Why your caseload is slow in 2026

Do you feel like your caseload has thinned this year? You’re not imagining it. Many therapists see fewer new inquiries, slower referrals, or clients taking longer to reschedule. Multiple structural forces converged in 2025 and 2026 to make it harder for willing clients to actually get to therapy, and most of those forces operate well outside any individual clinician’s control. Understanding them clearly is more useful than doubling down on marketing tactics that aren’t designed for this particular problem.

This post walks through what the 2025 and 2026 data shows, what is driving the shift, and which moves are worth considering.

What the data actually shows

The need for mental health care has not gone away. According to SAMHSA’s 2024 National Survey on Drug Use and Health, of the approximately 61.5 million adults with a mental health condition in 2024, roughly 29.5 million did not receive treatment. The gap between people who need care and people who receive it remains enormous.

One reason for the slowdown is the easing of the pandemic-era surge.

A 2025 study published in PNAS Nexus, using electronic health records from a large academic health system, found that mental health visit volume increased sharply at the start of the pandemic and then declined steadily from July 2021 through June 2024, with the steepest declines among clients in higher-deprivation areas.

Even busy practices are seeing the effect. The APA’s 2025 Practitioner Pulse Survey, published in December 2025, surveyed 1,742 licensed psychologists nationwide. About half (46%) reported having no openings for new clients and 40% currently have a waitlist. The same survey from 2024 found 53% with no openings. Most respondents reported stable workloads year over year: 59% were working the same amount as 12 months prior and 56% were treating the same number of clients.

On the telehealth side, the numbers are striking. Behavioral Health Business reported in January 2026 that behavioral health accounted for 67% of all telehealth visits in 2024, but that between 2023 and 2024, the total number of behavioral health telehealth visits fell by 10 million, the largest single-year decrease since the COVID-19 pandemic. The surge has been corrected. What remains is a more competitive, more fragmented market for a client pool whose ability to pay has come under increasing pressure.

On the supply side, the field is expanding. The U.S. Bureau of Labor Statistics projects 17% growth in mental health, behavioral disorder, and substance abuse counselors and 16% growth in marriage and family therapists between 2024 and 2034. Both several times the roughly 4% average projected across all U.S. occupations. Interstate licensure compacts (PSYPACT for psychologists, the Counseling Compact for LPCs) have reduced the friction of practicing across state lines. And starting in January 2024, LMFTs and LMHCs became eligible to enroll as independent Medicare clinicians.

A workforce growing faster than the population it serves, in a market leveling off after a multi-year surge: that is the picture.

Why this is happening: The macro forces at play

Continued effects of Medicaid unwinding and new federal cuts

The Medicaid “unwinding” (the process of redetermining eligibility after the pandemic-era continuous enrollment provision ended) moved more than 25 million people off Medicaid by September 2024, per KFF. A June 2025 GAO report found that of 89 million completed redeterminations, approximately 27 million individuals were disenrolled during the first year and a half of unwinding.  Medicaid enrollment declined 7.6% in fiscal year 2025 and is expected to be roughly flat in FY 2026. Coverage losses landed disproportionately on people with mental health conditions, according to research published in JAMA Health Forum in March 2025.

The behavioral health impact has been direct. A July 2025 Commonwealth Fund analysis found that 69% of disenrollments occurred for procedural reasons rather than actual changes in eligibility, and that many of those affected had mental health and substance use disorder conditions. Medicaid is the largest single payer of behavioral health services in the United States. When its rolls contract, the downstream effects reach private practices, especially those serving lower-income populations.

The next wave is just beginning. The One Big Beautiful Bill Act, signed into law on July 4, 2025, includes the deepest Medicaid cuts in the program’s history. Per the American Medical Association, OBBBA creates new administrative requirements (including work requirements) and restricts the way states finance their Medicaid programs. The Congressional Budget Office estimates roughly 7.8 million people will lose Medicaid coverage as a result. Researchers writing in the Milbank Quarterly in August 2025 noted that the burden of behavioral health conditions is higher among Medicaid enrollees, which means the contraction will hit behavioral health caseloads harder than most specialties.

