Latest / The Mental Health Evolution / Ep 41: The Coverage Gap Is a Policy Problem with Cara Cheevers

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Ep 41: The Coverage Gap Is a Policy Problem with Cara Cheevers · The Mental Health Evolution

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(Transcribed by TurboScribe. Go Unlimited to remove this message.) This podcast is part of the Frederick podcast
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network.
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Learn more at listenfrederick.com.
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Welcome to Mental Health Evolution, a podcast about
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what's changing in mental health and why it
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matters.
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I'm your host, Rachel Harrison, inviting you into
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honest conversations with people from all perspectives in
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the field, clinicians, tech founders, investors, insurance companies,
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and all the folks in between.
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Let's explore what's working, what's not, and what's
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next.
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Good morning, everyone.
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Welcome back to the Mental Health Evolution podcast,
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where we talk about how the landscape is
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rapidly evolving in the mental health industry.
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Today, we are joined by Kara Cheevers, Vice
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President of Coverage Policy at Inseparable.
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Inseparable is a national mental health advocacy organization
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on a mission to win better mental health
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care for everyone in this country.
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And they do that by research and data
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into real policy change at the state and
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federal level, championing lawmakers, closing coverage gaps, and
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building the kind of political will it takes
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to fix a system that has been falling
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short for a long time.
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Kara leads their coverage policy work focused on
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the structural and financial barriers that keep people
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from getting mental health care, including reimbursement disparities,
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provider shortages, and the ways insurance systems fail
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both patients and providers.
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And today, we're going to talk about what
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Inseparable does, what the data tells us about
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the mental health workforce crisis, and what clinicians
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can actually do about it.
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As always, before we talk to our guests,
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we're going to talk about a little bit
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of articles and give you some data about
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what's going on around this topic today.
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These may be helpful for listeners who want
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to learn more about this topic and dive
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deeper.
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And of course, we will have everything in
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the show notes if this is something that
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you want to take a deeper dive into.
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The first article is from the Health Resource
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Services Administration, and it's called The State of
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Behavioral Health Care Workforce.
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This is a 2025 article, and it gives
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us a national snapshot of where the behavioral
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health workforce stands right now.
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It finds that 40 percent of Americans, which
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is around 137 million people, live in a
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mental health professional shortage area, and it projects
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major shortfalls in counselors, social workers, and psychiatrists
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through the year 2038.
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Beyond the supply and demand numbers, it also
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highlights that low reimbursement, burnout, and limited scopes
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of practice are pushing providers out of the
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field or keeping them from taking insurance at
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all, which is definitely a theme that we
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have touched on in podcasts that we've recorded
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before.
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The second article from Pew Charitable Trusts is
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called State Policies Can Help Address the Mental
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Health Care Workforce Shortages, and this is from
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April 2026, a pretty recent article, and it
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looks at what states are actually doing to
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strengthen the mental health workforce.
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It highlights pipeline programs, streamlined licensing, and other
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state-level strategies that are helping recruit and
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retain behavioral health providers, with real examples from
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states that are starting to move the needle.
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It is a useful reminder that while federal
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policy gets most of the attention, states have
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meaningful tools available to them right now.
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And then lastly, this article is from the
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organization that CARA represents, Inseparable, the Workforce Report
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Bridging the Mental Health Care Gap, and this
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is from March 2026, so also very recent
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data, and this report that we will be
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discussing today assesses all 50 states and the
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District of Columbia on how well they are
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meeting their mental health workforce needs, and the
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findings are striking.
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Only four states meet more than half of
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their population's demand for mental health services, and
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nearly half of all states meet 25 percent
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or less.
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The report also found that in many states,
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therapists earn significantly less per session than comparable
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medical providers, which helps explain why so many
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providers are choosing not to accept insurance.
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It lays out three areas where state policy
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can make a real difference.
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Number one, building a workforce pipeline, number two,
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supporting the people already in the field, and
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number three, modernizing data and technology.
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Each of these pieces point to the same
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underlying problem, which is a system that asks
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mental health providers to do more with less,
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pays them less than their medical counterparts, and
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gives patients fewer in-network options than they
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have for other kinds of care.
