What They're Stealing From Us

On relational healthcare and the systems dismantling it

Published May 24th, 2026

by Michelle Roberts, MS, PLMHP

I am a therapist and I am a patient, and tonight I am sitting in the dark crying for the first time about my own loss.

I lost my therapist of seven years.

I had known for months that she was leaving her practice. The reason, when it finally became clear, was not dramatic. It was not a personal decision about me or about our work. It was a tax ID and a billing entity. A payer treating a long-standing therapist as if she had become a new provider because the paperwork around her practice changed. A bureaucratic mismatch so mundane it should not have been allowed to end something that took seven years to build.

But it was.

It became a small countdown in my head. Not dramatic. Not constant. Just there. A quiet clock.

I kept telling myself I would figure it out. There had to be more options. This couldn't be all that was possible.

So I did what I do. I researched. I pulled up the continuity of care rules. I called my insurance plan and asked about good cause change procedures. I looked up the Mental Health Parity and Addiction Equity Act. I read the federal network adequacy standards. I built a case in my head for every door I thought might still be open.

What I did not know yet, what I could not have known, was that the strongest new parity enforcement rules ever written were not being enforced. That companies had already identified this window. That the law I was reading as protection had been suspended by the time I found it.

I kept researching because I kept thinking I had not yet found the right lever.

Today was the first day I understood there wasn't one.

I was driving home. The grief came like I was watching a tidal wave from a distance, moving toward me from down the street, and then my car disappeared into a wall of violent water. Not metaphorically. That is what it felt like in my body. The seven years. The person who held me through things I have never said to anyone else. Gone because of a tax ID and a billing entity and a company that decided a network existed on paper.

I sat in the car outside my house for a long time.

And then I came inside and I started writing this.

Because I lost my therapist to the same kind of panel closure and managed care disruption that is now threatening seven of my own clients. I am sitting inside both sides of the wound at once. I know what it feels like as the clinician scrambling behind the scenes, calling, emailing, researching, trying to find a door that has not been nailed shut yet. I know what it feels like to believe there must be more options.

And I know now, tonight, what it feels like to run out of things to pursue.

So this is not abstract to me.

I am trying to protect my clients from losing their therapist while grieving the loss of my own.

I will not write about my clients' specific lives here. That is not a personal choice. It is the ethical standard of care, the same standard I am arguing these companies are violating when they treat therapeutic relationships as administrative units. The work that happens in a room between two people doing trauma work is protected not because it is shameful but because it is sacred. Because what gets said in that room was often never said anywhere else. Because the person sitting across from me trusted that the room would hold it.

What I can say is what that work is.

Some of it reaches far beyond one person's symptom reduction. The clients I am at risk of losing are doing work that changes what becomes possible for everyone who comes after them. They are the first in their families to try therapy. They are breaking silences that have lasted decades. They are getting sober. They are naming childhood harm that was never supposed to be spoken out loud. They are showing up week after week in communities where therapy has not always been accessible, culturally responsive, affordable, or safe.

These are not interchangeable appointments on a spreadsheet.

These are living relationships. These are rooms where whole family systems are changing because one person finally found enough safety to stop carrying the story alone.

And lately, some sessions have felt less like therapy and more like funerals I am already attending. The work is not ending because treatment is complete or because the client is ready. It is ending because an administrative system has decided that continuity no longer fits inside its network rules. There is an irreversible finality to that kind of ending, one I have no clinical language adequate for, because it is not a clinical ending. It is a tax ID. A panel closure. A letter. And the grief in the room is real and it is not chosen and there is nothing I can do to stop it from coming.

Witness is the heart of what is being stolen, and it is more specific than people understand.

Not every therapist is a witness. Not every therapist is meant to be. Clients need different things, and we are not interchangeable precisely because we are different, different in our approaches, our attunements, our theoretical frameworks, our histories, the particular quality of our presence. A good match for one person would be wrong for another. That is not a failure of the profession. It is the precision of it.

But witness is its own particular thing. And it is rare.

A witness is not a therapist who listens well. A witness is someone whose presence creates the condition in which the unspeakable can finally be spoken. Someone who does not flinch. Someone who has been there across enough time that they hold the before and the after at once, who can remember who you were before the thing that broke you and stay with you as you rebuild. Someone whose consistent, accumulated presence becomes its own form of proof that you are survivable.

That kind of relationship is not manufactured. It is not transferable. It is not reproducible in someone new because a managed care company decided it would be more convenient. It is built across years of showing up, of rupture and repair, of the small moments that accumulate into something a client can finally call safe.

Losing that witness is not the same as losing a therapist.

It is losing the only person who has ever held the whole story.

And I want to be honest about my side of this, because I think the field has not been honest enough.