If you take Medicaid, you’re likely already feeling the redetermination ripple. If you don’t, you’re still feeling it indirectly: clients who lose Medicaid sometimes shift to commercial coverage with high deductibles, but many drop out of care.

Rising deductibles in commercial coverage

For clients with employer-sponsored insurance, the question in early 2026 is rarely “Is therapy covered?” It is “How much will I pay before coverage actually kicks in?”

The KFF 2025 Employer Health Benefits Survey, published in October 2025, found that 33% of covered workers are now enrolled in a high-deductible plan with a savings option (HDHP/SO). A high-deductible health plan is one in which the enrollee pays a relatively high amount out of pocket (typically $1,650 or more for single coverage in 2025) before insurance starts paying for most non-preventive services. The average single-coverage deductible in 2025 was $1,886, 17% higher than in 2020. More than half (53%) of covered workers at small firms now face a deductible of at least $2,000. And starting in January 2026, the 2025 reconciliation law expanded HDHP-eligible plan categories significantly, with KFF reporting that 35% of Marketplace plans sold on HealthCare.gov are now HSA-eligible, up from just 4% in 2025.

Research published in JAMA Psychiatry and reviewed in a 2024 PMC paper found that increased cost-sharing under HDHPs is associated with reduced use of ambulatory mental health services, which is exactly the kind of ongoing outpatient work that fills a private practice. Clients who nominally have insurance coverage effectively behave like self-pay clients during the early months of the plan year, which for many practices means January through April becomes structurally slower.

For therapy specifically, this creates a predictable pattern: clients with HDHPs pay the full session rate out of pocket until they hit their deductible, which can take most of the year for someone attending weekly sessions.

The mental health workforce is growing faster than typical jobs

For most of the last decade, the field has been told there is a shortage. There is: HRSA’s 2025 State of the Behavioral Health Workforce brief still projects significant shortages of counselors, MFTs, psychologists, and psychiatrists. But shortage and saturation can coexist when distribution is uneven.

Two policy shifts have amplified the supply effect. In January 2024, LMFTs and LMHCs became eligible to bill Medicare as independent clinicians at 75% of the psychologist rate. And interstate licensure compacts have reduced the friction of practicing across state lines. The result is a more crowded market in many metro areas, especially for telehealth-delivered care, where geographic distance no longer protects an individual practice’s referral pipeline.

The mental health workforce is expanding rapidly. According to the U.S. Bureau of Labor Statistics Occupational Outlook Handbook, employment of substance abuse, behavioral disorder, and mental health counselors was projected to grow 17% from 2024 to 2034, far faster than the average for all occupations. About 483,500 such counselors held jobs in 2024.

This growth has concentrated in telehealth-enabled practice, where geographic barriers are lower. More clinicians in the market, especially when many are reachable via telehealth from anywhere in the same state, means more competition for the same pool of clients who can afford ongoing care.

This does not mean there isn’t enough need to go around. It means that the clients who are actively help-seeking and economically able to start and sustain treatment are distributed across a larger workforce than existed three or four years ago.

Economic pressure is pushing therapy out of household budgets

Therapy is not a luxury, but household budgets don’t always reflect that. For many middle- and lower-income clients, a weekly therapy session is a discretionary line item that gets evaluated against competing expenses when money gets tight.

Morgan Stanley’s 2025 consumer spending forecast projected that spending growth would slow from 5.7% in 2024 to 3.7% in 2025 and 2.9% in 2026, with “tariff-induced inflation, and policy uncertainty weighing on consumers.” TD Economics’ February 2026 analysis found that spending on essentials now makes up 61% of all spending for households in the lowest income group, up from pre-pandemic levels, leaving less room for discretionary purchases.

The direct link to therapy access is documented by consumer survey data. A 2026 report found that cost was cited as a barrier to mental health care by 41% of respondents in 2026, up sharply from 25% in 2025. Half of all respondents said they had reduced spending on therapy, gym memberships, or personal health due to rising costs.