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Cara Achievers has spent her career trying to
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change that, and today we're going to dig
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into how.
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So thank you, Cara, for being here for
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this conversation.
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Thank you so much for having me.
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I'd like to start with you and a
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little bit about how you got into this
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type of work.
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What inspired you to be an advocate here?
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That's a great question.
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I'm a social worker by training from West
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Michigan and got my bachelor's degree in social
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work and then eventually got my master's in
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social work as well.
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I'm not a clinician.
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I don't do micro-level social work, but
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I really enjoyed the classwork and the framework
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of the social work program and have used
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it to do systems level change my entire
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career.
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I've really focused on policymaking, systems reform, and
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grant making more broadly.
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And so with each kind of chapter of
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my career, it's brought me a little bit
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closer and closer to mental health system reform
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more broadly.
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With each step, you know, we look at
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this is a problem for this sub-population
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of people, and that also impacts everybody.
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And so I've just gotten a little bit
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closer and closer and closer to the root
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problem that is how our mental health system
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is not designed with people's and patients' best
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interests and needs at heart.
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I'm also a patient of the mental health
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system.
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I have my own mental health conditions.
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And despite the training, despite the privilege, and
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despite the access I have, I've in my
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life really struggled to get the care that
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I need when I need it.
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And my story is no different than others,
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you know, accruing significant financial harm and debt
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to get the mental health care that I
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needed because I didn't understand or wasn't able
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to find a therapist with my own insurance
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that I paid a lot of money for.
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My story is no different than any other
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persons in my community, probably on my same
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block in which I live.
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And so I've been really motivated to fix
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the system to make sure that others don't
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experience what I've experienced.
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And that way, we can really continue to
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mitigate the harm that is caused by our
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unfortunately dysfunctional mental health system.
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Yeah, I agree.
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And I mean, I know we have visited
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this issue too.
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It's difficult for providers to take insurance for
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a lot of reasons, reimbursement being one of
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them, barriers to getting sessions approved that they
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need being another, all kinds of things.
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And so understandably, going out and not taking
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insurance, and then that does put the burden
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then back on the clients and patients.
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And it's definitely something I've been in this
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field for 28 years.
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It's something I've seen since that whole time,
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right?
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It's not something that's changed or really evolved.
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It's sort of been the better the provider,
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the more likely it is they don't take
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insurance, unfortunately.
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You know, it's a really interesting point.
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And I've heard that kind of discussion point
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a lot where if it's a good provider,
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they don't take insurance.
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And that's something I've pushed back on for
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a long time, because there's so many incredible
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providers that do.
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And what I think about prior to joining
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Inseparable, I had the opportunity to serve at
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the Colorado Division of Insurance, where I led
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this Colorado's mental health parity enforcement work.
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And when I was at the division, my
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kind of euphemism or moniker that I would
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use when thinking about the enforcement work we
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were doing was to say, you know, I
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can't require a provider to take insurance.
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That's not my job.
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That's not my role.
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But what I can do is understand and
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solve for and fix the problems that disincentivize
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them or make it impossible to accept commercial
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insurance.
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And then from there, the market will do
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what it needs to do or providers can
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make their own decisions.
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However, we know, especially in the commercial insurance
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market, it is really hard to take commercial
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insurance, or it has been known to be
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really hard because of reasons like administrative burden,
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reimbursement rates being too low, submitting an application
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to join an insurance network, but then never
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hearing back from an insurance company or not
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hearing back for months and months and months.
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While you're still seeing a patient waitlist grow
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because there are people experiencing significant need, and
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then maybe you eventually hear back from the
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insurance company saying, yes, you can join, or
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maybe you don't hear back at all, or
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maybe you hear that the network is saturated
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and they don't need anyone.
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Well, you know that's not true.
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And so how do we solve for these
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inherent systemic problems and inaccuracies that ultimately harm
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a provider and their business and then a
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patient and their mental health?
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And so all of these things exist at
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once.
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And if we can solve for some of
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the system problems right now while also building
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a pipeline for the future, I think we
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can really ride the ship.