The culture of clinical training tells us that countertransference is something to monitor, manage, and minimize. That attachment to clients is a boundary problem. That the relationship is asymmetrical by design and the therapist's emotional life in the room is at best a tool and at worst a contamination.

That framing has done real damage, to clinicians, to clients, and to the public understanding of what therapy actually is.

The research is clearer than the culture admits. Relational theorists including Stephen Mitchell and Lewis Aron have established that the therapist's genuine emotional engagement, including what gets activated in the clinician by the client's material, is not a liability to be managed but often the mechanism of change itself. The therapist who is truly present, truly moved, truly affected is not a therapist who has lost their boundaries. They are a therapist doing the actual work.

These seven clients have made me a better clinician. Their courage has sharpened my attunement. Their grief has taught me where grief hides. Their survival has expanded my understanding of what the human nervous system will do to protect love and selfhood from disappearing. What I have learned in those rooms has made me more present for every other client I see.

That is not a boundary violation. That is what genuine therapeutic relationship produces.

And it is what is being destroyed when a managed care company severs a long-term clinical relationship mid-treatment with a letter.

I am not only afraid of being lost by them.

I am afraid of losing them.

There is a fantasy I keep having, because I care deeply about and respect my clients. The fantasy is that I will just absorb it.

I will absorb the reimbursement loss. I will absorb the unpaid labor. I will absorb the administrative burden. I will absorb the grief. I will make myself larger than the harm so my clients do not have to feel it.

But that is the trap.

That is exactly how this industry survives.

It counts on therapists to care so deeply that they subsidize the system with our bodies, our time, our nervous systems, our unpaid hours, our collapsing capacity. It counts on us to stay late, call again, appeal again, document again, hold again, care again. It counts on the fact that when the system fails, we will feel personally responsible for the pain that lands in the room.

And then when we finally cannot carry anymore, the field calls it burnout.

Instead of calling it what it is: extraction.

I am only a couple of years into this career, and I can already feel the industry trying to shrink my capacity before I have had the chance to fully grow into it. Not because I do not love the work. I love the work. That is the problem. The system knows we love the work. It knows we care about our clients. It knows we will try to preserve the relationship. It knows we will do the unpaid labor. It knows we will sit in our cars and cry and then go home and keep researching, keep emailing, keep fighting, keep trying to find one more way through.

It knows that healers are easier to exploit when we are attached to the people being harmed.

And we are attached. Ethically. Clinically. Humanly.

Trauma and attachment work is not a commodity. Therapists are not interchangeable providers on a spreadsheet. For many clients, the relationship is the treatment. The continuity is the treatment. The slow accumulation of safety is the treatment.

Behavioral health is targeted because the cost structure is different.

Trauma therapy is not a one-time procedure. It is not an annual visit. It is often weekly, sustained, long-term care. A client doing serious trauma or attachment work may generate forty to fifty claims in a year, sometimes more, and the clinical effectiveness of that care depends on continuity. For the client, that continuity is the treatment. For the managed care company, it is recurring liability.

The very thing that makes trauma therapy clinically effective is the thing that makes it financially undesirable to an insurer: sustained, frequent, relational care.

That is the financial motive underneath the maze. If a company can make the provider leave, deny the new contract, close the panel, terminate the relationship, or send the client into a directory full of dead ends, many clients will simply stop trying. Not because they no longer need care. Because the system has made care too exhausting to reach.

The cheapest client is not the healed client. The cheapest client is the exhausted client who stops calling.

That is forced attrition. And forced attrition saves money.

So when companies take public healthcare dollars, claim they provide access, and then create barriers that sever active therapeutic relationships, they are not just disrupting scheduling.

They are disrupting attachment repair.

They are manufacturing grief.

That is what ghost networks do.

A ghost network is when an insurance company or managed care organization maintains a provider directory that makes it look like clients have access to care on paper, while the access does not exist in real life. The directory may list providers who are not accepting new clients. Providers who no longer take the plan. Providers who are unreachable. Providers listed at the wrong location or with the wrong phone number. Providers who are credentialed but not actually active. Providers who are technically in-network while the company refuses to contract with enough actually available providers to meet actual need.

So the plan can say: we have an adequate network.

And the client calls and calls and calls and cannot find a therapist.

A ghost network is not just a bad list. It is a false promise made to people who paid for this coverage at the exact moment they are least able to keep fighting. It tells a person in crisis: help exists. Then it hands them a maze of disconnected numbers, closed panels, wrong addresses, and providers who were never actually available. It converts desperation into unpaid labor. It makes the patient prove the lie one phone call at a time.

That is not access. That is the appearance of access. It is paperwork organized to resemble care.

This is where the contradiction becomes impossible to ignore.