Direct-to-consumer platforms have changed where new clients first land

A few years ago, a person looking for a therapist typically opened an online directory or asked their primary care clinician. In 2026, that journey often starts on a venture-backed platform that did not exist in its current form during the previous business cycle.

Several platforms expanded sharply through 2025. In April 2025, Teladoc Health acquired UpLift to expand its BetterHelp segment’s insurance-covered offerings. In June 2025, Headspace launched “Therapy by Headspace,” a direct-to-consumer clinical therapy service available with insurance coverage in all 50 states. Insurer-backed platforms have continued to grow employer benefit footprints.

Two things follow. Clients who would have searched for an independent therapist now often start (and sometimes end) inside a platform. And the platforms have absorbed enough of the marketing oxygen in mental health that organic discovery for solo clinicians has gotten more competitive.

AI tools are absorbing some of the conversations that used to start with a clinician

AI has not replaced therapy. But for some prospective clients with subclinical concerns like friend conflict, breakup, or mild work anxiety, a chatbot is now where the first conversation happens.

A nationally representative survey of 1,058 U.S. adolescents and young adults aged 12 to 21, conducted by RAND researchers in early 2025 and published in November, found that 13.1% had used generative AI for mental health advice. Among those who had, two-thirds reported using AI at least monthly. Roughly one in five young adults aged 18 to 21 had used a large language model for mental health support.

Some friction-light conversations that used to be the entry point into therapy are now happening with software. Not all of those would have ended in a clinical referral. Some would have.

Reimbursement has not kept pace with the cost of running a practice

CMS finalized the Medicare physician fee schedule for 2026 in October 2025. The conversion factor rose modestly to $33.40 (or $33.57 for qualifying APM participants), a partial recovery from a 2.83% reduction that took effect in 2025. Commercial insurance has historically followed Medicare’s pattern; a Congressional Budget Office analysis of commercial claims data found that commercial plans paid in-network mental health clinicians 13% to 14% less than Medicare for psychotherapy and evaluation services.

And on the insurance side, a 2024 study from RTI International, analyzing insurance claims from more than 22 million people, found that in-network reimbursement rates for office visits with behavioral health clinicians were on average 22% lower than for medical and surgical clinicians. Patients were 3.5 times more likely to see a behavioral health clinician out of network than a medical/surgical clinician and 10.6 times more likely to go out of network for a psychologist.

The APA’s 2024 Practitioner Pulse Survey found that about a third (34%) of psychologists do not accept insurance, and the most commonly cited reason was insufficient reimbursement. Meanwhile, the cost of running a practice (including rent, software, continuing education, malpractice, billing, marketing) has risen with general inflation. The squeeze is real, and it explains why some clinicians are seeing fewer insurance-covered sessions per week even as demand for low-cost mental health care continues to climb.

And with parity rules being re-written because of challenges in court, the reimbursement gap remains in place with no near-term corrective mechanism on the horizon.

Those numbers explain why it’s hard to recruit clients who have insurance but can’t afford the out-of-network rates, and why staying in network at current reimbursement levels can make it economically difficult to sustain a practice.

What is and is not in your control

None of the forces described above are things you caused, and none of them can be fixed by posting more on social media or sending a newsletter.

You did not write OBBBA. You did not approve the 2025 Medicare cuts. You did not raise commercial deductibles or fund the venture round behind the latest direct-to-consumer platform. You also did not somehow lose the clinical skill that filled your caseload in 2025.

What is in your control: how easily clients can find you, how smoothly they move from inquiry to first appointment, how well your referral pipeline is maintained, and whether your current payer mix and fee structure still make operational sense given the market you’re actually in, and whether administrative drag leaves you any room to do any of the above.

A more honest reframe

The market is recalibrating after a five-year period that no clinician in private practice had seen before. Demand is settling toward a new baseline, the workforce is larger, payer dynamics are tightening, and the way clients find clinicians is genuinely changing. 

You are not a worse clinician than you were two years ago. The market is different. Adjusting to that is unglamorous work, and it’s also the work that protects the parts of your practice you most want to keep.