Over the past several months, I have been receiving a growing number of calls from people in Iowa who are looking for a therapist and are on Medicaid. Not a trickle — enough calls that I made a decision: I was going to start the credentialing process and try to serve this population.
I successfully credentialed with Iowa Medicaid Enterprise (IME), which opened the door to credentialing with Iowa's Managed Care Organizations — the for-profit insurance companies the state contracts with to administer Medicaid benefits. I am still waiting to hear from Iowa Total Care. But Molina Healthcare of Iowa responded quickly. Their answer was no.
Here is the exact letter I received:
"Hi Rich, Thank you for your interest in joining the Molina Healthcare of Iowa Network. At this time, the Iowa health plan is not considering new in-network behavioral health contracts. When this changes in the future, we will be happy to review the request at that time. We appreciate the interest and the opportunity to consider the inquiry. — Kelsey Cox, LBSW, Provider Relations Manager, Molina Healthcare of Iowa"
A flat rejection. No review of my credentials, no assessment of network need, no consideration of the patients calling my office who cannot find care. Just: we are not accepting new behavioral health providers.
What I later learned made it worse. Molina is not just declining new providers
they have been sending termination letters to behavioral health providers already in their network, removing them without cause. Providers who have been serving Medicaid patients for years are being quietly pushed out. The network is not just closed to growth. It is actively shrinking.
This is not a business decision that happens in a vacuum. It is happening in one of the most underserved states in the country, to the most vulnerable people in it. And it needs to be named for what it is: a social injustice.
The Scope of Iowa's Mental Health Crisis
Iowa's mental health provider shortage is not a new problem. It is a documented, persistent, and worsening crisis that affects every corner of the state.
According to the Health Resources and Services Administration (HRSA), as of 2024, Iowa has 72 federally designated Mental Health Professional Shortage Areas (MHPSAs). These are geographic regions, population groups, or facilities where the mental health workforce is so insufficient that the federal government formally recognizes them as underserved. Approximately 60% of Iowa's counties qualify as mental health shortage areas.
HRSA estimates that Iowa would need to add roughly 110 additional mental health practitioners just to meet the minimum threshold to remove its shortage designations — and that number does not account for unmet need among people who have stopped looking for care because they cannot find it.
The psychiatrist shortage is particularly severe. Iowa has approximately 3.5 psychiatrists per 100,000 residents
well below the national average of around 8 per 100,000, and far below what is needed to meet demand. The American Association of Medical Colleges projects a national shortage of up to 31,000 psychiatrists by 2030. Iowa is already living that future.
Rural Iowa carries a disproportionate share of this burden. In many rural counties, there is no psychiatrist within a reasonable driving distance. Telehealth has helped close some of that gap — but only for patients whose insurance actually covers telehealth services with an in-network provider. For Medicaid patients in a closed network, telehealth access is only as good as the network itself.
The Human Cost Behind the Numbers
The 2023 Iowa Behavioral Health Needs Assessment found that approximately 1 in 5 Iowa adults — roughly 500,000 people — experience a mental health condition in any given year. Of those, fewer than half receive any treatment. Among adults with serious mental illness, the treatment gap is even wider.
Iowa's suicide rate has been consistently above the national average. The 2022 Iowa Youth Survey found that 1 in 4 Iowa high school students reported feeling so sad or hopeless for two or more weeks that they stopped doing usual activities. Nearly 1 in 10 reported making a plan to attempt suicide.
Medicaid enrollees are among the highest-need individuals in this population. They are more likely to have co-occurring substance use disorders, trauma histories, chronic illness, and housing instability. They are also the least likely to be able to pay out of pocket for care when their insurance network fails them. When a Medicaid MCO closes its behavioral health network, it is not an inconvenience. For many people, it is the end of the road.
How Iowa Got Here: The MCO Experiment
Iowa transitioned its Medicaid program to a managed care model in 2016, contracting with for-profit insurance companies to administer benefits for approximately 700,000 Iowans. The stated goal was to improve care coordination and reduce costs. The reality has been more complicated.