Managed care organizations can claim a behavioral health network is saturated only if the directory is treated as real. But if the directory is full of providers who are not accepting new clients, no longer take the plan, cannot be reached, or are listed inaccurately, then saturation is not an access finding. It is a fiction produced by paperwork.

A ghost network allows a company to say two incompatible things at once: there are enough providers to serve the population, and there is no room to contract with actual available providers. The ghosts justify the lockout. The illusion of a full network becomes the legal cover for refusing living clinicians who are ready to take clients.

Here is what this looks like without naming a single client. A person finally finds a therapist after years of not trusting anyone. They begin trauma work. The relationship becomes clinically meaningful. Then the payer changes the rules. The therapist is no longer available under the plan. The client is handed a directory. They call ten names. Three do not answer. Two no longer take the plan. Two are full. One number is wrong. One only sees children. One has a six-month waitlist. By the end, the client has not been connected to care. They have been taught, again, that asking for help is humiliating.

A provider directory is not a neutral document. It is either telling the truth about what care is available, or it is participating in the lie that care exists because a name appears on a list.

The policy-level framing is complex. The human reality is not. Clients are losing people they trusted to help keep them alive.

Ravi Coutinho was 36 years old. He had moved to Phoenix and bought an Ambetter plan through HealthCare.gov, one of the most popular options on the exchange. He needed a therapist. He needed a doctor to refill his antidepressants. He called Ambetter 21 times. Representatives misunderstood his requests, would not send him a provider list, could not connect him to anyone. He went through the directory manually. He could not find an available provider. He was found dead in his apartment in May 2023.

ProPublica published his story in September 2024 as part of a yearlong investigative series called "America's Mental Barrier." His mother Barbara Webber filed a lawsuit in May 2025 against Centene and its subsidiary Health Net of Arizona, which operated her son's Ambetter plan, alleging the directory was inaccurate and misleading, that it gave him a false impression that care was available through his plan. Arizona regulators had previously cited Health Net of Arizona for inaccurate provider directories before Ravi died.

Ambetter is owned by Centene.

Ambetter operates in Nebraska.

I am not saying a ghost network killed Ravi Coutinho. His mother's lawsuit makes that argument and it will be decided in court. What I am saying is that a man made 21 calls and could not find a single available provider in a directory his insurer told him was real. And then he died. And the company that maintained that directory is the same company operating in Nebraska right now, serving the clients providers here are fighting to keep.

That is not abstract. That is what this costs.

Now I want to tell you what is happening in Nebraska specifically, because the numbers make the lie very hard to tell.

The companies at issue in the provider reports I am discussing are Nebraska Total Care, owned by Centene, and UnitedHealthcare Community Plan, along with Centene's Ambetter marketplace product. These are the companies tied to the panel closure, termination, continuity-of-care, and ghost-network patterns providers are documenting across Nebraska's professional community right now. Together they hold contracts reported as worth up to $4.25 billion each over the contract period, to provide care to approximately 347,000 low-income Nebraskans. Physical health, behavioral health, pharmacy, dental. All of it.

That is the public money these companies are paid to manage.

Here is what we know about how it has been managed.

In 2021, Nebraska Total Care spent 86 cents of every Medicaid premium dollar on actual medical care and kept 14 cents. The federal floor for Medicaid managed care is 85%. They were running one point above the minimum. The state built a mechanism to address this: an Excess Profit Fund, into which MCO profits above a certain threshold are deposited and held. By law, that fund exists to fill service gaps, improve the system, and sustain access to care. As of the 2022-2023 budget year, the ending balance in the Excess Profit Fund was $67.7 million.

$67.7 million sitting in a fund legally designated to fix the access problem.

While clients cannot find therapists. While providers are being terminated mid-treatment. While seven of my clients may lose the relationship that has taken years to build.

We do not know the current balance of that fund. We do not know what it has been spent on, or whether it has been directed toward the access gaps it was legally designated to address. That question deserves a public answer.

Nebraska is not the only state asking hard questions about these companies.

Centene operates Medicaid and marketplace plans across more than 30 states and serves more than 28 million Americans. It is the largest Medicaid managed care organization in the country. It has settled Medicaid overbilling allegations with at least 17 states, including Nebraska, for a total exceeding $900 million nationally. The Nebraska settlement alone was $29.3 million, signed by then-Attorney General Doug Peterson in December 2021. The state did not publicly announce that settlement until 10 months after it was signed. Nine months after the settlement, the state awarded Nebraska Total Care a new multibillion-dollar Medicaid contract anyway.

Across those states, the alleged pattern was consistent: Centene's pharmacy benefit management subsidiary submitted inaccurate billing requests, failed to disclose available discounts, and inflated dispensing fees, settling allegations of overcharging state Medicaid programs for prescription drugs across more than a dozen states. Illinois settled for $56.7 million. Ohio for $88.3 million. California for $215 million. These were not isolated incidents. They were a consistent pattern settled across the country, at least 20 states in total, with Centene setting aside $1.25 billion in reserves to cover the payouts.

