Episode 375: State of Therapy: What Happens When Insurance Stops Being Access.

You joined the panel for a reason. Probably a good one. You did not want the only people who could see you to be the people who could write a check, so you credentialed, you took the contracted rate, you learned the portal, and you told yourself the reimbursement was the price of doing right by your community.

Then the reason started coming apart. Your clients' deductibles reset in January and they disappeared for four months. A client told you they dropped their plan because the premium doubled. Somebody you had been doing real work with moved to once a month, then to "let me check my budget," then to nothing. And the panel you joined to reach people is now reaching fewer of them than it did two years ago.

This episode is not an interview. It is us, Kelly and Miranda, sitting down to talk about the state of the profession as of July 2026, starting with health insurance, because it is the thing quietly shaping treatment plans in practices all over the country. We are not neutral here. We run a business that provides health insurance to a team, so we have been staring at the same renewal numbers you have. Twenty years in, we have watched a lot of things break in this field, and a lot of clinicians rebuild around them. This is our read on what is actually happening and what we think you can do about it.

The subsidies did not get cut. They got left to expire.

There is a version of this story going around where a single bill took people's health insurance away. That is not quite what happened, and the difference matters if you want to know who to talk to about it.

The enhanced premium tax credits that had been lowering marketplace premiums since 2021 ran through the end of 2025. Congress could have extended them. Congress did not. There was no dramatic repeal vote; there was a deadline that came and went while everyone was looking somewhere else. At the same time, state insurance commissioners were signing off on double-digit rate increases for 2026 in state after state.

So when we talk about who allowed this, the list is longer than "insurance companies." It includes your state insurance commissioner, who in most states you actually vote for. It includes every member of Congress who decided the current arrangement was working as intended. Many of whom, worth noting, have coverage that does not ask them to clear a five-figure deductible before anything gets paid.

The takeaway: Know the actual mechanism, because "they took it away" and "they let it lapse" point you toward completely different people and completely different ballots.

The 2.6 million number is real, and the explanation you get depends on who you ask

Federal data released in June 2026 showed marketplace enrollment fell from 21.8 million people in February 2025 to 19.2 million in February 2026, a drop of about 2.6 million people, or 12 percent, the steepest single-year decline since the marketplaces opened in 2014.

There are two stories about why. The administration's position is that when subsidies made some plans free, brokers were able to sign people up improperly, and CMS canceled 250,000 unauthorized enrollments and identified 200,000 unauthorized plan switches in 2025. Independent analysts point to something simpler: coverage got much more expensive when the enhanced subsidies ended, and people either dropped it or never paid the first premium. Both probably contributed, but the price increase appears to have done most of the work.

For our purposes, the argument almost does not matter. Whether a person is uninsured because of a fraud sweep or because their premium doubled, they are sitting in the same place: needing care, without a card to hand you. And health policy experts expect enrollment to keep falling. This is not a blip you can wait out.

The takeaway: If your accessibility strategy depends on your clients having marketplace coverage, your accessibility strategy is shrinking without you touching it.

Your clients' deductibles are writing their treatment plans

Here is the part that should bother us as clinicians more than it does.

Somebody presents with major depression. Or a re-traumatization of chronic PTSD. Or anxiety that has taken over their functioning. You know what the standard of care looks like: weekly, sometimes twice weekly for a stretch, at a length that actually lets you open something and close it back up. And then the financial reality walks in and quietly overrules all of it. They can afford once a month, so they come once a month. Their plan reimburses a shorter session, so they get a shorter session.

We have all seen how that goes. They cancel, they travel, they come back six weeks later, and you spend thirty-five of your fifty minutes catching up, ten minutes attempting an intervention, five minutes closing, and then you run over anyway because you are trying to give them something real. You start the next session late. Your notes do not get done. Nobody in that room is getting what they came for.

That is not a treatment plan. That is a budget wearing a treatment plan's clothes. And the more of these we accept as normal, the more we are handing clinical decision-making to entities that do not hold a license and cannot be held to a standard of care. As more of those approval decisions get handed to AI, that problem gets worse, not better.

The takeaway: Notice when the frequency and length of care are being set by a deductible instead of by you. You can decide differently, and being clear about what you actually recommend is not a luxury add-on.

The billing workarounds are a symptom, not a strategy

We want to name something that has been happening for a long time and does not get talked about on podcasts.

Therapists have been bending their billing to make the math work. Sometimes with full intent, often without much. Billing one fee while accepting another. Recording a payment that did not actually happen and quietly eating the difference. Seeing someone twice a month while billing four. You can find these conversations in therapist Facebook groups, framed as puzzled questions about how anybody could possibly be living on these reimbursement rates.

