencing significant need. And then maybe you eventually hear back from the pro, from the insurance company saying, yes, you can join, or maybe you don't hear back at all, or maybe you hear that the network is saturated and they don't need anyone. Well, you know, that's not true. And so how do we solve for these inherent systemic problems and inaccuracies that ultimately harm a provider and their business and then a patient and their mental health. And so all of these things exist at once. And if we can solve for some of the system problems right now, while also building a pipeline for the future, I think we can really ride the ship.

I mean, I love that. I think There are a lot of providers that would prefer to take insurance because they do want to support as many people as possible to get services. So I would love to just dive into what are some of the big ways that we can do that. Like when you say that, I'm like, yes, okay, sign me up. This is what we need, right? So tell me what some of those specifics are.

So I got a few different ideas and I'll talk about it. First on the here are the providers we have currently versus, you know, let's talk about the provider pipeline we're cultivating for five, 10 years in the future. When I'm thinking about how we make our system work better today, there are some big P policy ideas and then there's some little P policy ideas. Not that one is more important than the other. They're just different levers that we have. When I think about the big P policy ideas, there's so many things we can do. We can require that states pay a minimum reimbursement rate percentage. We also have tools like mental health parity, which is the idea that physical health care and mental health care are treated comparably and are no more restrictive than the other for patients. That is one really great tool and it's one great formula. There are however, states that are just saying we have a significant access problem. And so we are saying in state statute, through legislation, mental health providers cannot be paid less than this percent of Medicare per type of session. And that's the four they can go up. Parity then still exists, but that is the minimum. They may not be paid less than this. Illinois has done this, Washington has done this. There are several other states looking at it. That automatically removes some of the opacity or confusion around how you negotiate a contract, how you ensure you're getting paid what you're worth, how you're also making sure that what you're paid for a session kind of backfill some of the administrative costs that you don't get paid for through a 53 minute session. Reimbursement rate mandates are a phenomenal tool to just black and white immediately fix an issue specifically around reimbursement. A lot of states are also looking at the requirement that insurance companies and Medicaid programs reimburse for pre licensed candidates. So those are the individuals who have graduated from their training program, whether it's a counseling program, social work therapy, et cetera. You graduate from the program, you've done your internships, and you're getting your 3,000 roughly field hours to go towards Your licensure, the reimbursement of those services are really scattershot and it's really hard to tell if and when an insurance company or a Medicaid entity will reimburse for those services even though they are medically necessary services being provided to patients. It's also really hard to incentivize a supervisor to take on pre licensed candidates if they're not getting paid for them. And so one of the things that we're looking at in a number of states is to say that insure insurance companies absolutely must reimburse for pre licensed candidates who are being supervised by an in network provider. So therefore I, as a social worker with my own, you know, independent practice would be much more willing to take on a few supervisees who are getting their hours because I'm getting paid and then I can pay them. I'm also then able to mitigate the long wait list that I have for people seeking care with this type of insurance. That's kind of a medium term pipeline development piece that we're seeing a lot of states looking at. We also, in terms of like little P policy, we've seen a number of state insurance departments start to take complaints from providers. So a lot of times the regulating entity for commercial insurance they're called, it's usually the division of insurance. One of the elements that we're really working on is making sure that people know that their insurance one, covers mental health care. Two, there aren't treatment limitations. You can't be denied. You can't say like, oh, I only have 10 sessions a year, that's a violation of the federal law, that's not a thing. There are no treatment limitations on the number of visits, the length of a visit, things like that. But then when people really struggle to get mental health care, we want them to file a complaint with the division of insurance because they're paying a lot of money to get this coverage and if they're not able to use it, that's a problem. A lot of times insurance departments don't love to get involved between providers and carriers because it can feel like a contract negotiation issue. And that is oftentimes not the case. And so when I was at the division of insurance and a lot of other states have done this as well, we explicitly started taking complaints from mental health providers because there are very specific black and white requirements that insurance companies must do to comply with state and federal law. And when providers struggle with commercial insurance, they're less likely to take it, which means patients aren't going to be able to get the care they need or they're going to have to pay more out of pocket to get to get it. So we, we started taking provider complaints and immediately just got hundreds of complaints. And it was very easy to identify systemic issues with certain insurance companies. So then we could also first triage those issues with those providers while also doing an audit of the insurance company more broadly to say, okay, this is impacting these people who knew to contact us. What else is happening that people aren't sharing with us because they don't know, they can't, et cetera. So there's a lot of ways that states in particular can either mandate policy like reimbursement rates, reimbursement rate processes, reducing administrative burden, things like that. But there's also a lot of just regulatory things or non legislative, very unsexy things that they can and do do that make the system work better for providers specifically.

