For more than a decade, Kaiser Permanente has been under the microscope for shortcomings in mental health care, even as it is held in high esteem on the medical side.

In 2013, California regulators fined the insurer $4 million for failing to reduce wait times, giving patients inaccurate information, and improperly tracking appointment data. And in 2023, KP agreed to pay $50 million, the largest penalty ever levied by the state’s Department of Managed Health Care, for failing to provide timely care, maintain a sufficient number of mental health providers, and oversee its providers effectively.

Now, Kaiser Permanente is back in the hot seat as mental health workers in Southern California wage a strike that’s in its fourth month. KP therapists and union representatives accuse the HMO giant of saddling workers with excessive caseloads and often forcing patients to wait twice as long as the state allows for follow-up appointments. They say that the staff is burned out and that this work environment makes it hard to recruit clinicians, exacerbating the staffing problem.

KP rebuffs these claims, saying the union is parading out old problems, seeking to create “an inaccurate and outdated perception” of KP’s care. They say the union’s pay demands are “in direct contrast to our commitment to providing quality, affordable care.”

Kaiser Permanente — the largest commercial health plan in California, with about 9 million members — is far from alone in struggling to provide adequate mental health care. A pandemic-induced shortage of health care workers has created obstacles for all health plans in recent years, on top of a preexisting scarcity. Moreover, many therapists decline to contract with insurers. And lingering bias in the health care system against mental health services — and patients — may also be at play.

Federal and state laws require health plans to provide mental health care on par with medical care. But many people who have sought therapy can vouch that those measures, known as mental health parity laws, do not seem to be followed consistently. You can spend hours or even days calling every therapist allegedly in your insurance company’s network and come away empty-handed.

Secret-shopper surveys of 4,300 randomly selected outpatient providers listed as accepting new patients showed that “an alarming proportion” of them were unresponsive or unreachable, according to a federal government report issued last month. And while that was true for medical providers, it was consistently worse for mental health and substance abuse care, according to the report.

In California, state regulators have been conducting behavioral health care investigations of the insurance companies they regulate to help identify the extent and causes of delays in care.

So far, the DMHC has investigated nine health plans (not including KP) and found dozens of violations related to appointment availability, timely access, quality of care, and patient appeals, department spokesperson Rachel Arrezola says. The agency also has identified numerous “barriers” that do not necessarily break the law but may make it more difficult for patients to get care, she says.

Mark Peterson, a professor at UCLA’s Luskin School of Public Affairs, notes that the open-ended nature of therapy can conflict with health plans’ focus on their bottom lines. “It may be once a week, it may be more than once a week and go on for years,” Peterson says.

For insurers, he says, the question is, “How do you put an appropriate limit on that?”

And the unwillingness of many therapists to accept insurance companies’ payment rates, or to abide by their restrictions, often leads them to decline participation in health plan networks and charge higher rates. That, Peterson says, makes therapy financially inaccessible for a lot of people seeking it.

Even if you have some coverage for therapy outside your health plan network, your insurer will pay only a percentage of the rate that it recognizes as legitimate. “If your therapist is charging $300 an hour, and your insurance company only recognizes $150 an hour, and they only pay 50% of what they recognize, now you’ve got a quarter coverage of your therapy,” Peterson says.

Since Kaiser Permanente is a closed system and patients don’t get reimbursed for care outside the network, access problems for its patients can be “highly pronounced,” Peterson adds.

In California, KP has accounted for over $54 million of the $55.7 million in mental-health-related fines the DMHC has levied on insurers in the past two decades. That includes the $50 million fine imposed in 2023, which was part of a settlement in which KP agreed to fix deficiencies the department found and to invest an additional $150 million in projects intended to enhance access to mental health care, not just for KP members, around California.

Officials at the National Union of Healthcare Workers, which represents some 2,400 KP mental health workers in the ongoing Southern California contract talks, say the HMO could easily invest enough to become a paragon of high-quality mental health care if it wanted to.

Greg Tegenkamp, the lead union negotiator, says KP could “lead the way to do the right thing.”

Kaiser Permanente says it already is doing the right thing, even as it acknowledges past shortcomings. In a recent statement, it said it has invested over $1 billion in new treatment spaces and more mental health providers since 2020.

“We’ve grown our workforce and increased our network of skilled therapists so that any Kaiser Permanente member who needs an appointment is able to get timely, high-quality, clinically appropriate care,” the company says.

In addition to higher wages and lower patient loads, workers want more time to complete follow-up tasks outside sessions and the reinstatement of a pension that was eliminated for those hired in Southern California after 2014.

Kaiser Permanente says that it already pays its mental health workers in Southern California about 18% above the market rate and that the current proposal would raise pay even more. KP recently raised its proposed wage increase by a modest amount, according to union officials.

KP refutes reports from workers about long wait times for patients seeking mental health appointments. It says the average wait time is 48 hours for urgent appointments and six business days for nonurgent ones, “which is better than the state’s requirement” of no more than 10 days.

But workers say KP patients still face long delays for follow-up appointments.

“It’s really hard for our patients to get regular, frequent appointments,” says Kassaundra Gutierrez-Thompson, a KP therapist in Southern California who is on strike. Gutierrez-Thompson says she’s seen it from both sides, since she is also a patient who sees a KP psychiatrist for depression and recently faced a big rescheduling delay after one of her appointments was canceled without notice.

As a provider, Gutierrez-Thompson says, she and her colleagues are expected to see patients “back-to-back-to-back.” She says some of her colleagues developed urinary tract infections when they couldn’t get to the bathroom. One even started wearing adult diapers, she says.

“The working conditions are like a factory,” Gutierrez-Thompson says. “We do such human work, but they would love for us to be robots with no needs and just see patients all day.”

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

By Bernard J. Wolfson
Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation, which is not affiliated with Kaiser Permanente.