We understand exactly how people get there. It usually starts with wanting a specific human being to be able to keep coming. It rarely starts with greed. But it is still fraud, and it puts your license between an insurance company's audit department and your client's care, which is a terrible place for your license to be standing.

The reason to say it out loud is that it tells you something about the system, not just about the individual clinicians. When large numbers of ethical, careful people are independently inventing workarounds to deliver ordinary care, the workaround is not the problem. The arrangement that requires it is.

The takeaway: If your business model only functions when you shade the paperwork, you do not have a business model. You have an exposure.

Doctors are already building around this, and it is worth watching

Physicians have been dealing with this longer and further along than we have, and some of them are building genuinely different structures rather than just complaining louder.

Direct primary care is the obvious one. A patient pays a monthly membership, sees the physician when they actually need to, and gets labs and imaging at or near cost, which is frequently far below what the same scan costs when it runs through an insurer. If you have never done this, try it once: ask what a procedure costs in cash. A lot of the time it is less than what you would pay against your own deductible, because the insurance-routed price was inflated on the way through by everybody who touched it.

The more dramatic version is a surgeon building the facility. In Austin, Dr. Elisabeth Potter opened RedBud Surgery Center, an outpatient center focused on breast reconstruction, including DIEP flap procedures for patients after mastectomy. Kelly could not summon her name on the recording, which is the least important thing about the story; the important thing is that she looked at what the same procedure was priced at through a hospital, decided that number was indefensible, and built somewhere it could be done for a fraction of it.

Notice what is not happening in either example. Nobody is providing worse care more cheaply. They are removing the layers that were inflating the price and keeping the clinical standard where it belongs.

The takeaway: The goal is not a discount version of a broken model. The goal is a better care model that happens to cost less because fewer people are taking a cut.

Count who has their hands in the pie

Which brings us to the question we would ask any therapist looking at their numbers right now: who is getting paid out of your sessions, and do you feel good about them?

Every third party you insert between you and your client has to be paid from somewhere. Either the cost goes up for the client, or the cost goes up for the insurer, or your reimbursement goes down. There is no fourth option where a venture-backed platform inserts itself into your work and the money appears from nowhere. Something gives, and it is usually your rate.

We are not saying never pay anybody. We pay coaches. We pay an operations manager. We feel great about it, because we know how they show up and what our clients experience when they interact with them. That is the actual test. Do you know what the emails going out under your name say? Do you know who is calling your clients, and when, and whether you would endorse how it went?

Most of us were never taught business, and the pitch is genuinely appealing: hand off the hard parts, sit down, do therapy. We get the appeal. We also remember what it was like to work under an agency supervisor who did not understand clinical work, and how fast that made everything worse. Handing your practice to people who do not do this work is the same arrangement with better branding. Those platforms do not exist without our labor. Not one of them.

The takeaway: Before you cut costs anywhere else, count the hands in the pie and decide which ones you would defend out loud.

Dose is not a discount

The most useful reframe in this whole conversation is about frequency and length, and it costs your clients nothing extra.

Run the thought experiment. Two clients, similar presentations, twelve sessions each. One comes weekly for twelve weeks. The other comes once or twice a month and takes seven months to get through the same twelve. Same money. The second person actually invested more time, because they spent seven months of their life in the process instead of three. Who got better results?

This is not a new idea. Twenty years ago, good therapists said, "You are going to come every week, and here is what that looks like," and they said it without apology. The same logic runs the other direction on session length. If you are doing depth work, EMDR, Brainspotting, anything with a real opening and closing, and half your session is spent getting in and getting out, then extending the session doubles or triples the actual processing time for the same fee. We have clinicians tracking their own data who find that intensives and extended sessions get better outcomes, faster, with more satisfied clients and cleaner mutual terminations. Not a promise, and not for every clinician or every population. But worth measuring in your own practice rather than assuming.

Group therapy belongs in this conversation too, at a fee that can genuinely sit near what a copay used to be. And there is the model we do not have a good name for yet, where a client pays monthly and has a set number of sessions available whether or not they use them all. Kelly keeps calling it the daycare model, which nobody loves. Naming suggestions welcome.

The takeaway: Before you lower your fee, look at whether the shape of the care is doing what it should. Often the same money, delivered in a better structure, gets someone better faster.

Lesson 8: Therapists are already built for this

Here is the encouraging part, and we mean it.

We already know how to work with cash-pay clients. Every insurance-based practice we have ever met would happily take a private pay client tomorrow. Many of you are already learning to market to them. We do not have the layered upcharge problem the medical system has, where a service costs many times what it should because six entities touched it. Our overhead is a room and our training.

