In the past week, I have had three clients tell me that they have received letters from their insurance companies stating that their premiums will increase in the new year due to the changes to the Affordable Care Act (ACA). According to the Johns Hopkins Bloomberg School of Public Health, if ACA premium tax credits expire at the end of the year, which seems more likely as the government shutdown continues, “premiums are predicted to increase for 2026 by an average of 75 percent.” For one client whose policy covers her and her spouse, this will mean an increase from $1,600 a month to $3,400 a month, more than some monthly mortgage payments. I do not doubt that I will be hearing this type of update from more clients as we reach the end of the year. There is an undeniable financial impact, but beyond that, a significant and possibly devastating psychological effect as well. For some of my clients, this will mean their ability to access therapy will be threatened in a month and a half.

I practice in a relatively affluent area of New Jersey where, perhaps, some therapy clients would be able to pay out of pocket, however I choose to accept insurance for a simple reason—it not only creates access to mental health services, but also that most working Americans (despite their socioeconomic status) would prefer to use the health benefits that they pay into, either through their paychecks or through the ACA marketplace. When access becomes a barrier, general mental health is bound to suffer as a result. The client I mentioned above expressed a fear that, due to the potential increase in her premium, she will not be able to continue to afford weekly therapy. The next layer of this is that it puts me, the therapist, in a bind of my own: my ethical responsibility is to the continuity of treatment, but how can I provide this continuity when I cannot ensure payment, and I am running a small business? The layers of impact go well beyond the obvious; this affects not only clients but also mental health providers.

The potential effects of ACA cuts extend beyond the clients who have traditional HMO or PPO insurance plans; those who rely on Medicaid are particularly at risk. Medicaid has been a healthcare lifeline for many individuals in underserved areas or who suffer from a disability, and reducing its reach and coverage means putting many people at risk of losing access to vital services. For mental health, this can mean reduced access to behavioral health programs, intensive outpatient programs, substance abuse recovery programs, and countless other mental health supports and services. The repercussions of this can be devastating to the psychological health of many people.

Beyond the anecdotal reporting of my own clients, however, there are statistics and medical professionals’ experiences to support the point that cuts to the ACA will have a direct effects on mental health and access to mental health services: according to one analysis by FamiliesUSA, Medicaid cuts could put 380 rural hospitals at risk of shutting down—these hospitals are often the only option for mental health or behavioral healthcare in rural areas. Health professionals note that many patients without access to care arrive at the ER in crisis, often with untreated mental health issues and long waits for placement. Funding cuts will only worsen these problems. According to the Milbank Memorial Fund, a New York nonprofit that works to improve healthcare outcomes and advocate to policymakers that Medicaid coverage loss will “decrease access to mental health and substance treatment among US adults and children; reduce Medicaid mental health and substance use benefits for those who remain covered; and worsen behavioral health workforce shortages.”

We face an unprecedented mental health access crisis at this moment in our country’s history. The services that many people rely on have never been so immediately and profoundly threatened. The psychological effect of these cuts and changes to longstanding programs may be long-lasting and irreversible. Until now, it was straightforward in my practice: conduct the session with the client, collect the copayment, file the insurance claim, and await payment from the insurance company. Now, with the significant changes outlined, what was straightforward becomes complicated for both the client and the therapist. What happens when the client cannot afford to carry health insurance and, by extension, is forced to pay out-of-pocket? Suddenly, what was once a reliable weekly therapy session now becomes dependent upon affordability, budgeting, and prioritization with other expenses. And what happens when the therapist is torn between an ethical responsibility toward continuity of care and a financial question of how to keep their practice afloat?