What the Biden Mental Health Plan Means for Private Practitioners

In his State of the Union address on March 1, 2022, President Biden took note of the mental health crisis in the US and announced an ambitious plan to address it. The White House followed up with a fact sheet providing more details. Considering its broad scope, how might the Biden mental health plan impact private practice therapists?

It’s worth noting that the president can’t simply execute all parts of this plan on his own. Some elements of it can be implemented through executive order, while others will require Congress to pass new laws. So in this review, we’re looking at the plan as the White House has presented it—while understanding that there are likely to be revisions along the way. 

How the Biden Mental Health Plan Could Impact Private Practice

Here are some of the areas where mental health professionals in private practice could see impact from the Biden administration’s mental health strategy, if it were to be adopted as described in the White House fact sheet.

Expanded access to care

One action the Trump administration took early in the pandemic was to allow Medicare providers to provide mental health services across state lines. The Biden administration appears interested in making this allowance permanent, though of course it would only apply to clients receiving services through Medicare. Since master’s-level counselors and family therapists are not currently included in Medicare (and the president’s plan makes no mention of ongoing efforts to add them), those professionals would not benefit from this change.

The new Biden mental health plan mentions additional efforts to expand access to care through telehealth, though the current proposal is to simply gather stakeholders and figure out how to best do this. There are a number of possible outcomes, and changes could take years to develop.

Another way the Biden plan seeks to improve access to care is by making it more affordable, eliminating copays for three visits with a mental health professional each year for every person with health coverage. While the impact here may not be major, it could result in somewhat increased demand for mental health services among those with insurance that covers mental health care.

Parity enforcement

Federal parity law (or laws requiring insurers to cover mental health and substance abuse care on a similar level as physical health care, without imposing different deductibles or coverage standards) has been on the books for decades. But as NPR has noted, the federal government does little in the way of parity enforcement, leaving this up to the states instead. 

The result of lackluster enforcement has been that we’re moving further away from parity, rather than closer to it. One way to think about parity is to consider how much care is provided in out-of-network settings. In theory, if the barriers to care are no greater for mental health care than they are for physical health care, then the percentage of services provided out-of-network should be similar between the two. 

According to an analysis commissioned by the Mental Health Treatment and Research Institute, from 2013 to 2017 the disparity between out-of-network utilization for behavioral health and out-of-network utilization for medical care increased by 85 percent. In other words, the disparity (quite literally, lack of parity) between medical and mental health care nearly doubled. As of 2017, Americans were more than 5 times more likely to go out of network for behavioral healthcare than they were for medical care.

The Biden mental health plan promises to “expand and strengthen” parity at the federal level, using budget mechanisms. But there is little detail beyond this, other than the requirement for insurers to provide three sessions without copays each year as noted above, and the following potentially-important piece on network adequacy. 

Network adequacy

Potentially, the four most important words in the White House fact sheet are “adequate network of providers.” Here are those words as they appear in context:

“The President’s fiscal year 2023 (FY23) budget will propose that all health plans cover robust behavioral health services with an adequate network of providers, including three behavioral health visits each year without cost-sharing.”

That “adequate network” phrasing may not appear to mean much if you’re not familiar with policymaking around insurance coverage, but it could be a big deal. Inadequate provider networks are often a reason why individuals who have coverage for mental health care can’t actually access that coverage, and wind up resorting to fee-for-service providers or going without care entirely.

If the Biden administration is serious about enforcing meaningful network-adequacy requirements for insurers (a very big “if”), insurers could be forced to recruit more therapists to join their panels. And to do that, they’ll need to pay better. Despite the protestations of the insurance industry, parity is very much about pay, and it’s network adequacy that connects the two. If you don’t have enough mental health providers in your network to make mental health care accessible to those you insure, then you’re not providing true parity in your coverage.

Improved insurance reimbursement rates for providers could be the biggest impact that private-practice therapists experience from this plan. But “could” is the key word. We’ll have to wait and see what the inclusion of “adequate network of providers” turns out to mean in substantive, policy terms. A meaningful network adequacy requirement, paired with more robust federal enforcement of parity requirements, could be a game-changer.

Areas with minimal impact on private practice

To be clear, there’s a lot in the plan, and it’s worth reviewing the full fact sheet to get a deeper understanding of all the different parts. There are some components of the plan that wouldn’t likely have have a significant impact on private practice clinicians, like: 

• Expanded scholarship and loan forgiveness programs
• The creation of a national “988” suicide prevention hotline (which was already in the works) and additional funding for local crisis response centers
• Doubling the number of school-based mental health professionals

What is Not Included in the Biden Mental Health Plan

Biden’s new plan addresses a number of concerns raised by both the public and by mental health professional groups. At the same time, it appears to leave out some specific concerns that could be addressed at the federal level. Some issues not addressed in the proposal include:

Changes to the No Surprises Act

Private-practice mental health professionals have reeled at the No Surprises Act and its requirement to provide detailed Good Faith Estimates to any clients not using insurance to pay for treatment. Several professional groups have been working together to press for changes that would make this less burdensome for practitioners, who typically were already subject to strict legal and ethical rules for fee transparency. The proposal makes no mention of the No Surprises Act or the headaches that GFEs have caused.

Changes in requirements to work for federal agencies

Possibly the easiest and fastest way to increase the number of people in the mental health workforce would be to make it less burdensome to become a therapist. That is, to reduce education and supervised-experience requirements that wind up pushing many talented professionals out of the mental health workforce early in their careers. While these requirements are largely set at the state level, the federal government sets standards for employment within federal systems, and could act fairly quickly to reduce requirements for therapists wanting to serve military and Medicare populations, just as two major examples. Reducing job qualifications, however, does not appear to be on the table at this time.

Loan forgiveness for private practitioners

Private practice clinicians typically are not eligible for federally-funded loan forgiveness programs like the Public Service Loan Forgiveness program. This creates something of a chicken-and-egg problem for policymakers, who would like to attract more mental health workers to community mental health settings. Some clinicians who work in private practice do so out of financial necessity, and that necessity is often tied to their educational debt. It makes sense from a policy perspective that the government wouldn’t want to provide loan reimbursement to those who don’t need it and aren’t working for public benefit, but it’s also fair to say that more clinicians would likely work for public benefit if they could afford to do so. 

What Happens Next

Much of the plan is supposed to be included in the White House’s fiscal year 2023 budget proposal. The president’s proposed budget is just step one of the federal budget process, so it’s best to consider the White House budget proposal as something of a statement of the White House’s priorities rather than concrete spending numbers. There’s an extensive back-and-forth that occurs before the federal budget is finalized.

Some components, like bringing together stakeholders from various federal departments to consider ways of improving access to mental health care via telehealth, can be done via executive order and don’t need congressional approval. But many of the substantive policy changes included in the White House plan do require legislation. 

While the plan largely avoids being explicit about calling on Congress to act where the White House can’t, you can start to see those differences when you assess keywords. The things that the President can do alone are things that “will” happen. The things that require Congressional approval are things that the president “believes” should be in place, such as stronger online privacy protections for children. 

So, the elements of this plan will move forward in several different parts. It’s likely that where congressional approval is required, some of the pieces that the White House would like to see are going to be significantly changed, or removed entirely. Still, it’s remarkable that mental health care appeared in the State of the Union Address at all, and that the President’s plan is such a high-profile proposal. It speaks to the sense that this is an area where government action is desperately needed, and where bipartisan action is possible to improve the state of mental health care overall.