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I mean, I love that.
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I think there are a lot of providers
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that would prefer to take insurance because they
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do want to support as many people as
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possible to get services.
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So I would love to just dive into
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what are some of the big ways that
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we can do that?
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Like when you say that, I'm like, yes,
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okay, sign me up.
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This is what we need, right?
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So tell me what some of those specifics
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are.
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So I've got a few different ideas and
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I'll talk about it first on the, here
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are the providers we have currently versus, you
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know, let's talk about the provider pipeline we're
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cultivating for five, 10 years in the future.
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When I'm thinking about how we make our
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system work better today, there are some big
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P policy ideas, and then there's some little
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P policy ideas, not that one is more
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important than the other.
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They're just different levers that we have.
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When I think about the big P policy
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ideas, there's so many things we can do.
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We can require that states pay a minimum
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reimbursement rate percentage.
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We also have tools like mental health parity,
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which is the idea that physical health care
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and mental health care are treated comparably and
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are no more restrictive than the other for
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patients.
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That is one really great tool, and it's
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one great formula.
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There are, however, states that are just saying
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we have a significant access problem.
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And so we are saying in state statute
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through legislation, mental health providers cannot be paid
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less than this percent of Medicare per type
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of session.
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And that's the four.
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They can go up.
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Parity then still exists, but that is the
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minimum.
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They may not be paid less than this.
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Illinois has done this.
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Washington has done this.
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There are several other states looking at it.
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That automatically removes some of the opacity or
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confusion around how you negotiate a contract, how
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you ensure you're getting paid what you're worth,
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how you're also making sure that what you're
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paid for a session kind of backfills some
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of the administrative costs that you don't get
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paid for through a 53-minute session.
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Reimbursement rate mandates are a phenomenal tool to
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just black and white immediately fix an issue,
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specifically around reimbursement.
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A lot of states are also looking at
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the requirement that insurance companies and Medicaid programs
12:06
reimburse for pre-licensed candidates.
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So those are the individuals who graduated from
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their training program, whether it's a counseling program,
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social work, therapy, etc.
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You graduate from the program, you've done your
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internships, and you're getting your 3,000 roughly
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field hours to go towards your licensure.
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The reimbursement of those services are really scattershot,
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and it's really hard to tell if and
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when an insurance company or Medicaid entity will
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reimburse for those services, even though they are
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medically necessary services being provided to patients.
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It's also really hard to incentivize a supervisor
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to take on pre-licensed candidates if they're
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not getting paid for them.
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And so one of the things that we're
12:50
looking at in a number of states is
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to say that insurance companies absolutely must reimburse
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for pre-licensed candidates who are being supervised
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by an in-network provider.
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So therefore I, as a social worker with
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my own, you know, independent practice, would be
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much more willing to take on a few
13:10
supervisees who are getting their hours because I'm
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getting paid and then I can pay them.
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I'm also then able to mitigate the long
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wait list that I have for people seeking
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care with this type of insurance.
13:20
That's kind of a medium-term pipeline development
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piece that we're seeing a lot of states
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looking at.
13:25
We also, in terms of like little p
13:26
policy, we've seen a number of state insurance
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departments start to take complaints from providers.
13:32
So a lot of times the regulating entity
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for commercial insurance, they're called, it's usually the
13:38
division of insurance.
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One of the elements that we're really working
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on is making sure that people know that
13:43
their insurance, one, covers mental health care.
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Two, there aren't treatment limitations.
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You can't be denied.
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You can't say like, oh, I only have
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10 sessions a year.
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That's a violation of the federal law.
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That's not a thing.
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There are no treatment limitations on the number
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of visits, the length of a visit, things
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like that.
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But then when people really struggle to get
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mental health care, we want them to file
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a complaint with the division of insurance because
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they're paying a lot of money to get
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this coverage.
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And if they're not able to use it,
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that's a problem.
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A lot of times insurance departments don't love
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to get involved between providers and carriers because
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it can feel like a contract negotiation issue.
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And that is oftentimes not the case.