And Nebraska gave them a new contract.

If Nebraska previously recovered $29.3 million from Centene over pharmacy-benefit allegations, then Nebraska should be willing to ask what behavioral health access failures may have cost the public now. The question is not whether Centene is broke. Their premium and service revenues rose from $145.5 billion in 2024 to $174.6 billion in 2025. The question is what corporate strategies a company uses to protect margin when recurring costs rise. Centene's own 2025 financial reporting identifies higher Medicaid medical costs, driven in part by behavioral health, as a factor increasing its health benefits ratio. Behavioral health is not incidental to the business model. It is one of the recurring costs the company has a documented financial incentive to control.

The public deserves to know whether Nebraska's Medicaid dollars are being used to build actual behavioral health access, or whether access is being suppressed while the appearance of access is maintained.

If a company is paid public dollars to maintain access to care, and it maintains the appearance of access while actual access collapses, the question is no longer whether the system is inefficient. The question is whether the public is being defrauded.

The ghost network problem specifically has been the subject of sustained national journalism. ProPublica ran a yearlong investigative series called "America's Mental Barrier" documenting the ways insurers blocked access to mental health care. The Wall Street Journal investigated Centene's Medicaid networks in early 2026 and found that in one Missouri suburb, Centene claimed 28 child psychiatrists available to Medicaid patients. Eleven of those practices had seen zero Medicaid patients that year. The Lown Institute published research in February 2026 documenting ghost networks across Medicaid and Medicare Advantage nationally. A class action alleging ghost networks in behavioral health against Elevance Health was allowed to proceed by a federal judge in 2026. This is not a fringe concern. It is an active area of national investigation, litigation, and journalism.

Nebraska is a data point in a story these reporters are already tracking. If you are a journalist covering managed care access, Medicaid fraud, or behavioral health parity, providers in Nebraska are documenting this pattern in real time and are willing to talk.

UnitedHealthcare, which manages two of my seven affected clients through its Nebraska Medicaid product, was forced out of Louisiana's Medicaid program entirely after the state sued over allegations that it overcharged Louisiana Medicaid for prescription drugs from 2015 to 2023, with potential liability estimated between $388 million and $768 million. The company also refused to produce audit documents the state was legally entitled to review. UnitedHealthcare's Louisiana Medicaid participation ended March 31, 2026, affecting 330,000 people. That is the company currently managing behavioral health access for low-income Nebraskans.

Nebraska providers have been warning each other in plain sight.

In reviewing provider community discussions in Nebraska over the past several years, a pattern emerges that is too consistent and too widespread to be dismissed as isolated frustration. I am not naming the specific communities to protect their members, but the documentation exists across multiple groups, multiple years, and multiple provider types. I reviewed it. I talked to colleagues. The pattern is undeniable, and it is one of systemic harm.

Providers report contracts terminated without cause, with termination notices mailed to addresses providers had updated years prior. Claims denied after information mismatches that providers say occurred inside NTC's own system. Audits conducted with no clear criteria communicated. Appeals filed and denied without meaningful review. Provider relations representatives who do not respond. Clawback demands for sessions that were clearly delivered. And most recently, a wave of mass terminations concentrated in Omaha and Lincoln, affecting mental health providers specifically while medical, dental, and other specialty providers in the same networks were not receiving termination letters.

According to community documentation compiled in May 2026, an NTC head administrator confirmed to at least one provider that the network is oversaturated by approximately 30% in certain areas and that their state contract caps the number of providers per geographic region. The official response to all provider inquiries about termination is a single scripted line: we are exercising our right to terminate your contract without cause.

But the state's own training programs for community-based clinicians have confirmed there is a provider shortage in Nebraska behavioral health. The company is claiming oversaturation. The state's own data says shortage. Both cannot be true.

The terminations are not random. They are concentrated among solo private practice clinicians. Group practices credentialing through Independent Provider Associations are being retained. Technology company groups that credential providers under group NPIs at lower reimbursement rates are continuing to be accepted. The network is not simply shrinking. It is being restructured toward delivery models that cost less per claim and afford the company more administrative control.

Providers also reported that Nebraska Total Care's contract representatives stated the company was only credentialing MDs and APRNs, prescribing providers only, and was not credentialing licensed counselors or therapists.

Centene settled allegations in Nebraska in 2021 centered specifically on pharmacy benefit manipulation: inflating drug costs, overcharging for prescription drugs. That settlement was $29.3 million. The same company is now reported to be preferring prescribers over non-prescribing behavioral health clinicians in its Medicaid network.