Meanwhile, demand is not softening. Searches for therapy keep climbing, and increasingly for specific therapy, for a particular population or presentation, from someone who actually understands it. People have gotten more sophisticated about their own care. They walk in with a hypothesis and a question, they advocate for themselves and their families, and they are looking for depth rather than something generic. That is good news for anyone willing to be genuinely good at a specific thing.

There are large medical practices that are structurally unprepared for a world where their patients are uninsured. We are not one of them. You are not one of them.

The takeaway: The need is not shrinking. It is getting more specific. That is a solvable problem, and it is solvable in your favor.

Read the full episode transcript

Kelly: (00:00) Welcome back to our podcast, Starting a Counseling Practice Success Stories. Today is not a success story. Today you're getting me and the amazing Miranda Palmer.

Miranda: (00:14) And me, not me, is Kelly Higdon, who is a fantastic friggin' human. And if you just suddenly found us, we've been together as business partners since twenty ten. So much has changed since then in our profession, and there's a lot of things that have stayed the same. Some good, some not so good.

But today we're going to talk about the state of the profession and what's happening in July of 2026. What are we navigating as therapists, as human beings, as practice owners, or potential practice owners? What are the things happening out there that we're keeping an eye on? And we thought today we'd talk about health insurance as a starting point, from a different perspective. Because as business owners, as people who provide health insurance, we're already planning what kind of benefits we're offering our team of private practice coaches and our operational team for 2027.

We're having the experience personally of looking at the way our benefits came back last year as subsidies were expiring for our employees, and how we keep seeing the premiums go up and the deductibles go up while the actual coverage goes down. What we've noticed is that while technically we have health insurance, realistically our insurance is mostly just an out. It's not really giving a lot back. We're paying premiums, and because we have high deductible plans, and because it's hard to get care, we end up not actually utilizing our insurance. We're finding that paying out of pocket to see a primary care doctor is cheaper than going through someone who takes our insurance.

Checkups are quote unquote covered, so you get one annual thing per year. But what does that mean if I'm getting one annual checkup and I've invested five figures in premiums for it? And the promise is that if I had a catastrophic event, and I only paid several thousand more, that event would be covered.

People are trying to figure out how to navigate this. Some people are leaving the country because they've realized they can get better care elsewhere, that they can get comprehensive or even basic or catastrophic care in other countries, and pay less for the medications they or their children need. Some people are banding together into other kinds of plans and programs, saying, wait, when insurance companies were first created they were nonprofit organizations to help people in the hospital for something unexpected and catastrophic, so people were not bankrupted.

And people have health insurance, and health insurance for health care is still bankrupting people. So something's not working in the system. And then, how does this all impact us in terms of mental health care? For those of you who have been accepting insurance specifically because you want to make your care accessible: what happens when the people you wanted to create accessibility for do not have health insurance, because health insurance isn't actually creating accessibility for them?

Kelly: (05:20) And that's what we've seen change with the new big, beautiful bill, and how it changes the subsidies. A lot of subsidies were lost.

Miranda: (05:33) For clarity's sake, it isn't that the bill did anything specific to the subsidies. It's that the subsidies went out after a certain period of time and it did not renew them.

Kelly: (05:50) Yeah, it did not renew them.

Miranda: (05:52) Regardless of the bill, Congress could have extended the subsidies and they did not. They said, actually, we don't need that. This is great. It's working as intended. We like the way that health insurance is in America, and we think these are perfectly appropriate rates. And at the same time the subsidies were expiring, insurance commissioners were giving the okay for insurance companies to increase their premiums by double digits, depending on what state you're in.

There are a lot of people who've been involved in allowing the cost to be what it is. It isn't just insurance companies. Your insurance commissioner, who might be appointed but is probably elected. Every single member of Congress. They all allowed this to happen and they're not really doing anything about it, while they all have insurance that doesn't have any deductible. They have access to great care, working a hundred days a year. Interesting. Huh?

Kelly: (07:06) And they're estimating 2.6 million people are no longer insured because these subsidies are now gone. The Department of Health and Human Services is saying it's because they cracked down on fraudulent accounts, but analysts are saying no, the subsidies are gone and people can no longer afford to have the health plan. So more and more people are not insured, and the very people that therapists want to serve by being on insurance panels are no longer on insurance panels. So then what do we do about access? I foresee that continuing unless something changes with the ACA or the way we do health care in this country.