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And so when I was at the division
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of insurance, and a lot of other states
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have done this as well, we explicitly started
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taking complaints from mental health providers because there
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are very specific black and white requirements that
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insurance companies must do to comply with state
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and federal law.
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And when providers struggle with commercial insurance, they're
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less likely to take it, which means patients
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aren't going to be able to get the
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care that they need, or they're going to
14:47
have to pay more out of pocket to
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get it.
14:49
So we started taking provider complaints and immediately
14:52
just got hundreds of complaints.
14:54
And it was very easy to identify systemic
14:56
issues with certain insurance companies.
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So then we could also first triage those
15:00
issues with those providers while also doing an
15:04
audit of the insurance company more broadly to
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say, okay, this is impacting these people who
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knew to contact us.
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What else is happening that people aren't sharing
15:14
with us because they don't know, they can't,
15:16
etc.
15:17
So there's a lot of ways that states
15:19
in particular can either mandate policy, like reimbursement
15:23
rates, reimbursement rate processes, reducing administrative burden, things
15:27
like that.
15:28
But there's also a lot of just regulatory
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things or non-legislative, very unsexy things that
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they can and do do that make the
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system work better for providers specifically.
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Okay, that's an amazing list.
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I'm wondering, is there an example, you kind
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of, you highlighted Illinois as having some of
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these laws.
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Is there a specific example that can kind
15:52
of demonstrate for our listeners how this might
15:55
look, how this might roll out?
15:57
Yeah, a lot of states use legislation as
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the primary driver to implement insurance reform.
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That's one strategy, that's one lever.
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So Illinois is one that I referenced.
16:08
There was a bill last year that did
16:09
a lot of things, including requirement for reimbursement
16:13
for pre-licensed candidates.
16:14
Colorado did it as well.
16:16
Colorado also passed a law, it was championed
16:19
by several representatives and senators, that explicitly said
16:24
carriers or insurance companies must credential a mental
16:28
health provider within 60 days.
16:30
So no more multi-buff ghosting application.
16:34
It specifically says that a mental health provider's
16:38
application must be either approved or denied within
16:41
60 calendar days.
16:42
And there's all of these communication requirements in
16:45
that timeframe.
16:46
And if that insurance company doesn't respond either
16:49
way on that 60th day, they're automatically admitted
16:52
into network and that any claims submitted would
16:55
be considered in network.
16:57
That is something that many states have done,
16:59
many, many states.
17:01
Also looking at pre-licensed candidate reimbursement.
17:03
We're also looking at different tools around ghost
17:06
networks to make sure that insurance companies are
17:08
engaging with providers proactively in a documentable, traceable
17:13
way to say, hey, we want to make
17:15
sure that you're still interested in staying in
17:16
network.
17:17
How is this going for you, et cetera.
17:20
Ultimately, we want to make sure that patients
17:22
who are seeking care have the most reliable
17:24
and accurate lists of names and individuals to
17:28
providing care and accepting new patients as possible.
17:32
Colorado has done some great work.
17:33
New Mexico has done some amazing work.
17:35
New Mexico, a few years ago, at the
17:37
leadership of Senator Hickey, removed all cost sharing
17:40
for mental health visits for patients.
17:43
So providers are still going to get paid
17:44
what they're contractually obligated to get paid.
17:47
It just says that insurance company cannot charge
17:49
a copay or coinsurance for mental health care
17:52
for patients.
17:53
We know that cost is a huge barrier
17:54
to care.
17:55
And so there's a lot that states are
17:57
doing on affordability for patients more broadly.
17:59
I could speak for days about the very
18:02
cool things that states are doing legislatively and
18:04
regulatorily.
18:05
I think it is really important to note
18:07
that legislation is one really great tool.
18:10
We have some amazing lawmakers in states who
18:13
are running bills, passing bills, and doing incredible
18:16
work to make sure providers and patients alike
18:19
are treated well within the insurance space.
18:23
It is also really important to note that
18:25
that's one tool.
18:26
There are some incredible, incredible administrative staff, regulators,
18:31
Medicaid entities, governors, who are doing really great
18:35
insurance reform or access reform.
