December 4, 2025

I am a licensed, clinical psychologist, who has practiced in New York City for the past 50 years. I work remotely. I work primarily with patients who get their treatment paid for by insurance companies. I see people from a range of income levels.

Except for a few who pay out of pocket, I don’t know how much people pay for therapy. Neither do they. The amount they pay is a percentage of what they pay monthly for the health insurance itself that covers many other health expenses. To figure out how much that is would require a lot of time, skill and effort in wading through the obscure and confusing legal explanations the insurance companies make available to the public.

As more and more cuts are made to mental health reimbursements, in both Medicaid policies and private policies, it is even more difficult to tell how much a patient pays for mental health treatment or any other health care on a regular, individual basis. One thing is very clear: In many non-Medicaid policies, there is a required co-pay the patient must send directly to the therapist for each session. Often, the co-pay has been very low, around $15.00 — a small fraction of the cost of the individual session. But the co-pays have been increasing.

Co-pays under Medicaid are zero. Not long ago, I had a patient who started to make enough money to become ineligible for Medicaid. She had to find a regular insurance company. When she sent me the new insurance information, I sent it to my billing service that sent me the payment information. The billing service informed me that this patient, who had spent years on Medicaid and now finally was making enough money to barely pay her bills, would have to pay me a co-pay of $50 every week.

Another moneymaking gimmick

There is another gimmick the insurance companies use, which, along with the cuts to mental health care, is a way for them to make money. With regular, non-Medicaid insurance, the insurance companies have developed an insidious system they are using more and more. They state clearly that the patient is eligible to receive counseling sessions, and they will pay the fee.

However, in the subclauses of the densely written contract, they mention there is a deductible. That often means that the insurance company does not start paying until the patient has received a certain amount of therapy, accumulating a fairly large debt. The insurance company determines how large that debt is. The service is counted, but the debt is transferred to the therapist, who has worked for free.

For psychotherapy, that often amounts to six to 12 months’ worth of sessions. When the therapist finds out about the deductible, they can see the patient for free or make some kind of deal to be paid for the first six months to a year of therapy before the deductible is paid off. Often the patient is not aware that this has been part of the agreement. Then they suddenly notice it in one way or another, and it’s too late to avoid accumulating a huge debt.

When someone suddenly notices they have a debt that they feel obligated to pay off, it is very discouraging. It can cause a person to give up on therapy and quietly disappear. The deductible issue has been around for a while, but it’s increasing along with the increase in the cost of health care in general.

I have a billing service that gets insurance information about each patient and lets me know the terms of their policy. That way, I might catch the problem early and inform my patients of their obligation, so they don’t build up a large debt. But not every therapist is able to help their patients in this manner.

Crisis worsening in many ways

Another way the mental health care crisis has gotten worse is if patients lose or change their health care coverage, especially with Medicaid policies. Medicaid policies are not uniform across the board. They are provided by many smaller insurance companies that have their own exclusive networks that a person has to apply for as a practitioner. It takes roughly a year to be accepted from the time of application.

If a patient needs care by a specific provider for specific needs in one area of health, they may have to change policies and give up other, longtime providers to get the doctor they urgently need. That might mean the end of other medical relationships with the patient. Under Medicaid, a patient can’t legally continue for any amount of money on a private basis. Increasingly, people are losing their Medicaid coverage or the Medicaid insurance companies shift business partners to other companies that do not cover the patient, which can effectively stop therapy for them.

The patients need to start fresh, with other caregivers, including psychotherapists, who are members of the new insurance company. This interferes with continuity of care.

As cuts keep happening to what health insurance companies will pay for and the cost of individual sessions on a private basis is increasingly out of reach, therapists and patients have to be alert to what insurance companies are doing. They are making their contracts unreadable and their fees unpayable, and therapists have to figure out how to help make it possible for people to pay for their sessions.

Ultimately, we have to get rid of for-profit health care and the capitalist system that fosters it.

Health care is a right! Free, quality health care for everyone!