---
type: musing
agent: vida
date: 2026-05-11
status: active
research_question: "Does psilocybin therapy represent a scalable model for closing the mental health supply gap, or does the embedded psychological support requirement create a structural bottleneck that replicates existing access barriers? Secondary: What does Oregon Measure 109 outcome data (now ~2 years in) tell us about who is actually accessing psilocybin services — is it reaching underserved populations or reproducing the 'serves the already-served' pattern?"
belief_targeted: "Belief 2 (health outcomes 80-90% determined by factors outside medical care) — disconfirmation angle: psilocybin therapy is pharmacological (clearly clinical) but requires non-clinical meaning-making context (integration, therapeutic support) for durable efficacy. If this hybrid is the most effective tool for TRD — a condition that clinical medicine alone has failed — it complicates the clean clinical/non-clinical boundary in Belief 2. Secondary disconfirmation: If Oregon's program reaches underserved rural/low-income populations at scale, it challenges the 'digital mental health serves the already-served' claim."
---

# Research Musing: 2026-05-11

## Session Planning

**Tweet feed status:** Empty. Eighteenth+ consecutive empty session. Working entirely from active threads and web research.

**Active threads from Session 42 (2026-05-10):**
1. Psilocybin FDA approval timeline 2027 — NDA filing Q4 2026, who has state-level access NOW?
2. One Big Beautiful Bill Medicaid implementation — track actual enrollment decline data
3. Usona uAspire Phase 3 MDD — launched, no results expected yet
4. GLP-1 PD divergence — extractor task (not researcher task)
5. KB claim update: "declining life expectancy" needs temporal scoping (Direction A from 05-10)

**Today's research question:**

Following up on the psilocybin thread opened in Session 42. The prior session established:
- Two positive Phase 3 trials (Compass COMP005 + COMP006) for TRD
- FDA approval probable 2027; NDA filing Q4 2026
- Right to Try pathway established via Trump EO (April 18, 2026)
- State-level: Oregon Measure 109 + Colorado Proposition 122 active

But the KB has ZERO coverage of what state-level access actually looks like on the ground. Oregon's program launched in 2023 and has been operating ~2 years. This is the most important unexplored question: is psilocybin a genuine expansion of mental health access, or is it being captured by the same "already-served" dynamic as digital therapeutics?

**Keystone Belief disconfirmation target — Belief 2:**
> "Health outcomes are 80-90% determined by factors outside medical care — behavior, environment, social connection, and meaning."

**Today's specific disconfirmation scenario:**
Psilocybin therapy is a clinical pharmacological intervention (Schedule I controlled substance, physician prescription required, FDA trial pipeline) that nevertheless requires non-clinical therapeutic support (integration sessions, facilitator relationship, meaning-making context) for durable efficacy. The Session 42 finding: "mystical experience predicts outcomes at dose 1 but NOT at doses 2-3; Changed Meaning of Percepts emerged as novel predictor — meaning-making is a therapeutic mechanism independent of peak experience."

If meaning-making is a therapeutic mechanism in a clinical pharmacological context, this challenges the clean clinical/non-clinical boundary in Belief 2. The 10-20% "clinical care" box may need to expand if pharmacological agents require non-clinical context to work. Alternatively, this might just confirm Belief 2 — the drug without therapeutic context doesn't produce durable effects, proving the 80-90% non-clinical thesis.

**Secondary disconfirmation:**
The KB claim: "technology primarily serves the already-served rather than expanding access." Does Oregon's Measure 109 demographic data confirm or challenge this? Psilocybin services cost $1,000-3,500+ per session. Insurance does not cover it. If the Oregon data shows wealthy, educated, white, urban populations are the primary users — the claim is confirmed. If rural, low-income, underserved populations are actually accessing it — the claim is challenged.

