Two Dimensions of Access: Availability and Affordability of Mental Health Care Across the U.S.
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Access is the first gateway to mental health care utilization, shaping who ultimately receives support and who does not. Yet access is multidimensional, influenced concurrently by structural, financial, and social conditions. Among these, availability and affordability remain especially consequential. Prior research has indicated shortages of psychiatrists and provider counts, but has rarely considered affordability in conjunction with availability. This study addresses these gaps by analyzing over 460,000 psychotherapists listed in the Psychology Today directory, which provides consumer-facing data on fees and insurance acceptance. We constructed county-level indices of availability (providers per 100,000 residents) and affordability (ten-session cost relative to disposable income) across 2,565 U.S. counties. Results show persistent rural–urban disparities, with provider density being highest in metropolitan cores and lowest in rural and conservative counties. At the same time, financial burdens were systematically greater outside large urban areas, especially in the South. Although availability and affordability frequently overlap, important divergences emerge, including counties with providers present but financially inaccessible. Regression analyses reveal that income is the strongest predictor across both indices, with political partisanship and racial/ethnic composition also shaping access. By integrating supply and cost, this study empirically reframes accessibility as multidimensional and identifies regions most affected by dual burdens. Findings highlight affordability as a distinct axis of accessibility and underscore the need for targeted workforce and financial interventions, including Medicaid expansion.
