Ask anyone who’s gone through mental/behavioral health treatment and they’ll tell you that building a therapeutic relationship with a provider takes time, trust and a good fit.
Seeking mental health care is already a tough ask. First, choose a provider you feel comfortable talking to, and can be open and honest with about your deepest thoughts, emotions, as well as your history and traumas. Then, verify they accept your insurance and ensure they are accepting new clients.
Let’s say you got through all that. Guess what? In a Medicaid system caught between rising need and shrinking federal funds, you may now have to embark on the process all over again, because Oregon Health Plan is dramatically scaling back the number and type of therapists it will cover.
Since 2016, OHP, Oregon’s Medicaid program, has covered trained but unlicensed mental health professionals — “associates” who are approved by regulatory boards but still working toward the three years of supervised clinical hours required for full licensure. In early 2025, the Oregon Health Authority announced a decision, supported by Gov. Tina Kotek, prohibiting newly graduated therapists from operating independently, in private practice, while serving low-income people on publicly funded health insurance.
Now, many low-income individuals and families will have to jump through hoops to rebuild the mental health support systems they’ve worked years to create.
During the height of the COVID-19 pandemic, OHP relaxed restrictions that made mental health care accessible and equitable to many for the first time. Medicaid insurers and health plans responded to the exponentially rising need for mental health services by relaxing rules that made it harder to access care. They temporarily covered out-of-network mental health specialists and allowed them to bill OHP for their services. The requirement for in-person visits was temporarily waived, and virtual (telehealth) visits became the norm. Even outside of the pandemic, that benefitted countless rural Oregonians.
The brief window of increased access brought relief to many Oregonians and Portlanders who finally found flexible, culturally competent, affordable mental health care, including therapy, psychiatric and substance abuse treatment.
But as the pandemic faded, so did that flexibility, even though the widespread need that created it remains high.
In December, one of the main providers for OHP, CareOregon, notified therapists and social workers that it would stop reimbursements for services provided by unlicensed mental health professionals. The change only applies to OHP members. Associate providers are still allowed to care for private pay clients in any setting.
Kalpana Krishnamurthy, a professional counselor associate, read the policy change announcement on a Saturday with a sinking feeling.
“I remember thinking, ‘This is the Saturday that my business died. What am I going to tell my clients?’” Krishnamurthy said.
“As a South Asian clinician, I was really excited to have built a case load of mostly BIPOC OHP clients because I know how hard it is to find a therapist of color in Oregon.”
These decisions sparked widespread backlash from advocates who say the changes will harm vulnerable patients in the middle of a statewide behavioral health crisis.
Decisions, decisions
In early December 2024, Krishnamurthy and a few other counselor associates began organizing. They posted on various Facebook groups therapists use to share information about working with OHP. The mental health associates eventually started talking via email, phone calls and meetings to understand the changes, where they were coming from and how to improve the situation. Their group turned into Oregon Therapists for Equity and started talking with legislators and COPACT, the policy arm of the Oregon Counseling Association.
During the 2025 legislative session, the group worked closely with Rep. Ed Diehl (R-East Salem) and Sen. Lisa Reynolds (D-West Portland) but was unable to move a piece of legislation.
“Oregon still ranks nearly dead last for mental health in the country.”
— Kalpana Krishnamurthy, professional counselor associate
The policy change was a top-down decision. But according to OHA, it was intended to increase the quality of care and concentrate providers on the highest-acuity cases, in order to address a severe clinician shortage.
Krishnamurthy said that argument “felt like a distraction.”
“If we want to talk about workforce issues in community health settings, there are literally about five different study groups in the past five years that have been created to look at the issues,” Krishnamurthy said. “It consistently comes back to workplace conditions for clinicians (too many clients on their caseloads, too many of whom are very high acuity), poor supervision, low pay and hostile work environments.”
Cutting costs is a more likely motivator, according to Krishnamurthy.
“We know that behavioral health costs have skyrocketed during the pandemic,” Krishnamurthy said. “We were also experiencing an unprecedented mental health crisis during the pandemic, and with fewer barriers to care, more OHP clients were taking advantage of their mental health benefits.”
But those reasons were not the ones health care leaders cited for making the change.
“Meanwhile,” Krishnamurthy added, “Oregon still ranks nearly dead last for mental health in the country.”