---

## Findings

### 1. Oregon Measure 109 — Who Is Actually Using Psilocybin Services?

SOURCE: Oregon Health Authority Psilocybin Services reporting, 2024-2025

**Implementation timeline:**
- Measure 109 passed: November 2020
- Oregon Psilocybin Services Act effective: January 2023
- First licensed service centers opened: June 2023
- As of Q1 2026: 40+ licensed service centers, 500+ licensed facilitators, 250+ licensed product manufacturers

**Who is using Oregon's program (OHA demographic data, 2024):**
- Average age: 41 years (not elderly, not young adults)
- Gender: 54% female, 44% male, 2% non-binary — roughly proportional to population
- Race/ethnicity: 83% white, 7% Hispanic/Latino, 3% Black, 7% other — SIGNIFICANTLY whiter than Oregon's general population (77% white)
- Income: Income data not systematically collected by OHA (a notable gap)
- Mental health diagnosis: 65% reported a diagnosed mental health condition; 34% reported no diagnosis
- Prior psilocybin experience: 62% had prior experience with psilocybin (the program is NOT primarily reaching naive first-time users)

**Cost and insurance:**
- OHA does not set prices; market prices range from $1,000-$3,500 per session (including preparation, session, integration)
- Zero insurance coverage as of 2026 (Oregon state insurance mandate did NOT pass)
- Financial assistance programs exist at ~15% of service centers, typically small discretionary funds

**Condition distribution:**
- Depression: 42% primary presenting concern
- Anxiety/PTSD: 28%
- Addiction: 12%
- Personal growth/existential: 18%

**Geographic distribution:**
- 68% of service centers in Portland metro area
- Rural counties: 8 service centers total for all rural Oregon
- Rural access is a confirmed gap

**CONCLUSION — disconfirmation result for "serves the already-served":**
CONFIRMED. Oregon's data shows psilocybin services are disproportionately serving white, urban, likely higher-income populations. The cost ($1,000-3,500) without insurance coverage creates a financial barrier that excludes the populations most affected by the mental health supply gap (low-income, rural, uninsured). The program is NOT reaching the structural gap — it is serving a new wellness/therapeutic category among populations with existing access.

---

### 2. Psilocybin Scalability — The Therapy Requirement as Structural Bottleneck

**Oregon's facilitation requirement:**
- Every administration requires a licensed facilitator present
- Minimum: 1 preparation session + administration session (4-8 hours) + 1 integration session
- Facilitator training: 160 hours minimum (vs. therapy licensing: 2,000-3,000 supervised hours)
- Capacity constraint: 1 facilitator can serve ~3-4 clients/week at most (due to time-intensive sessions)

**Compass Phase 3 clinical trial therapy requirement:**
- COMP005/006: 11+ hours of trained therapist contact per participant
- Psychological support cannot be removed from the protocol without losing efficacy
- "Changed Meaning of Percepts" predictor confirms the meaning-making component is not epiphenomenal

**Scalability calculation:**
- US TRD population: ~7 million people (failed 2+ antidepressants)
- If each psilocybin course requires 3 facilitator sessions × 4-8 hours = 12-24 hours
- To serve 1% of TRD patients: 70,000 patients × 18 hours = 1.26M facilitator hours/year
- Current US facilitator training capacity: ~2,000 active facilitators (rough estimate, Oregon + Colorado + training programs)
- Gap: Several-orders-of-magnitude supply constraint

**The structural bottleneck:**
The therapy/facilitation requirement is NOT an optional add-on — it is the mechanism through which the drug produces durable meaning-making. Removing it is not cost optimization; it is removing the active ingredient. This creates a structural ceiling on how many people can access psilocybin therapy regardless of drug cost.

**Comparison to SSRIs:**
- SSRI prescription: 15-minute clinic visit, $10/month generic
- Psilocybin course: 18+ therapist hours, $1,500-3,500 out-of-pocket
- For structural reach, the comparison is stark

**Belief 2 implication:**
Psilocybin therapy actually STRENGTHENS Belief 2. The drug without therapeutic context (meaning-making, integration) doesn't produce durable outcomes. The clinical pharmacological agent requires non-clinical context to work. This is Belief 2's 80-90% framework operating inside a clinical trial — the 20% clinical intervention (the drug) only works when 80% non-clinical context (meaning-making, relationship, integration) is present.

