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This story is part of, CNET’s coverage of how real people are coping with the high cost of living in the US.
When you’re struggling with your mental health, navigating the system to find affordable therapy makes it even harder. That’s the case with Emily K., a 25-year-old who has a specific kind of OCD, or obsessive-compulsive disorder. Since she was diagnosed at age 17, she’s never found an in-network therapist, and only briefly had a therapist with a low copay.
Now that she’s unemployed, she’s paying $450 a month to continue her insurance through her previous job, plus $175 for her therapist every other week. Though she can get a $50 reimbursement each session from her insurance, the process requires submitting superbills, or detailed invoices from her provider, and takes about three months. Her entire unemployment check goes toward paying rent, so Emily is strained to get funds for her antidepressants and mental health treatment. “It’s eating up my savings,” Emily said.
Most hour-long psychotherapy sessions in the US range from $100 to $200, or more in large metropolitan areas. Though some large insurance plans cover mental health benefits, therapists get such a low payoff that they opt out of insurance panels. In the end, patients are the ones who pay the price, coughing up rising insurance premiums while facing a shortage of in-network practitioners — or discovering that out-of-network providers, who are far more common, are simply cost prohibitive.
Paying out of pocket for weekly therapy sessions can add up to thousands of dollars per year. Individuals in search of affordable mental health care are left relying on a network of online services, free clinics, support groups, educational programs, nonprofits and low-cost counselors.
Still, nearly half of the 60 million people in the US with mental health conditions go untreated, according to the advocacy group National Alliance on Mental Illness, or NAMI. The situation is particularly dire for Black people and historically disadvantaged groups, who are more likely to be uninsured and experience lower-quality care, or not receive treatment at all. Racial and ethnic minorities also face discrimination in the mental health care system, lack of diversity among practitioners and stigma in their communities around mental illness.
The high cost of mental health services took center stage during the pandemic. Depression and anxiety rates more than tripled, from 9% in early 2020 to 33% in 2021, affecting one out of three adults in the US, according to research from Boston University School of Public Health. The surge in demand for mental health treatment was felt acutely by advocates with the NAMI HelpLine, a free, nationwide peer-support service that provides information and resources to people in need. There’s been a 65% to 75% increase in help-seekers since March 2020, according to Dawn Brown, national director of NAMI HelpLine Services.
As mental illness affects peoples’ lives more broadly — financially, socially and physiologically — experts are noting how that impact ripples out into society at large, becoming interconnected with disability, addiction, homelessness, incarceration and increased rates of suicide. Politicians are starting to take the mental health crisis more seriously, but patients need to band together to put more pressure on insurance companies, said Margie Ryerson, a licensed marriage and family therapist in San Francisco.
Asking for help and knowing where to look are crucial first steps. “People are reaching out to untraditional sources of support and guidance,” said Brown, noting how emotional support is an effective and crucial component of recovery. “Peer support is an option that can get people through really difficult times and provide them with guidance and hope,” she said.
Audrey Chu was a freshman in college when she sought treatment for trauma related to sexual assault. Chu found quality help through the university health system for a $20 copay each session. But after dropping out of school, she started medication that required monitoring by a psychiatrist, who didn’t take insurance. Each 20-minute session cost her $300 out of pocket.
Insured patients regularly face obstacles getting an in-network mental health provider. In a 2016 survey by NAMI, 34% of people with private insurance said they had difficulty finding a therapist who accepted their coverage. In Chu’s case, she later found a therapist who was covered and charged a $71 copay each session. But two years later, she discovered that her therapist had been in a constant battle with the insurance company to get reimbursed.
Typically, in-network therapists receive a very low flat reimbursement rate per session, set by insurance providers. In the San Francisco Bay Area, where the cost of living is astronomical, psychologist Alice LoCicero said that private practitioners who are paid by insurance barely make a living wage. Insurance-based therapists are also burdened with mandatory documentation for claims, hours that are unpaid.
Ryerson, who’s been a therapist for about 30 years, started off accepting insurance but soon realized the rate wasn’t worth all the extra work required. “After 10 years of practice, my reimbursements from insurance hadn’t increased at all,” she said.
Ryerson had a number of patients with eating disorders, and for those with insurance, she was required to submit paperwork to insurance representatives to justify continued care. She also did additional consulting with psychiatrists and nutritionists to coordinate treatment for these patients, adding hours to her day.
Because there’s little incentive for practitioners, an increasing number of therapists have stopped accepting insurance. It was a hard choice for Ryerson, who said insurance companies should start making a “good faith effort” to negotiate with mental health practitioners and make it more appealing by offering higher rates, which would in turn benefit patients.
Insurance companies also limit the number of therapy sessions that are covered, while binding clinics to limited sessions, which can make treatment ineffective. Ellie Bendetson, a pediatric occupational therapist, described how when she started at an insurance-based clinic, she had to cap her time talking to families of patients because insurance covered only one 50-minute session per week. The clinic was required to bill any call over 10 minutes. “We constantly had to prove to insurance that the child needed treatment,” Bendetson said. “What I wanted to do was make sure they had a high quality of life, but that goes beyond what insurance covers.”
She eventually moved to a private-pay clinic, where patients were encouraged to submit their receipts for each session to their health insurance to get some money back. “Typically, the ones who get reimbursed are the ones who know how to use the system,” Bendetson said. Fortunately, a pro bono insurance advocacy program at the clinic assists patients with filing these claims. “We have to help patients advocate for themselves, but until they gain the knowledge, insurance companies will always have the upper hand,” she said.
During the pandemic, insurance companies began loosening restrictions on coverage and waivers for remote mental health, or telehealth, counseling sessions. For Emily K., it was a blessing because it widened the pool of specialists she could see. “It’s really helpful that my insurance started covering remote sessions because of the pandemic,” she said. “There are far more options and I can see people who are located further out from where I live.”
Chu also started seeing a psychiatrist through a virtual clinic that accepted her insurance, with a $40 copay. But Chu noted that the quality of the virtual sessions was significantly lower than the out-of-network clinic she went to before. “They were rushing through a checklist during my sessions. My previous doctor asked detailed questions on how my medications were affecting me,” she said. Still, she was grateful for the convenience and affordability.
Teletherapy apps provide accessible options for people seeking mental health support, which is helpful, according to Brown. But the bigger question is whether Congress will hold insurance companies accountable for what’s called “parity,” the idea that mental health and addiction care are covered at the same level as care for other health conditions. “It should be as easy and affordable to find a licensed clinical social worker or psychologist as it is to find an optometrist or podiatrist,” Brown said. NAMI’s policy advocacy efforts have centered around enforcing parity.
In the meantime, patients in need of affordable mental health care can try turning to an array of low- or no-cost support groups, services and treatment options. Given that free or affordable arrangements are often difficult to nail down, Psychologist Alice LoCicero said individuals should make sure to go with something that’s helpful to them, and not just settle for the first option they find.