A company previously alleged to have profited from pharmaceutical overcharging is reported to be shifting its behavioral health network toward prescribers. That is not proof of intent. It is a question regulators should be required to answer publicly.

There is one more thing that happened that deserves to be named directly, because it is the most specific harm in this whole piece.

When NTC terminated provider contracts in late 2025, it sent letters directly to clients before providers had any opportunity to speak with them. According to multiple providers in the community, the letters stated that the provider had chosen not to provide services to NTC members any longer.

If accurately reported, that is a materially misleading statement. Providers were terminated without cause. They did not choose to leave. The letter told their clients they had chosen to leave.

At least one provider learned about the letter when a client called in distress before the provider had any warning. The relationship was disrupted by a lie about who ended it, delivered directly to the client, before the provider could offer any clinical context or transition planning.

Sending a letter to a client in active treatment stating their therapist voluntarily ended the relationship, when the company ended it, is a clinical harm. It lands in the exact attachment wound that therapy exists to heal. It tells a person who has spent months or years learning to trust that the person they trusted chose to leave them.

And the timing compounds everything. NTC's termination letters went out in December 2025, after open enrollment for Nebraska's Heritage Health program closed on December 15. Nebraska Medicaid clients can switch plans only during Annual Open Enrollment from November 1 to December 15 each year, or within the first 90 days of initially enrolling. Clients cannot switch to a different Medicaid MCO until November 2026 open enrollment, nearly a full year after the terminations took effect. The community has noted this timing. Letters sent after enrollment closed ensured clients could not move immediately. And the letter they received told them their therapist chose to leave.

Providers in Nebraska communities also began receiving certified letters from Ambetter in early 2026. According to provider community reports, Centene terminated the Ambetter brand and Celtic Insurance, another Centene subsidiary, is taking over the 2026 marketplace contract. The ownership does not change. The name does.

Now let me tell you about the audits.

The aggressive clawback problem in Nebraska is documented. Nebraska Public Media and the Flatwater Free Press investigated and reported on MCOs auditing small mental health providers and demanding tens of thousands of dollars back based on documentation technicalities. One Lincoln therapist received a demand for over $21,000. Providers described being told they would not be reimbursed for sessions because notes were not written to the auditor's standard, even when care was clearly delivered and clinically appropriate.

The result: therapists dropped their Medicaid panels. Providers who served a majority of low-income clients left Medicaid entirely because the financial risk of staying became untenable. The clients who needed the most protection lost the providers most committed to serving them.

Senator John Frederickson, a Democrat from Omaha and a former mental health provider, introduced LB380 and LB381 in January 2025 specifically in response, legislation aimed at limiting the ability of MCOs to weaponize audits against small behavioral health providers. The bills followed public investigative reporting. They were necessary because the harm was real enough and widespread enough that it required a law to stop it.

Let that land.

Nebraska had to pass legislation to stop managed care companies from bankrupting the therapists serving the state's most vulnerable population.

The companies did not stop on their own.

The terminations and the audits are not separate problems. They are the same pressure system operating on multiple levers simultaneously. Alongside the terminations, Ambetter and NTC announced in November 2025 that 2026 Medicaid rates would be aligned with Medicare reimbursement rates, widely understood as a significant pay cut. This matters in Nebraska specifically because the Nebraska Legislature approved a 17% increase in behavioral health reimbursement rates in 2023, a recognition that the system was underfunding mental health care and that providers needed more support to serve Medicaid populations. That increase was supposed to flow through to providers and improve access. Instead, providers are now being terminated while the MCOs receiving that increased public funding simultaneously announce they are cutting rates back toward Medicare floors. The state put more money in. The companies are paying providers less. The question of where that difference went deserves a public answer.

Separately, on May 20, 2026, Alma, a digital therapy enablement platform that contracts with insurers on behalf of therapists, notified its providers that Aetna would be implementing three rate changes effective July 15, 2026. Extended therapy sessions, the 53-minute appointments that are standard in trauma and attachment work, will be reimbursed at the same rate as shorter 37-to-52-minute sessions. Highly complex evaluation and management visits will be reimbursed at the same rate as moderately complex ones. And doctoral-level providers conducting those evaluations will be paid at the rate of master's-level providers. For a psychologist seeing patients through Alma and billing extended sessions, this is effectively a 42% pay cut.

The clinical distinction between a 37-minute session and a 53-minute session in trauma work is not administrative. It is the difference between enough time and not enough time. Clients doing trauma work almost universally need the full session. That is not a preference. It is how trauma processing works. You cannot complete a trauma processing window in 37 minutes. The extended session code exists because the clinical literature supports it. Flattening the rate is a financial decision dressed up as an administrative one.