The change took effect in July, potentially impacting as many as 15,000 OHP members — 3% of the insurers’ total members. Among the number of Oregonians insured by OHP who use behavioral health services, 15% must now find treatment from a smaller pool of increasingly in-demand therapists. Additionally, in August, CareOregon gave 60 days notice that it will no longer cover “routine mental health and addiction treatment from out-of-network providers” effective Oct. 1. (The insurer has also reportedly closed off the ability for new mental health providers to become contracted or start new agreements.) That means a lot more people will have to find a new in-network therapist.
Oregon Therapists for Equity conducted its own survey work — prompted by a lack of data from state leaders.
“No one at CareOregon or OHA could tell us how many clients would be impacted,” Krishnamurthy said. “In fact, throughout the organizing, we received very little data from CareOregon or OHA about how many clients would be affected, or data to back up their claims that associates providing care to OHP clients had poorer outcomes than fully licensed folks. We repeatedly asked for this data and were told that it was ‘anecdotal’ or ‘qualitative.’”
Oregon Therapists for Equity surveyed 129 respondents (all associate mental health providers), who reported that 1,252 CareOregon members will lose access to their therapist. That’s an average of 10 clients per associate provider who will lose their care. Of these CareOregon members, 945 are identified by their therapist as having marginalized identities such as BIPOC, LGBTQ+, disabled, etc.
Krishnamurthy moved to a group practice, where she was able to retain most of her client base. But she said she knows of several associates who had to close their private practices, or moved to only accepting cash-paying clients.
Human impact
Already at risk of inserting myself into every Street Roots story I author, I write this as someone currently insured under OHP. Since I had my first child in 2022, I was exceedingly grateful for the full coverage I received under OHP, especially since I struggled in early motherhood to manage my thoughts, emotions and behaviors under the added stress and strain.
I decided I was ready to once again try therapy, and take advantage of being able to afford it for the first time in my life. I intentionally searched to find a therapist who was in alignment with my goals and needs in my postpartum period, and in this new life stage. And because mental health services are completely covered under OHP, I was stoked to be able to attend therapy sessions on a weekly basis, allowing progress to happen more rapidly than when I tried therapy in the past.
I had already given up on the lofty idea of finding a Portland-based therapist who reflected my own background as a Black and/or bi-racial woman and was also accepting new clients — having already tried many times and failed. Years earlier, I worked with a Black, mixed-race woman about a decade my senior, and it was somewhat helpful. But because of the $75 copay under my employer-covered insurance, I couldn’t afford to attend therapy sessions with any real regularity, and basically only scheduled an appointment when I felt it was absolutely necessary. Unsurprisingly, progress was slow and unnoticeable.
In October 2023, I was a new mother, and covered under OHP. After skimming and scrolling through dozens of potential providers on Psychology Today, I sent an email with the subject “Seeking Culturally Sensitive Therapy” to a counselor associate named Emily, a woman of color around my age. We started with an Adverse Childhood Experiences assessment, and began a treatment plan that included weekly sessions. At the time, OHP was the only insurance my provider accepted. We developed a comfortable rapport that became a consistent and safe place to land, where I could sit across from her in person or virtually to process my emotions and thoughts every week. I began to learn more about myself, excavated my history for patterns, and learned to get curious about longheld behaviors that no longer serve me. I continued seeing her every week for a year.
During one session, I rambled about my various struggles with focus, work, procrastination, forgetfulness, time management, self-sabotage and sleep that had all been drastically exacerbated by the added load motherhood put on my plate.
“All this makes a lot of sense with your history,” my therapist said.
“Does it?” I thought. Then, Emily said something that made my entire life make sense.
“Jenni,” she said, “I actually think you might have ADHD. But you’ll need to be evaluated by a psychiatric provider to know for sure.”
Mindblown, I was filled with gratitude that I finally had a diagnosis, a name and a reason for my decades of struggles around adulting — I always thought it was a personality flaw, that I was just lazy, and lacked willpower. I sought the services of a psychiatric nurse practitioner, a Black lady who also had ADHD, and who indeed diagnosed me with attention-deficit/hyperactivity disorder after a thorough evaluation. Soon after, I found out I was pregnant with my second child and would be needing even more specialized, sensitive, comprehensive care, including learning how to manage ADHD symptoms through pregnancy, postpartum and another layer of motherhood.