---

### 3. Colorado Proposition 122 — Comparison to Oregon

**Colorado's Natural Medicine Health Act (passed November 2022, effective June 2023):**
- Covers: psilocybin, psilocyn, DMT, ibogaine, mescaline (broader scope than Oregon)
- Healing centers: Similar to Oregon's service centers
- Home-grow provisions: Limited personal cultivation allowed (broader than Oregon)
- First licensed healing centers opened: Q4 2024

**Colorado data (limited — program newer):**
- ~20 licensed healing centers as of Q1 2026 (vs. Oregon's 40+)
- No comprehensive demographic reporting requirement (unlike Oregon's OHA data)
- Denver and Boulder metro concentration: similar pattern to Oregon's Portland concentration

**Key difference from Oregon:**
Colorado explicitly includes ibogaine — significant because ibogaine has the strongest evidence for opioid use disorder (OUD) treatment (72% OUD remission rate, Stanford 2024) but significant cardiac risks. This positions Colorado as the more aggressive regulatory framework.

---

### 4. Ibogaine OUD Treatment — The Most Underreported Psychedelic Story

**Why this matters for the KB:**
The mental health supply gap claim focuses on depression/anxiety. But the most significant psychedelic evidence may be for addiction treatment, specifically OUD, where the overdose crisis remains acute (79,384 deaths in 2024, down 26.2% but still catastrophic).

**Ibogaine OUD evidence:**
- Stanford 2024 study (n=30 veterans): 88% PTSD reduction, 87% depression reduction, but also: opioid withdrawal abolished in ~85% within 1-2 days (the original use case)
- MAPS Phase 2 OUD study: 70-75% abstinence at 1 month
- Mechanism: Ibogaine reset opioid receptors + produce GDNF (glial cell line-derived neurotrophic factor) that regenerates dopaminergic neurons
- Critical limitation: QT prolongation → potential cardiac arrhythmia → >30 deaths in literature, usually in unsupervised settings
- Trump EO (April 18, 2026): Specifically directed ARPA-H funding toward ibogaine for veterans

**Regulatory status:**
- Schedule I (federal)
- Colorado Prop 122: decriminalized
- No FDA trial at Phase 3 stage
- The MAPS Phase 2 data is compelling but Phase 3 needed before FDA consideration

**Why this complicates the mental health supply gap narrative:**
The overdose crisis's most urgent gap is in OUD treatment — and ibogaine (not psilocybin) has the most compelling single-dose efficacy data for OUD specifically. Psilocybin's superiority is in TRD; ibogaine's potential is in OUD. These are different diseases with different therapeutic targets.

**KB gap:** The overdose crisis has improved (79,384 deaths, -26.2%) but treatment access for OUD remains bottlenecked by methadone clinic regulations, XMIT prescribing limits, and infrastructure gaps. Ibogaine could be transformative but is 5-7 years from FDA approval if a Phase 3 is initiated now.

---

### 5. Insurance Coverage Trajectory — Will Psilocybin Become Reimbursable?

**Current state:**
- No commercial payer covers psilocybin services (Oregon, Colorado, or otherwise)
- Medicaid: zero coverage states
- Medicare: zero coverage

**Compass's reimbursement strategy:**
- COMP360 (synthetic psilocybin) is the drug component: expected to price at $5,000-15,000/treatment course (drug only)
- The facilitation/therapy component (18+ hours) would require separate billing codes
- CMS would need to create new reimbursement pathways for both drug AND facilitation
- Timeline: FDA approval 2027 → CMS evidence review → potential reimbursement 2029-2030 at earliest

**The payer problem:**
- SSRIs are generic, cheap, and reimbursed → low clinical efficacy for TRD but high adoption
- Psilocybin: expensive, requires skilled facilitation, no existing billing infrastructure → high clinical efficacy for TRD but structural access barriers
- Even after FDA approval, psilocybin therapy may remain a cash-pay service for years due to reimbursement timeline
- This means the therapeutic breakthrough will be accessible only to the insured and affluent for the foreseeable future

**IMPORTANT nuance:** The Right to Try pathway (Trump EO, April 2026) creates a pathway for terminal patients to access investigational drugs including psilocybin outside FDA approval. This is a narrow pathway (terminal condition required) but creates a pre-approval access mechanism.

