How do we reach mental health parity if therapists don’t take insurance?

It's no secret that trying to find a psychotherapist in California who accepts your health insurance is becoming more difficult. Where I live in Los Angeles, it's easy to find a therapist (or 20) in a single office building along Wilshire Boulevard. But chances are, most of them don't accept my insurance, or any insurance. Other areas of the state face a similar issue. 

California enacted a mental health parity law in 1999, which was reinforced with the signing of the Affordable Care Act about a decade later. Under these laws, insurance companies are required to cover mental health visits at the same rate as physical health visits. On paper this may be true, but in practice, accomplishing true mental health parity is more complex. 

A 2017 survey of licensed marriage and family therapists — the most common psychotherapy license in the state — found that 42% of therapists surveyed did not accept insurance. The trend tracks across other license types too. According to a Milliman report commissioned by the Mental Health Treatment and Research Institute, people with a PPO health plan were 5.6 times more likely to go out of network to find a mental health provider compared to a medical or surgical clinician. Meanwhile, community mental health centers and clinicians who do take insurance or offer affordable sliding-scale fees have long waiting lists.

The impact on those seeking mental health care is huge. Instead of paying what might be a $30 copay each session for a covered office visit, many in California pay $120 or more per session to see an out-of-network therapist. This puts therapy out of reach for thousands of Californians. A National Council for Behavioral Health report found that while 56% of those surveyed wanted to seek mental health treatment, 42% said cost and poor insurance coverage kept them from accessing services. Another 25% said they would have to choose between paying for mental health treatment or covering their basic living expenses. Even with a PPO insurance plan that pays a portion of out-of-network costs, the price per therapy session will likely be at least double the copay for other office visits. 

However, for a large percentage of psychotherapists, it's not sustainable to join an insurance panel — if they can get on a panel. The average reimbursement for a therapy session from an insurance company is $60, a number that hasn't increased in 10 to 20 years. Many psychotherapists say they can't afford their overhead costs in addition to the extra time it takes to file paperwork and grapple with third-party payers compared to what insurance will reimburse. A large percentage of psychotherapists opt out of the health care system completely, which means we still have a long way to go to reach true mental health parity. This is especially true in California: A 2017-2018 Kaiser Family Foundation survey found more than 1.5 million Californians face unmet mental health needs. 

As a 2020 Center for Health Journalism California Fellow, I will explore how the high rate of psychotherapists who do not accept insurance undermines mental health parity laws and increases disparities in mental health care in the state of California. I will investigate the issue from the perspective of patients, providers, insurance companies, lawmakers, mental health advocates and health policy experts as well as explore potential solutions on the table in California. As the 2020 presidential election heats up, it's clear health care will be a central topic of debate. Just as candidates have begun prioritizing the disability community in their campaign strategies, access to mental health care has risen to the front lines of the presidential debate. Now is the time to take a closer look at this issue to truly understand the barriers to mental health parity. 

In my reporting for The Mighty, I will also identify how communities, organizations and individuals across California are working to solve the issue of psychotherapy insurance coverage and increase equity in mental health care. Highlighting how stakeholders want to solve this aspect of mental health parity could illuminate a potential path forward and provide hope for those who need better mental health care.