And some physicians and doctor groups are speaking up. They're providing a different kind of service. In primary care, you can have a membership model where you pay a monthly fee and then you can go to the doctor when you need to. And then they offer things like the X-ray or the MRI at cost or lower, much lower than what it would be through your insurance company. I don't know if you've ever done this, but if you had a procedure or you needed some sort of scan or blood work, ask what it would cost if it was just cash. For me, sometimes it's less than if I billed through my insurance because of my deductible. Yes, I'm contributing to my deductible, but I'm probably never going to get down that deductible this year. The cost is so inflated when it's billed through insurance companies.

Ready to Build a Practice That Stays Standing When the System Does Not?

None of this works if you are running your practice on subsidy. Not the government kind; the kind where you personally absorb the gap between what care costs and what someone can pay, month after month, out of your own income and your own weekends.

We hear it constantly: "I cannot afford my own therapy right now." That sentence should stop us every time. It means a licensed clinician is providing care while being priced out of care. That is not sustainable and it is not noble; it is just a business that has been quietly set up to fail its owner. You cannot build accessibility on a foundation that is eating the person providing it.

What actually changes this is unglamorous. Knowing your real numbers. Setting fees that reflect the work. Getting clear about frequency and length and saying it out loud in the first session. Reading the contracts you are already in. Deciding which hands stay in the pie. None of it requires you to stop caring about access; most of it makes your access more durable, because a practice that pays you is a practice that is still open in three years.

That is the work in Business School for Therapists. It is a blend of live coaching and self-paced curriculum, plus a community of clinicians who normalize niching, real fees, and clinical depth. Twenty years in, it is the work we wish someone had handed us when we were spending our own weekends figuring this out.

If you want to start free, the training library at zynnyme.com/free has sessions on insurance contracts, platform contracts, and AI ethics in practice. Or come find the rest of the episodes at zynnyme.com/podcast. And tell us what you thought of this one. We genuinely want to know whether it landed as useful or just depressing.

Key Takeaways for Therapists

• The enhanced ACA subsidies expired at the end of 2025 rather than being repealed; Congress could have renewed them and did not.

• Marketplace enrollment dropped about 2.6 million people between February 2025 and February 2026, the steepest single-year decline since 2014, and experts expect further declines. OpenPROpenPR

• If you took insurance to be accessible, that strategy is reaching fewer people every year without you changing anything.

• Watch for the moment a deductible starts setting frequency and session length instead of clinical judgment.

• Billing workarounds are widespread and understandable and still put your license at risk. Treat them as a signal about your model, not a solution.

• Physicians are building membership and direct-pay models that lower cost by removing layers, not by lowering the standard of care.

• Every third party in the chain gets paid out of your session. Count them, and decide which ones you would defend.

• Weekly cadence, extended sessions, intensives, and groups can improve outcomes without asking clients for more money.

• Demand for specialized therapy keeps rising. Being genuinely good at a specific thing is the most durable position available.

Resources

Free training library: https://www.zynnyme.com/free

Platform Contracts Exposed: https://www.zynnyme.com/free/platforms

Ditching Insurance and Platforms: https://www.zynnyme.com/free/ditching-insurance

Private Practice Under Pressure: Ethics, AI, and the Fight to Keep Therapy Human: https://www.zynnyme.com/free/private-practice-under-pressure-ethics-ai-and-the-fight-to-keep-therapy-human

The AI Policy Every Therapist Needs, with Dr. Maelisa McCaffrey: https://www.zynnyme.com/free/the-ai-policy-every-therapist-needs

RedBud Surgery Center, Austin, Texas: https://redbudsurgerycenter.com/

Dr. Elisabeth Potter, MD: https://www.drpotter.com/

Are Third-Party Credentialing Platforms a Lifeline or a Trap? https://www.zynnyme.com/blog/are-third-party-credentialing-platforms-a-lifeline-or-a-trap-a-deeper-look-at-the-ethics-and-sustainability-of-alma-headway-and-grow-therapy

Alma, Headway, and the Big Question: https://www.zynnyme.com/blog/alma-headway-and-the-big-question

What to Ask a Recruiter Before Signing a Therapy Platform Contract: https://www.zynnyme.com/blog/what-to-ask-a-recruiter-before-signing-a-therapy-platform-contract

All episodes: https://www.zynnyme.com/podcast

Business School for Therapists: https://news.zynnyme.com/business-school/

About the Authors: Kelly Higdon and Miranda Palmer are the co-founders of ZynnyMe and creators of Business School for Therapists. Since 2010, they've helped tens of thousands of therapists build sustainable practices through organic digital marketing strategies that actually work—without wasting money on ads or time on tactics that don't convert. Because your practice deserves to be found by the people who need you most. Learn more here.