Iowa currently contracts with three MCOs: Molina Healthcare of Iowa, Iowa Total Care (a subsidiary of Centene Corporation), and UnitedHealthcare Community Plan. All three are subsidiaries of large, publicly traded national corporations with shareholders and quarterly earnings expectations. Their financial incentives are not perfectly aligned with the goal of maximizing access to behavioral health care.
Managed care organizations are paid a fixed per-member, per-month capitation rate by the state. Every dollar spent on member care is a dollar that does not become profit. Behavioral health services — therapy, psychiatric medication management, crisis intervention — are among the most expensive and most utilized services in a Medicaid population. The financial logic of closing a behavioral health network, from a shareholder perspective, is not difficult to follow.
Iowa's MCO contracts do include network adequacy standards
requirements that MCOs maintain a sufficient number of in-network providers to ensure timely access to care. The Iowa Department of Health and Human Services is responsible for monitoring and enforcing those standards. But enforcement has been inconsistent, and the standards themselves have not kept pace with the scale of the provider shortage.
When Molina closes its behavioral health network to new providers and simultaneously terminates existing ones, the question that should be asked — loudly, and by regulators — is: how does this plan continue to meet its network adequacy obligations? And if it cannot, what are the consequences?
What This Looks Like on the Ground
The people calling my office are not abstractions. They are Iowans who have done everything right. They have a Medicaid card. They have identified that they need help. They have picked up the phone and called a therapist. And they are being told, again and again, that no one in their network is available, accepting new patients, or even still in the network at all.
The experience of repeatedly being turned away from mental health care is itself traumatizing. It confirms the fear that help is not available, that their needs are too much, that the system was not built for them. For someone already struggling with depression, trauma, or suicidal ideation, that message can be lethal.
This is not a neutral outcome. It is a predictable consequence of allowing for-profit corporations to administer public health benefits without adequate accountability for access.
What Needs to Change
Iowa's mental health crisis will not be solved by any single policy change. But there are concrete steps that would make a meaningful difference.
First, the Iowa Department of Health and Human Services must enforce network adequacy standards with real consequences. MCOs that cannot demonstrate sufficient behavioral health network capacity should face financial penalties, corrective action plans, and — if necessary — contract termination. A network adequacy standard that is never enforced is not a standard. It is a suggestion.
Second, Iowa should require MCOs to publicly report behavioral health network data
the number of in-network providers by county, average wait times for a new patient appointment, and the number of providers added and removed from the network each quarter. Transparency is a precondition for accountability.
Third, Iowa should explore whether the managed care model is serving the behavioral health needs of its Medicaid population — or whether a carve-out model, in which behavioral health benefits are administered separately from physical health, would produce better access outcomes. Several states have moved in this direction precisely because for-profit MCOs have demonstrated an inability or unwillingness to adequately manage behavioral health networks.
Fourth, Iowa should expand loan repayment and incentive programs for mental health providers willing to practice in shortage areas and accept Medicaid. The workforce shortage is real, and it will not be solved without making it financially viable for providers to serve this population.
A Note on Why I Am Writing This
I want to be clear about something. I am not writing this because I am angry about a rejection letter. I am writing this because the rejection letter is a symptom of a system that is failing the people it was designed to serve.
I am continuing the credentialing process. I am still waiting to hear from Iowa Total Care. I am committed to serving Medicaid patients because the calls I have been receiving are from real people in real need, and I have the ability to help.
But one provider accepting Medicaid does not fix a broken system. What fixes a broken system is naming the problem clearly, holding the responsible parties accountable, and demanding that the people making decisions about Medicaid managed care in Iowa answer for what is happening to the most vulnerable Iowans in their networks.
If you are an Iowa Medicaid enrollee who has been unable to access mental health care, your experience matters and your voice matters. Contact the Iowa Department of Health and Human Services at 1-800-338-8366. File a grievance with your MCO. Contact your state legislators. The Iowa Legislature's Health and Human Services committees have oversight responsibility for Medicaid managed care — they need to hear from constituents about what is happening.
If you are a mental health provider in Iowa who has received a network termination letter from Molina or another MCO, consider sharing your experience publicly and with the Iowa Department of Health and Human Services. Individual stories, aggregated, become data. Data becomes policy.
The people calling my office deserve better. Iowa deserves better.