Dear Dangerously in Love with Finance,
I’m scared. I’m angry. And if I’m being honest, I’m exhausted from trying to hold it all together.
I own a private therapy practice in Ohio. Most of my clients are low-income, and about 65% of them are on Medicaid. They’re not just numbers to me—they’re trauma survivors, new mothers with postpartum depression, veterans, and teens on the edge. These are real people I’ve walked with through the darkest parts of their lives.
With the One Big Beautiful Bill Act (OBBBA) passed, I feel like the rug has been yanked from under all of us. I’ve been hearing about reduced federal Medicaid funding, potential cuts to covered services, stricter eligibility, and lower reimbursement rates. I’m still trying to understand what all the policy details mean, but here’s what I do anticipate: no-shows, clients losing coverage mid-treatment, and even worse—people disappearing from therapy without closure.
How am I supposed to keep my doors open with all these changes?
I have rent, staff, and bills to pay. I’m not trying to be a martyr. I just don’t know how to reconcile my heart for service with the very real financial pressures I’m now facing.
What should I be doing right now—financially and operationally—to navigate this new world of Medicaid mental health reimbursement?
Signed,
—Holding On By a Thread in Ohio
Dear Holding On By a Thread,
First of all, let me say this clearly: your fear is valid, your frustration is justified, and your service is deeply needed. You are the heartbeat of your community’s support system—and the emotional labor you carry deserves not just acknowledgment, but strategy and financial sustainability.
Take a deep breath—we’re going to walk through this and build a plan that protects both your mission and your margins.
💣 What OBBBA Changed—And Why It’s Impacting You Now
The One Big Beautiful Bill Act (OBBBA) is a sweeping piece of legislation that slashed federal Medicaid funding by up to $930 billion over the next decade. And here’s the gut-punch for providers like you: mental health services are considered “optional benefits” under Medicaid law, which means individual states can (and likely will) scale back those services to balance their budgets.
Here’s what mental health providers like you are about to face:
This isn’t just policy—it’s a cash flow crisis. And without strong financial management for therapy practices, even the most mission-driven clinicians won’t survive the fallout.
📉 Revenue Real Talk: Medicaid Is Not a Reliable Foundation Right Now
Here’s the hard truth: if 65% of your therapy revenue comes from Medicaid, your income is officially unstable.
From a CFO perspective, here’s what you need to do now:
- Evaluate your payer mix.
No single payer—especially Medicaid—should account for more than 50% of your income. It’s time to diversify. If private-pay clients or commercial insurance are less than 20% of your caseload, start shifting that ratio. - Know your true reimbursement per session.
How much are you really making after overhead, billing costs, and taxes? If you’re getting $85/session for Medicaid clients and spending $70 to deliver that care, you’re barely surviving—and that margin disappears with one no-show or denied claim. - Rethink your business model.
Explore subscription-based therapy, group therapy options, or sliding scale private-pay services. These models can stabilize income and reduce overreliance on fragile Medicaid reimbursements. This isn’t about abandoning clients—it’s about building a business that can actually afford to keep helping them.
🛠️ Operational Shifts for Medicaid Survival
Let’s talk about your systems. OBBBA has added enormous billing and eligibility burdens. You’re not just a therapist anymore—you’re a Medicaid case manager, compliance monitor, and financial juggler.
Start with these moves:
🤝 You Deserve Support—Not Self-Blame
You didn’t cause this system to change. But you are responsible for how your business responds to it. And right now, that means stepping into financial leadership for your private practice.
Here’s what to do:
- Get professional help reviewing your books
- Build a smarter revenue mix
- Start using tools that help you plan—not just react
You didn’t become a therapist to be a financial analyst. But now, the health of your therapy business depends on having real numbers, real clarity, and a plan that protects your mission.
You are not a failure because the system failed you. You are a business owner. And the next move is yours.
✅ If you need help with financial forecasting, rebalancing your payer mix, or building a model that works even with Medicaid cuts, reach out. I offer CFO services for mental health providers in the U.S.—and together, we’ll protect the heart of your work.
With clarity and care,
Dangerously in Love with Finance
This article is designed to provide information only and should not be considered legal or tax advice. Because of the complexity of the law and the variables in your own personal tax and accounting situation, you can’t rely on our advice specifically related to your unique circumstances. In order to get the best tax savings and legal advice available to you, you should consult with your own accountant, attorney or advisor regarding your particular facts and circumstances. Healthy Bodies of Finance is an accounting firm that specializes in working with health and wellness providers. We provide monthly accounting & bookkeeping services and financial education. For more information on our specialized services for health and wellness providers please contact us at info@healthybodiesoffinance.com