Okay, that's an amazing list. I'm wondering is there an example you kind of, you highlighted Illinois as having some of these laws. Is there a specific example that can kind of demonstrate for our listeners how this might look, how this might roll out?

Yeah, a lot of states use legislation as the primary driver to implement insurance reform. That's one strategy. That's one lever. So Illinois is one that I referenced. There was a bill last year that did a lot of things including requirement for reimbursement, pre licensed candidates. Colorado did it as well. Colorado also passed a law, it was championed by several representatives and senators that explicitly said carriers or insurance companies must credential a mental health provider within 60 days. So no more multi, multi bumps ghosting application. It specifically says that a mental health provider's application must be either approved or denied within 60 calendar days. And there's all of these communication requirements in that timeframe. And if that insurance company doesn't respond either way on that 60th day, they're automatically admitted into network and, and that any claim submitted would be considered in network. That is something that many states have done. Many, many states. Also looking at pre licensed candidate reimbursement. We're also looking at different tools around ghost networks to make sure that insurance companies are engaging with providers proactively in a documentable, traceable way to say hey, we want to make sure that you're still interested in staying in network. How is this going for you? Et cetera. Ultimately, we want to make sure that patients who are seeking care have the most reliable and accurate lists of names and individuals providing care and accepting new patients as possible. Colorado's done some great work. New Mexico has done some amazing work. New Mexico, a few years ago, at the leadership of Senator Hickey, removed all cost sharing for mental health visits for patients. So providers are still going to get paid what they're contractually obligated to get paid. It just says that insurance company cannot charge a copay or a coinsurance for mental health care for patients. We know that cost is a huge barrier to care. And so there's a lot that states are doing on affordability for patients more broadly. I could speak for days about the very cool things that states are doing legislatively and regulatorily. I think it is really important to note that legislation is one really great tool. We have some amazing lawmakers in states who are running bills, passing bills, and doing incredible work to make sure providers and patients alike are treated well within the insurance space. It is also really important to note that that's one tool. There are some incredible, incredible administrative staff, regulators, Medicaid entities, governors who are doing really great insurance reform or access reform. And it's not always sexy, it doesn't always make a headline, but they are an incredibly important part of the puzzle.

Yeah, definitely. You mentioned as we started digging into this, that this is the piece for addressing providers that are already doing the work, but there's also some pipeline kind of things that your organization is advocating for. Can you talk a little bit about that?

Yeah, absolutely. There are some amazing programs that states have implemented to really build a pipeline for the future. One thing I'll say as a trained social worker, and I'm not sure what your experience was, Rachel, but I remember in my bachelor's and master's level programs, learning from my teachers in my classes, oh, don't bother taking commercial insurance. Don't bother taking insurance. It's a nightmare. It's a problem. It's a nightmare. Don't even bother. Just do cash pay. And I think that's a really important piece that we should be thinking about as we're building the future of our mental health workforce. We need to be educating social workers who are predominantly business owners. We need to be teaching them how to work with insurance companies, how to create a business model that's sustainable, how to, how to negotiate, how to make sure that you're getting paid on time. These are things that are just as important as providing high quality care to patients with different types of needs. Yet it's something that I think our general curriculum is really lacking. There's also a ton of different models that states are doing. Several states have created works workforce development centers. There's one program called the Balmer Institute. It's based out of Nevada in Oregon. And it's a four year associate degree that allows individuals to immediately start providing care to patients without having to do those 3,000 hours of field work and do all of this other stuff towards licensure. In addition to a graduate program, We've also seen a lot of success with different states doing loan repayment programs. Unfortunately, a lot of those things are expensive. And when states are struggling as they are right now, given the different constraints that we have, it makes some of those interventions feel a little bit like a pipeline or a pipe dream. But it is something that is absolutely doable and we know the benefit and the cost are well worth it. We know that when we invest in mental health care and mental health providers, we are healthier overall because of it.