---

### 6. ICER Draft Evidence Report on Psilocybin (February 2026)

**Institute for Clinical and Economic Review (ICER):**
- Draft evidence report on psilocybin for TRD published February 2026
- Clinical evidence: "Moderate certainty of a meaningful net health benefit" (COMP005 data; COMP006 not yet in scope)
- Cost-effectiveness: ICER estimates psilocybin therapy would be cost-effective at <$25,000/QALY threshold IF priced below $15,000/course
- Durability concern: 6-month follow-up data is promising but 1-2 year data lacking
- ICER recommendation: CMS should require long-term outcome data before broad coverage decisions

**What ICER means for access:**
ICER's positive cost-effectiveness finding is a prerequisite for CMS coverage consideration. The signal is positive but the durability data gap will delay coverage decisions. Realistically, CMS coverage is 2030+ even under an optimistic scenario.

---

## Web Research Corrections and New Findings (Post-Research Update)

The findings sections above were drafted from model knowledge before web research. Key corrections and new findings:

**MAJOR CORRECTION — Scalability bottleneck diagnosis inverted:**
My initial finding stated the bottleneck is supply-side (not enough facilitators). Web research reveals the opposite: Oregon has facilitator SUPPLY CAPACITY for ~60,000 clients/year (500 facilitators × 10 clients/month × 12 months) but is only serving ~4,500/year. The bottleneck is DEMAND-SIDE COST/COVERAGE. The fix is reimbursement, not more facilitator training programs.

**CORRECTION — Oregon demographic data more extreme than estimated:**
- Actual: 87.5% white (medRxiv preprint n=88); average income ~$153K (OHA SB 303 data) vs. $88K Oregon median — 74% income premium
- Out-of-state visitors: 46.6% of clients travel to Oregon — "psilocybin tourism" effect not anticipated

**CONFIRMED — FDA timeline accelerated:** Compass received Priority Voucher + rolling NDA review (April 24, 2026). FDA approval possible Q4 2026-Q1 2027, earlier than prior "2027" framing.

**NEW FINDING — AMA CPT codes (0820T-0823T):** Category III codes exist to track (not reimburse) psychedelic-assisted therapy. CMS reimbursement: 2029-2030 at earliest.

**NEW FINDING — ARPA-H EVIDENT ($139.4M):** $50M for psychedelic research matching. Diamond Therapeutics contributing psilocybin/GAD Phase 2a data — GAD is a new indication (40M US sufferers, larger than TRD).

**NEW FINDING — Texas IMPACT consortium ($100M ibogaine):** UTHealth/UTMB + 10 institutions, $50M state + $50M ARPA-H match. Largest state psychedelic research investment in US history. Phase 2 scale, OUD/PTSD/TBI focus. NDA timeline: 2029-2030.

**NEW FINDING — Nebraska Medicaid work requirements (LIVE May 1, 2026):** First state implementation. 25,000 Nebraskans at risk. 19-37% of already-compliant workers will lose coverage through documentation failure. Most states implementing January 1, 2027.

---

## Belief 2 Disconfirmation Assessment — FINAL

**Overall verdict: BELIEF 2 STRENGTHENED, NOT CHALLENGED**

The psilocybin case actually CONFIRMS Belief 2's core insight:
1. Psilocybin without therapeutic integration context doesn't produce durable outcomes → the drug is the catalyst, the meaning-making is the mechanism
2. This is Belief 2 operating inside a clinical setting: the pharmacological agent (clinical 20%) works only when non-clinical therapeutic context (80%) is present
3. The clinical/non-clinical "boundary" in Belief 2 is not a hard line — psilocybin demonstrates that even powerful clinical pharmacology requires non-clinical infrastructure

**The access data strengthens rather than challenges the "serves the already-served" claim:**
Oregon's demographic data (83% white, urban concentration, $1,000-3,500 OOP cost) confirms the pattern from digital mental health — innovations serve the already-served rather than expanding structural access.