This also fits a broader pattern. In late 2024, Optum cut its rates through both Alma and Headway, the two largest digital therapy platforms. The platforms collect insurance contracts at a network level, then pay therapists a per-session rate that is a fraction of what the insurer pays them. When a platform absorbs a payer rate cut, the platform's margin holds. The clinician absorbs the loss. The same pattern is now repeating with Aetna and Alma. The delivery model itself, where a third-party tech company holds the insurance contract and the clinician is effectively a subcontractor, is part of what makes these cuts possible.

Terminations. Rate cuts. Panel closures. Credentialing denials. Audit demands. Misleading client letters. All at once.

This is not a bad season. It is a structure designed to make independent behavioral health practice financially unsustainable for the providers most committed to serving the people who need care most.

Here is what explains why everything feels so disorienting right now.

Nebraska is, as of May 1, 2026, the first state in the nation to implement federal Medicaid work requirements under HR1, ahead of the national implementation date of January 2027. Between 25,000 and 41,000 Nebraskans are at risk of losing coverage. The Urban Institute estimates the national changes could result in up to 10 million people losing Medicaid coverage over the next two years.

We are simultaneously cutting the number of people eligible for Medicaid, shrinking the provider network through panel closures and terminations, operating under MCOs with documented histories of settling Medicaid overbilling allegations in multiple states, sitting on a $67.7 million Excess Profit Fund whose current disposition is unclear, and doing all of this while the strongest new federal mental health parity enforcement rules ever written are sitting on a shelf, while the older and weaker parity framework remains far less protective than what was supposed to be in force right now.

That last piece matters.

Congress passed the Mental Health Parity and Addiction Equity Act to require that insurance companies cover mental health care at the same level they cover medical and surgical care. In September 2024, the federal government finalized new rules requiring insurers to prove, with documentation, that their behavioral health restrictions were not more limiting than their medical equivalents. Closing a behavioral health panel while keeping medical panels open is exactly the kind of disparity those rules were designed to catch.

In May 2025, the Trump administration suspended enforcement of those 2024 rules under a deregulation executive order, responding to a lawsuit filed by an employer lobbying group. The enforcement pause applies through at least 18 months after litigation concludes. The administration has indicated it may rescind or significantly modify the rules entirely. The older statutory parity requirements remain, but the stronger enforcement infrastructure built on top of them is gone for now.

This is happening at the exact moment the public is naming mental health as one of the most urgent health concerns of our time. Ipsos polling found that mental health has become the top health concern globally, surpassing cancer, with U.S. data showing Americans naming mental health far more often than cancer as a top concern. The public is not confused about the need. Patients are not confused about the need. Providers are not confused about the need. This is not a competition between illnesses. Cancer deserves every ounce of urgency it receives. The point is that the public now understands mental health as a life-and-death concern too. Yet behavioral health is still treated administratively as optional, shrinkable, delayable, and disposable.

The only entities behaving as if behavioral health access can be narrowed without consequence are the companies paid with public dollars to provide it.

From the ground, this looks like extraction. Companies with documented overbilling histories operating inside a regulatory window where the strongest enforcement has stalled, collecting public Medicaid dollars, narrowing behavioral health networks, leaving providers and clients to hold the grief. The result is the same regardless of intent: weakened enforcement, narrowed networks, public money, exhausted providers, and clients left calling names from directories that do not answer.

Here is the mechanism. A managed care company claims its network is full. It supports that claim with a provider directory padded by ghosts. Then it uses the alleged fullness of that ghost network to deny new contracts, close panels, or terminate existing provider relationships. When clients lose care, they are directed back into the same inaccurate directory. Many give up. The company keeps the public money, pays fewer claims, and calls the network adequate because the spreadsheet still says it is.

That is not a glitch. That is forced attrition.

I kept thinking there were more options. This couldn't be all that was possible.

It was.

The disorientation providers and clients feel right now is real.

It is supposed to be real.

Confusion and exhaustion are not accidental byproducts of this structure. They are recurring outcomes of it.

These are the questions Nebraska regulators should be required to answer publicly.

How many behavioral health providers listed in each MCO directory are currently accepting new clients?

How many listed providers have seen at least one Medicaid client from that plan in the last six months?

How many behavioral health panel closure notices have been issued in the last year?

How many provider termination notices have been sent, and how many were mailed to outdated addresses?

How many continuity-of-care requests have been approved, denied, delayed, or left unresolved?

How many clients have been told or led to believe their therapist ended the relationship when the payer caused the disruption?

What is the current balance of the Excess Profit Fund, and exactly how has it been spent?

And if the network is adequate, why are available providers being locked out while clients cannot find care?

These are not complicated questions. They are measurable. And if the companies receiving billions in public dollars cannot answer them, they should not be allowed to keep claiming their networks are adequate.

Here is what I need from the people whose job it is to stop this.