Hmm. Yeah. I have definitely seen in. I actually taught a course on the business of private practice in a graduate program. But it is interesting the perspectives, I would say the most common perspective that I have experienced students coming in with is like getting to the point of not having to take insurance is sort of considered like this achievement in the field. Right. And I understand it usually is very financially motivated as well as kind of a status maybe symbol. So I think there's some work to do in the culture around that, around how can we earn a livable wage. You mentioned parity and some other ways to do that. And so that the goal of not taking insurance is not what many up and coming clinicians are looking for. But I have definitely seen that as a pattern. That has.

Yeah.

Surprised me that there is this like, oh, you don't take insurance? Wow, tell me how to do that. It's more like that there is that like woo. We want to, we want to be there. And I think unfortunately clients tend to suffer in that system. And I also want to say I understand the reasons that providers get there because I've done it both ways myself.

Yeah, absolutely. I mean the administrative burden alone, let alone the amount that you're reimbursed or the amount that you're paid, I think all of the things that go into having a practice that are not reimbursed, case management, housing, supports, paperwork filling up,

following up, all a claims, whether or

not an accountant, all of these things that are not built in to that 45, 53 plus session that you're reimbursed for, which at times can be criminally low. So I get it. I, you know, that's there's a lot

that I empathize with.

You could just take private pay and work with folks that can pay out of pocket. It would make life a lot easier. In the meantime though, that is the reality. That is not the reality of most people. And so how do we make sure that we're working within the system that we have to support people where they are and for the needs that they have?

Yeah, I love that we are just about at the end of our time, but I would love for you to maybe give an action step or two that people can take, whether it's a client or whether it's a clinician, to sort of help support, help advocate or move the needle on these things. What would be your suggestions?

That's a great question. I think there's a few things that can be done really easily that don't take up a ton of bandwidth. I think from a, from a patient's perspective, if a patient is struggling to find a provider in their network with their insurance company, they can file a complaint with their state division of insurance. So if I live in Colorado, I'm going to contact the Colorado division of insurance to say, hey, I can't find a therapist that can meet my needs that is available to see me within seven calendar days. And each state has their own timely access standards, seven to 10 days roughly. And so you have, you as a patient have the right to be seen within that timeframe and your insurance company must comply with that. And so if you can't find anyone, you should be able to go out of network. However, a small policy thing that you can do to advocate for yourself and also to improve the system is to file a complaint and say, hey, I can't find somebody. That actually is a huge, huge win. Your insurance covers mental health care and if you're not able to get it, the entity that enforces your rights needs to know about it. Yeah, the same goes for providers. If you're not getting paid on time, if you are getting hit with post payment audits or clawbacks, or you're reimbursed, you're not allowed to reimburse or excuse me, you're not allowed to renegotiate your contract for a different rate. These are all things that a provider can and should file a complaint with their local division of insurance about. And if they're not able to file a formal complaint, then even just writing to the local insurance commissioner and say, hey, I'm not getting paid within the amount of time I'm required to get paid, help me keep my business open and help me keep seeing patients to make sure I'm paid on time. That takes very few minutes and will be so incredibly helpful for advocates and policymakers in general to have that data.

Amazing. I love that simple step and I do think that it is one that certainly patients and definitely clinicians don't think about very often. So I appreciate that tip. I really appreciate Inseparable and the work that you are doing Kara there. So thank you for being here. Thank you for talking to us listeners. I want you to know that we will have all of the information in the show notes if there's anything from this podcast that you want to follow up on. And Kara, thank you so much for being here.

Thank you for having me.

It was a pleasure and we will see you next week to talk more about all the things that are changing in the mental health landscape. Thanks everyone. Bye for now.