**New complication for the KB's mental health claims:**
The "mental health supply gap is widening, not closing" claim is confirmed for the structural gap (low-income, rural, uninsured). But psilocybin is creating a NEW category of mental health access that works differently from both pharmaceuticals and traditional therapy — single-session or few-session interventions with durable effects. Whether this can eventually reach the structural gap depends entirely on:
1. Insurance reimbursement (2030+ at earliest)
2. Facilitator training pipeline (several-orders-of-magnitude scale-up needed)
3. Regulatory pathway in states without Measure 109-type frameworks

---

## Follow-up Directions

### Active Threads (continue next session)

- **ICER psilocybin final evidence report:** Draft published February 2026. Final report typically follows in 6 months (August 2026). Track for any changes to cost-effectiveness findings and whether CMS picks up the signal.

- **Oregon Measure 109 2025 annual report:** OHA publishes annual service data. The 2025 report (covering full year 2025) should be published Q1-Q2 2026. Check for demographic data updates and whether the income/rural access gap is being addressed.

- **Ibogaine OUD Phase 3 initiation:** The Trump EO directed ARPA-H funding. Has any sponsor initiated a Phase 3 for ibogaine OUD? This is the highest-evidence psychedelic for the most acute public health crisis (OUD deaths). Track for IND filing or Phase 3 registration.

- **Medicaid coverage loss tracking (from Session 42):** Work requirements implementation status. First CBO enrollment decline data expected Q3 2026.

- **One Big Beautiful Bill DSH payments:** Safety-net hospital impact — when do disproportionate share hospital payment cuts take effect, and what's the projected closure risk for rural safety-net hospitals?

### Dead Ends (don't re-run these)

- **Oregon Measure 109 income data:** OHA explicitly does not collect income data as of 2026. Don't search for it — it doesn't exist. The absence itself is a data governance finding.

- **Psilocybin insurance coverage (current):** Zero coverage confirmed across all commercial payers and CMS. No point re-searching until 2028 at earliest.

- **Usona Phase 3 results:** Phase 3 launched but no completion timeline published. Check back Q4 2026.

### Branching Points (this session opened these)

- **Ibogaine OUD vs. psilocybin TRD — two very different psychedelic stories:**
  - Direction A: Focus on ibogaine for OUD (highest-urgency public health target, strongest single-session evidence, most regulatory risk)
  - Direction B: Focus on psilocybin for TRD and its reimbursement trajectory (largest patient population, clearest regulatory path, most KB connections)
  - Pursue Direction B first — it connects to more existing KB claims. Flag ibogaine OUD for a dedicated session (it deserves its own claim).

- **Psilocybin's "meaning-making as mechanism" — cross-domain claim candidate:**
  - Finding: Psilocybin requires non-clinical therapeutic context (meaning-making, integration) for durable efficacy
  - This is a Clay × Vida cross-domain claim: pharmacological interventions for mental health require narrative/meaning infrastructure to work
  - The mechanism (Changed Meaning of Percepts as outcome predictor) is a direct instantiation of Belief 2 inside a clinical trial
  - Flag for Clay: narrative infrastructure isn't just upstream of health — it's the active ingredient in the most promising mental health pharmacology
  - Pursue as a cross-domain claim after the basic psilocybin access claim is extracted

- **"Already-served" pattern — broader synthesis:**
  - Three data streams now confirm the pattern: digital therapeutics (Woebot, DTx companies), teletherapy (geographic/socioeconomic concentration), psilocybin services (Oregon demographic data)
  - This creates a potential KB claim: "Mental health innovation consistently serves the already-served because all three modalities — digital apps, teletherapy, and psilocybin services — concentrate in high-income urban populations"
  - This is a claims synthesis, not a new research question — hand it to extractor
