What single-payer health care would mean for California therapists

California flagThe Healthy California Act — California’s single-payer bill — continues to make progress through the state legislature. If signed into law, it would make California the first state to have a statewide single-payer health care system, even as the federal Affordable Care Act may be scaled back. How would single-payer health care impact therapists, counselors, and related mental health providers?

Here, I’ll do a quick review of what we know so far. It’s broken down into three questions providers rightly ask about the bill: How would it impact my client load? How would it impact my rates? And, How would it impact how I run my practice?

Client load

Single-payer health care would clearly increase access to mental health care by covering it for people who could not previously afford it. Costs are known to be a barrier to access to mental health care even among those who have insurance. So reducing the costs of mental health services to zero should increase use. But whether access leads to actual utilization is surprisingly difficult to predict.

Partly this is because cost is by no means the only barrier to people accessing mental health care. As I discussed in Saving Psychotherapy, many consumers do not believe they can find a therapist they will like or trust. (Quite often, that belief is based in experience.) Some do not have providers close to them who speak their language or understand their cultures. And while stigma sometimes gets more emphasis than it deserves — it typically ranks at the bottom of surveys of consumers asking why they didn’t seek help when they knew they needed it — among some populations it is a very real concern.

Adding to the complexity here, some therapists would choose to participate in the state system while others would not. So whether your particular client load increases or decreases would depend not just on you and your choice to participate. It would also depend on how many others make that choice.


The most anxiety I hear from therapists and counselors about single-payer health care comes from those who have thriving, high-rate private practices. These therapists typically do not accept insurance, though they may offer superbills to clients. They are understandably concerned that a system that covers all Californians would force them into a difficult choice: Either participate in the system (and accept a reimbursement rate that might be far lower than what they currently charge*), or refuse to participate (and potentially watch as their clients leave them for other providers they can see at no cost).

This is a tough issue to navigate, because there are several responses that are true-but-not-reassuring. Clients who can afford to pay high cash amounts for therapy now would still be able to afford it after the system takes effect. Most Californians already do have health insurance that covers mental health care — if you have a practice that thrives outside of that system, it will likely continue to. If you look to countries that have single-payer systems in place, there are often thriving private-pay systems that exist beyond the single-payer system.

If California’s bill goes through, one of the big issues that will determine its success is called network adequacy. In other words, are there enough providers for each health care service to meet the demand for that service? Network adequacy is a major reason why, as things are today, having insurance that covers mental health is very different from being able to actually access care.

That same issue — network adequacy — is why LMFTs and LPCCs, the two license types currently not reimbursible through Medicare, are almost certain to be included in Healthy California coverage. The system could easily fail without them.


Here is where we have the clearest picture of how therapy practices would likely change under the bill. For therapists who are not participating in the system, superbills would likely go away and clients would need to pay full rates. For those in-network with various companies, rather than working with multiple insurance companies and their various reimbursement patterns, you would simply work with a single state entity. Many private and group practices that currently employ staff members to do billing could greatly reduce the hours for those staff members, reducing the overall cost of running a practice.

Of course, the state would have some specific documentation requirements just as insurers do now. But those requirements would be consistent for every client. It is quite likely that the overall administrative burden of running a practice for insurance clients would decrease significantly.

At this point, there remain a great many unknowns for therapists curious about this bill. Since the practical realities of it are largely in the “to be determined” category, arguments in favor or against the bill are often framed in general terms. It would cover everyone (which might actually be a problem). It would save billions of dollars (or not). It’s the right thing to do (or not). NASW and AAMFT-CA have taken positions of support; the other mental health associations remain on the sidelines for now. They may take formal positions as more of the specifics of the bill are determined.

And of course, there’s no guarantee that Governor Brown would sign the bill even if it gets to his desk. He has been openly skeptical so far.

The bill has gotten through the state Senate. The state Assembly will hear the bill in the weeks ahead. If it survives committee and floor votes there, it goes to Governor Brown for his signature or veto.

* – Not only have reimbursement rates under the bill not been set yet, but even a formula for determining rates is not set. The determination of such a formula is left in the hands of the state agency that would be responsible for administering the system. So no one can say with certainty at this point what their rate under the system would be.