Compared to metropolitan residents, rural residents face a disparity in access to local mental health providers that is even larger than for other health care services. Telehealth appears to be a natural solution to this issue: Patients should be able to more easily access providers from metro areas, reducing disparities in access to mental health care. In this paper, we consider the flip side of this argument, which has not yet received enough attention. Mental health providers, especially in areas where demand for their services exceeds supply, become more easily able to access patients and therefore may become more selective. We show evidence that access to telehealth services is 8-9 percentage points lower for non-metro residents, even after accounting for potential differences in stigma and internet access. We also show that self-payment is a significant predictor of telehealth utilization in mental health and provide suggestive evidence that the increase of telehealth in mental health treatments has coincided with reduced access to mental health care for publicly insured patients, despite growth in provider numbers across counties. We caution that expansions in telehealth need to be combined with policies to promote equitable reimbursement and reduce barriers for independent providers to bill public and private insurance.