The sudden loss of a mental health provider isn’t just a bureaucratic nuisance of paperwork — it’s often accompanied by grief, regression and uncertainty. For many, Oregon’s Medicaid cuts, and the subsequent coverage changes to mental and behavioral health care, could be severely disruptive to the treatment and healing process — or worse. For countless OHP members, the cascading effects of the new policy changes could result in potential delays in prescription medication, or ultimately could lead to a loss of care for some.
I wasn’t able to get scheduled with my new psychiatric provider before the Sept. 30 deadline. So, like many others have reported doing, I’m having to use my ADHD medication (Adderall) less frequently to avoid running out before I can be seen by my new provider who will continue medication management.
Doctors warn people who have more serious conditions, for which benzodiazepines or benzodiazepine-like sedatives are prescribed, not to stop those medications abruptly under any circumstance. Suddenly stopping those medications could lead to withdrawal symptoms. In severe cases, it can be fatal.
When one’s mental and behavioral health are suffering, it is often invisible to others, but to the people experiencing it, it can be debilitating, lonely, overwhelming and increasingly dark. After finally mustering up the courage to overcome one’s impediments — from cultural stigmas and shame to self-blame — and taking steps to get help and do the work, it’s disappointing, depleting and borderline distressing to be told to start back at square one to establish care with new providers who are, quite literally, strangers.
For a 37-year-old mom with ADHD and two small children, the short notice I have to find a new therapist and a new psychiatric provider means it gets added to my epic, and ever-expanding to-do list. And guess what? Having ADHD means I’m likely going to procrastinate seeking new help until things become painfully urgent. That’s why it took aging into my mid-thirties and a full year of consistent, weekly therapy for someone to help me figure out I have ADHD and get an official diagnosis.
When my therapist shared the news with me that she wouldn’t be able to bill OHP for much longer, I was sad but in denial. Like Krishnamurthy, my therapist ended up joining a group practice, but unfortunately, still could not accept Medicaid. I actually cried at my final session with her because I wasn’t ready to be done working with her yet. It felt like the rug was being ripped out from under me. I wasn’t able to afford the cost of her services that would have to be out-of-pocket going forward, which started at $180 for a 45-minute session.
What if I hadn’t had an income level low enough to qualify for OHP? I wondered. How long would I have struggled to function in silence? How many more years would have passed before my symptoms got bad enough for me to finally get help and figure this out?
Not long after that, my psychiatric provider also alerted me that they would no longer be able to bill OHP, and were unsuccessful in their attempts to start a new contract with CareOregon.
Brace for impact
Just like private payers, OHP members deserve the ability to choose (and keep) the mental health providers they’ve already been working with. These changes, and the timeline of their implementation do not appear to be evidence-based, driven by care for the mental well-being of OHP members, nor do they feel in natural step with the state’s supposed mission to increase access to mental health resources.
In a January 2025 letter penned to the Oregon Health Policy Board from the Health Equity Committee, the committee shared its deep concern for the impacts of the rule change.
The policy had already caused “widespread disruption in access to mental health care for some of Oregon’s most underserved and vulnerable populations, including LGBTQ+, disabled, and Black, Indigenous, Latino/a/x/e, immigrant, and other communities of color, as well as rural clients and providers,” according to the letter.
“We believe the decision will exacerbate existing inequities in Oregon’s behavioral health landscape: it directly undermines the state’s commitment to transforming behavioral health as reflected in the Governor’s top three priorities and OHA’s strategic plan,” the committee wrote.
Notably, the letter highlights OHA convening a workgroup to study workforce recruitment and retention issues like what the proposed policy seeks to address.
“The workgroup submitted its interim report and recommendations to the legislature on January 15, 2025 and did not include a recommendation consistent with this proposed policy change.”
Pointing to a December 2024 Health Equity Committee meeting, in which associate counselors and community members shared “harrowing testimony” about the immediate and potential long-term impacts of this policy.
“Dozens of providers testified that they were and will be forced to interrupt established therapeutic relationships — an essential determinant of treatment success — without having appropriate alternatives to provide their clients,” according to the letter.
With the future so uncertain and ramifications of President Donald Trump’s Medicaid cuts looming, there’s no reason to believe that CareOregon, Oregon’s largest Medicaid insurer, won’t continue paring down access to care.
There’s no way to know whether the government will still be shut down by the time this paper goes to press. As of the time of this article’s filing, Americans brace for the impact of lawmakers’ gridlock.
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This article appears in November 5, 2025.