Governor Pillen and Nebraska DHHS, Division of Medicaid and Long-Term Care

You hold the MCO contracts. You are contractually obligated to monitor network adequacy. You were proud to be first in the nation to implement Medicaid work requirements. Be first in the nation to audit the behavioral health networks of the companies you are paying billions to maintain. We need a public accounting of the Excess Profit Fund, its current balance, what it has been spent on, and whether it has been directed toward the access gaps it was legally designated to address. We need formal network adequacy audits. We need continuity of care protections enforced, not suggested.

Nebraska DHHS Division of Medicaid and Long-Term Care dhhs.ne.gov | 402-471-3121

Nebraska Department of Insurance

Ambetter is a marketplace plan fully subject to mental health parity law. Closing a behavioral health panel while medical panels remain open is a textbook nonquantitative treatment limitation (NQTL) disparity under MHPAEA. Every provider who has received a panel closure notice for a behavioral health specialty while comparable medical panels remain open has grounds for a formal parity complaint. The volume of those complaints is data. Start counting them.

Nebraska Department of Insurance doi.nebraska.gov | 402-471-2201 | 877-564-7323 File a complaint: doi.nebraska.gov/file-a-complaint

Senator John Frederickson and the Nebraska Legislature

You introduced LB380 and LB381. You already knew something was wrong. What is happening now, the panel closures, the terminations, the continuity of care disruptions, the Excess Profit Fund whose disposition is unclear, the client letters misrepresenting who ended the relationship, is connected to everything your legislation was trying to address. Providers are watching it happen and documenting it. We need you to hold the line and make the connection publicly.

Senator John Frederickson nebraskalegislature.gov | jfrederickson@leg.ne.gov | 402-471-2617

CMS Region 7

Federal Medicaid managed care regulations require network adequacy. The behavioral health access patterns being documented in real time by Nebraska providers are consistent with ghost network dynamics already litigated and settled nationally with these same companies. Nebraska warrants federal scrutiny.

CMS Region 7: 816-426-5233 File a Medicaid complaint: medicaid.gov/contact-us

Organizations that can help:

What every provider needs to document right now:

Save everything. In a folder. Organized. Dated.

Denial letters with stated reasons. Panel closure and network saturation notices. Contract termination letters. Credentialing approvals that did not result in active panel participation. Contradictory notices from the same MCO. Screenshots of directory listings for providers you know are not accepting the plan. Continuity of care requests and their outcomes, without client-identifying information. Any communication from an MCO to a client suggesting the provider, not the company, initiated the separation. Records of how long clients have waited, how many directory names proved unavailable, how many calls it took. Documentation of claims denied due to provider demographic mismatches where updated information had already been submitted. Audit notices, audit outcomes, audit silence. Requests for repayment. Written-off balances.

Date everything. Name the MCO on everything.

One letter is a complaint. A hundred letters from across the state is a pattern that cannot be dismissed.

How to investigate a ghost network, if you want to build the case:

A ghost network investigation is not complicated. It is tedious, and that is by design.

Pull the directory. Go to the MCO's online provider directory for your region and pull the full list of in-network behavioral health providers. Screenshot it or export it with a date stamp. That date matters because directories change and companies will claim they were updated.

Call the list. Work through it systematically. For each provider, call and ask three things: Are you currently accepting new patients? Do you currently accept this plan? Is your directory listing accurate? Log every call with the date, the provider name, the number you called, and what you were told. Note if the number is wrong, disconnected, or goes to a practice that has no knowledge of being listed.

Document the gap. Compare what the directory claims against what you found. How many listed providers were actually available? How many were unreachable? How many were listed incorrectly? How many said they had not accepted that plan in months or years? That gap, expressed as a percentage, is the ghost network.

File what you find. A completed call log submitted to the Nebraska Department of Insurance as a network adequacy complaint is evidence. The same log submitted to Nebraska DHHS is a contract compliance concern. The same log sent to a journalist is a story.

You do not have to do all of this alone. If ten providers each call twenty names and log what they find, that is two hundred data points. That is enough to make the gap visible in a way that cannot be dismissed as anecdote.

Talk to each other.

Not just in DMs and hallways and voice memos sent from parking lots. Talk in public. Use your social media. Contact journalists. The stories happening inside our professional community, the audit demands, the panel closures, the clients who cannot find care, the providers leaving Medicaid, the directories that do not reflect reality, these stories need to reach people who can carry them further. Nebraska Public Media, the Flatwater Free Press, the Lincoln Journal Star, and the Omaha World-Herald have already reported on pieces of this. They need to hear more. They need to hear it from more of us.

What goes unsaid stays invisible. What gets named gets counted.

My supervisor Tiffany Eisenbraun at Liminal Therapy has been leading advocacy efforts around this issue, including outreach at the professional association and state level. More providers need to understand what we are looking at and why it is not just their individual problem.

