Blog

KFF Health News published an article about the shortage of mental health providers in the state, noting that "California was short roughly a third of the 8,100 psychiatrists and 117,000 licensed therapists it needed." The article also reported that "While the state has opened more slots for training in recent years, it can cost as much as $250,000 a year and requires 12 years of postsecondary education."

Being short one-third of the needed staff seems like a very difficult challenge. Unfortunately, even if the state had money to throw at the problem, the training pipeline would make it difficult for the training programs to address the shortfall in the near-term. On top of that, the article reports that there is some question as to whether the federal government might reduce the $1.9 billion of Medicaid funds to "train, recruit, and retain behavioral health workers, enticing them with scholarships and loan repayments, and helping schools fund new residencies and fellowships." If some other states had excess mental health providers, California might be able to attract them with higher wages or allow more remote visits. Realistically, however, the shortfall has taken years to develop and will likely require years to resolve.

Public policy can be difficult to get right, and incentives can have unintended consequences. KFF Health News published a piece describing the challenges that a "benefit cliff" caused. Medicaid provides health insurance for low-income individuals. Understandably, there is an income threshold, above which individuals are no longer eligible. In practice, however, this means that individuals who are earning just under the threshold could perversely end up worse off if they receive enough income to exceed the eligibility threshold, but not enough to cover insurance premiums. The person profiled in the article decided to under-report his income, noting "I don't want to be a fraud. I don't want to die ... Those shouldn't be the only two options."

A better way of handling income eligibility would be to price the Medicaid insurance premium, and then cover it completely for individuals whose income is below a certain threshold. Then, as people's incomes rise, the subsidy is decreased, but the individual is always better off when making a higher income. At some income level, the subsidy would disappear entirely.

Insurance premiums have been rising for decades now, but the rise for next year is expected to be higher than usual. KFF Health News reports that "insurers nationally are seeking a median rate increase ... of 15% ... That's up sharply from the last few years. For the 2025 plan year, for example, KFF found that the median proposed increase was 7%." Exacerbating the situation is that federal subsidies for premiums are slated to expire at the end of this year. While Congress might extend the subsidies, if they do not, "policy experts estimate, the average amount people pay for coverage could rise by an average of more than 75%."

One complicating factor seems to be that at least some insurers are "tacking on extra percentage point increases in their 2026 rate proposals to cover effects of policy changes." The logic appears to be that if premiums are too expensive, then the healthy are more likely to drop coverage, leaving those who need more medical care. To compensate, insurers might need to raise premiums even more the subsequent year, perhaps leading to more healthy people dropping out of the insurance pool. If this cycle repeats, it can lead to what is known as an "insurance death spiral."

Some time ago, Congress passed legislation to protect patients from surprise billing. As KFF Health News points out, though, such protection mostly extends to out-of-network patients (including uninsured and self-pay). Apparently, the legislation also included wording regarding in-network patients, requiring "what amounted to a good-faith estimate of out-of-pocket costs for patients with insurance, but that provision has not been implemented, since, nearly five years later, the government still has not issued rules about exactly what form it should take."

Oddly enough, out-of-network (including uninsured) patients appear to have more rights under the No Surprises Act than insured patients. Patients with insurance can request an estimate, but providers appear to not be bound by those estimates. When patients are shocked by some charges (the article cited an example of a provider charging $2,700 for a nasal swab), it seems that providers can simply say "Healthcare billing is complex and includes various factors and data points, so actual charges for care provided may differ from initial estimates. We understand the frustration these discrepancies can cause."

Behind the sad personal story that KFF Health News opened their piece with, there is an interesting policy question of who should pay for ambulance rides, and what limits should apply. As background, the No Surprises Act "says that for most emergency services, patients can be billed for out-of-network care only for the same amount they would have been billed if it were in-network." However, it appears that ground ambulances were not included in the emergency services covered by the law. As a result, calling for an ambulance ride could trigger an expensive out-of-network bill. Patients do not choose which ambulance service provider is dispatched, and even if patients could select the service, such a choice does not seem practical in light of an emergency.

It seems that 20 states have legislated patient protection against surprise out-of-network bills for ambulance services, but the other states have not. One concern is that "forcing insurers to pay more would lead to higher health coverage costs for everyone." It is probably the case that such policy of requiring insurers to cover ambulance rides would not lead to an immediate and massive jump in premiums, but there remains the policy question of whether the change might cause people to become too cavalier with expensive rides. Still, patients delaying emergency room treatments out of a fear of financial costs may cost the system even more.