18:38
And it's not always sexy.
18:40
It doesn't always make a headline, but they
18:42
are an incredibly important part of the puzzle.
18:44
Yeah, definitely.
18:45
You mentioned as we started digging into this
18:48
that this is the piece for addressing providers
18:51
that are already doing the work, but there's
18:53
also some pipeline kind of things that your
18:56
organization is advocating for.
18:58
Can you talk a little bit about that?
19:01
Yeah, absolutely.
19:02
There are some amazing programs that states have
19:05
implemented to really build a pipeline for the
19:08
future.
19:09
One thing I'll say as a trained social
19:11
worker, and I'm not sure what your experience
19:13
was, Rachel, but I remember in my bachelor's
19:15
and master's level programs, learning from my teachers
19:19
in my classes, oh, don't bother taking commercial
19:22
insurance.
19:23
Don't bother taking insurance.
19:24
It's a nightmare.
19:25
It's a problem.
19:26
It's a nightmare.
19:27
Don't even bother.
19:27
Just do cash pay.
19:29
And I think that's a really important piece
19:31
that we should be thinking about as we're
19:33
building the future of our mental health workforce.
19:36
We need to be educating social workers who
19:39
are predominantly business owners.
19:41
We need to be teaching them how to
19:43
work with insurance companies, how to create a
19:46
business model that's sustainable, how to negotiate, how
19:49
to make sure that you're getting paid on
19:51
time.
19:52
These are things that are just as important
19:53
as providing high quality care to patients with
19:57
different types of needs, yet it's something that
19:59
I think our general curriculum is really lacking.
20:02
There's also a ton of different models that
20:04
states are doing.
20:06
Several states have created workforce development centers.
20:10
There's one program called the Balmer Institute.
20:13
It's based out of Nevada and Oregon, and
20:15
it's a four-year associate degree that allows
20:18
individuals to immediately start providing care to patients
20:22
without having to do those 3,000 hours
20:24
of field work and do all of this
20:26
other stuff towards licensure in addition to a
20:29
graduate program.
20:30
We've also seen a lot of success with
20:32
different states doing loan repayment programs.
20:35
Unfortunately, a lot of those things are expensive,
20:36
and when states are struggling as they are
20:38
right now, given the different constraints that we
20:42
have, it makes some of those interventions feel
20:46
a little bit like a pipeline or a
20:47
pipe dream, but it is something that is
20:49
absolutely doable, and we know the benefit and
20:52
the cost are well worth it, and we
20:54
know that when we invest in mental health
20:56
care and mental health providers, we are healthier
20:59
overall because of it.
21:01
Yeah, I have definitely seen, and I actually
21:05
taught a course on the business of private
21:07
practice in a graduate program, but it is
21:10
interesting the perspectives.
21:12
I would say the most common perspective that
21:14
I have experienced students coming in with is
21:17
like getting to the point of not having
21:20
to take insurance is sort of considered like
21:23
this achievement in the field, right?
21:27
And I understand it usually is very financially
21:30
motivated as well as kind of a status
21:32
maybe symbol, so I think there's some work
21:35
to do in the culture around that, around
21:38
how can we earn a livable wage?
21:42
You mentioned parity and some other ways to
21:44
do that, and so that the goal of
21:48
not taking insurance is not what many up
21:51
-and-coming clinicians are looking for, but I
21:55
have definitely seen that as a pattern that
21:57
has, yeah, surprised me that there is this
21:59
like, oh, you don't take insurance?
22:01
Wow, tell me how to do that.
22:03
It's more like that there is that like,
22:05
woo, we want to be there, and I
22:07
think, unfortunately, clients tend to suffer in that
22:10
system, and I also want to say I
22:13
understand the reasons that providers get there, because
22:16
I've done it both ways myself.
22:18
Yeah, absolutely.
22:20
I mean, the administrative burden alone, let alone
22:23
the amount that you're reimbursed or the amount
22:25
that you're paid, I think all of the
22:27
things that go into having a practice that
22:28
are not reimbursed, case management, housing supports, paperwork,
22:33
filling up, following up by claims that are
22:36
not tied, being an accountant, all of these
22:38
things that are not built in to that
22:43
45, 53 plus session that you're reimbursed for,
22:46
which at times can be criminally low.