I cannot become the clearinghouse for the whole state. I am carrying my own caseload, my own clients' grief, my own loss, my own health. But I am going to keep researching and keep naming the pattern.

Because this is not just about my seven clients.

It is not just about my therapist.

It is not just about one provider getting denied.

It is about whether companies receiving billions in public dollars are providing the access they are paid to provide. It is about whether a directory is allowed to stand in for a relationship. It is about whether profit is allowed to masquerade as care. It is about whether companies with documented histories of settling Medicaid overbilling allegations in multiple states, and facing national scrutiny around access, network adequacy, and behavioral health care, are allowed to keep contracting with states, keep narrowing networks, keep padding directories, keep exhausting the healers, and keep counting on the grief of clients and providers to absorb the shock.

The burden of proof should not be on the people who paid for this coverage, on clients in crisis, on communities that have never had enough access, and on the providers trying to serve them.

The burden should be on companies receiving billions in public dollars to prove that their networks are real.

If they cannot prove that listed providers are reachable, available, accurate, and actively taking clients, then they should not be allowed to call that network adequate. And they should not be allowed to use that false adequacy to lock out the very providers willing to serve.

We have the capacity.

We are naming it.

A witness held across years cannot be replaced.

A relationship built slowly, across months and years of hard-won trust, cannot be reproduced in someone new because a managed care company decided it would not be.

Our clients deserve actual care. Not access that only exists in a directory. Not a list of names that do not answer. Not the performance of a network.

Real care. The kind built slowly. The kind that costs years to make and cannot be replaced. The kind that holds you across every version of yourself until you can hold yourself.

That is what is being stolen.

And the companies profiting from public Medicaid dollars while they do it should have to prove that the networks they are paid to maintain are real.

Sources

ProPublica, "America's Mental Barrier" series and Ravi Coutinho coverage

Flatwater Free Press and Nebraska Public Media on Nebraska MCO audits

Lincoln Journal Star on Nebraska Total Care contract award

  • "Nebraska Medicaid company gets new contract despite $29 million overbilling settlement": journalstar.com

Centene settlement history

  • KFF Health News / California Healthline on the $215M California settlement and 17-state list: californiahealthline.org
  • STAT News on Kansas, Ohio, Mississippi, Illinois, Arkansas settlements: statnews.com

KFF on Nebraska Medicaid work requirements

  • "A Closer Look at Nebraska, the First State Planning to Implement a Medicaid Work Requirement": kff.org
  • "An Early Look at Policy Decisions as States Get Ready to Implement Work Requirements": kff.org
  • Governor Pillen press release (May 1, 2026 implementation): governor.nebraska.gov
  • NPR on first day of implementation: npr.org

Louisiana Illuminator on UnitedHealthcare Medicaid exit

  • "UnitedHealthcare will end Medicaid contract with Louisiana in 3 months, affecting 330,000 people": lailluminator.com
  • "Louisiana starts to wind down UnitedHealthcare's Medicaid contract": lailluminator.com

Nebraska Excess Profit Fund

MHPAEA enforcement suspension (May 2025)

  • U.S. Department of Labor official notice (May 15, 2025): dol.gov
  • Crowell & Moring legal analysis: crowell.com
  • Littler legal analysis (ERIC lawsuit and EO 14219 context): littler.com

Wall Street Journal / Lown Institute on ghost networks

Elevance / Carelon class action

  • Becker's Payer, "Elevance mental health 'ghost network' lawsuit to move forward, judge rules": beckerspayer.com
  • Fierce Healthcare on the Carelon-NYSHIP class action: fiercehealthcare.com

Centene 2025 / 2026 financial reporting

  • Q4 2025 / full-year 2025 press release (premium revenue $174.6B, behavioral health driving HBR): sec.gov
  • Q1 2026 press release: investors.centene.com

Ipsos Health Service Report

  • 2024 report (mental health overtakes cancer as top global concern): ipsos.com
  • 2025 report PDF: ipsos.com

Aetna rate cuts through Alma (May 2026)

  • Behavioral Health Business, "Aetna Cuts Rates with Alma-Contracted Therapists" (May 21, 2026): bhbusiness.com

Optum rate cuts through Alma and Headway (late 2024)

  • ClearHealthCosts, "2 digital mental health platforms cut pay rates for therapists with UnitedHealth's Optum": clearhealthcosts.com
  • ClearHealthCosts follow-up, "UnitedHealth-Optum pay cut makes clinicians reassess value of tech mental health platforms": clearhealthcosts.com

Michelle Roberts is a licensed psychotherapist and trauma specialist at Liminal Therapy in Lincoln, Nebraska. She is a published poet and the author of Never Surface Level.