22:49
So I get it.
22:50
I, you know, that's, there's a lot that
22:52
I empathize with, and you could just take
22:54
private pay and work with folks that can
22:56
pay out of pocket.
22:57
It would make life a lot easier.
22:59
In the meantime, though, that is the reality.
23:01
That is not the reality of most people,
23:04
and so how do we make sure that
23:05
we're working within the system that we have
23:07
to support people where they are and for
23:10
the needs that they have?
23:11
Yeah, I love that.
23:13
We are just about at the end of
23:15
our time, but I would love for you
23:18
to maybe give an action step or two
23:21
that people can take, whether it's a client
23:24
or whether it's a clinician, to sort of
23:27
help support, help advocate, or move the needle
23:31
on these things.
23:32
What would be your suggestions?
23:34
That's a great question.
23:35
I think there's a few things that can
23:37
be done really easily that don't take up
23:39
a ton of bandwidth.
23:40
I think from a patient's perspective, if a
23:43
patient is struggling to find a provider in
23:45
their network with their insurance company, they can
23:48
file a complaint with their state division of
23:51
insurance.
23:52
So if I live in Colorado, I'm going
23:54
to contact the Colorado division of insurance to
23:57
say, hey, I can't find a therapist that
24:00
can meet my needs that is available to
24:02
see me within seven calendar days.
24:05
And each state has their own timely access
24:08
standards, seven to ten days roughly.
24:11
And so you as a patient have the
24:13
right to be seen within that time frame,
24:16
and your insurance company must comply with that.
24:18
And so if you can't find anyone, you
24:19
should be able to go out of network.
24:21
However, a small policy thing that you can
24:23
do to advocate for yourself and also to
24:26
improve the system is to file a complaint
24:28
and say, hey, I can't find somebody.
24:30
That actually is a huge, huge win.
24:33
Your insurance covers mental health care, and if
24:35
you're not able to get it, the entity
24:37
that enforces your rights needs to know about
24:40
it.
24:41
The same goes for providers.
24:43
If you're not getting paid on time, if
24:45
you're getting hit with post-payment audits or
24:49
clawbacks, or you're reimbursed, you're not allowed to
24:53
reimburse, or excuse me, you're not allowed to
24:55
renegotiate your contract for a different rate, these
24:58
are all things that a provider can and
25:01
should file a complaint with their local division
25:04
of insurance about.
25:05
And if they're not able to file a
25:06
formal complaint, then even just writing to the
25:09
local insurance commissioner and say, hey, I'm not
25:11
getting paid within the amount of time I'm
25:13
required to get paid.
25:14
Help me keep my business open, and help
25:16
me keep seeing patients to make sure I'm
25:18
paid on time.
25:19
That takes very few minutes and will be
25:22
so incredibly helpful for advocates and policymakers in
25:27
general to have that data.
25:29
Amazing.
25:30
I love that simple step, and I do
25:32
think that it is one that certainly patients
25:35
and definitely clinicians don't think about very often.
25:39
So I appreciate that tip.
25:41
I really appreciate Inseparable and the work that
25:44
you are doing, Cara, there.
25:46
So thank you for being here.
25:48
Thank you for talking to us.
25:50
Listeners, I want you to know that we
25:52
will have all of the information in the
25:54
show notes if there's anything from this podcast
25:56
that you want to follow up on.
25:58
And Cara, thank you so much for being
26:00
here.
26:01
Thank you for having me.
26:02
It's a pleasure.
26:03
And we will see you next week to
26:05
talk more about all the things that are
26:07
changing in the mental health landscape.
26:10
Thanks, everyone.
26:11
Bye for now.
26:12
Thanks for listening to the Mental Health Evolution
26:15
podcast.
26:16
Join the conversation.
26:17
Find us on socials, send us your thoughts
26:20
and tell us what you're seeing in your
26:22
corner of the mental health world.
26:23
Until next time, stay curious and keep evolving.