As 2020 approaches, behavioral health providers are faced with a complex landscape filled with financial and regulatory uncertainty. With ongoing shifts in healthcare policy and funding, many providers are unsure about what to expect in the year ahead. However, despite these uncertainties, experts from the National Council for Behavioral Health are optimistic about the potential for positive changes in the field.
At the forefront of these discussions is Rebecca Farley David, vice president of policy and advocacy at the National Council, who addressed the topic during a keynote speech at the Community Behavioral Healthcare Association (CBHA) of Illinois’s 47th Annual Conference. David’s outlook for fiscal year 2020, which began on October 1, 2019, was largely positive, though she acknowledged the significant challenges that still exist. According to David, while a government shutdown seems unlikely, and major cuts to mental health and addiction programs funded by the Substance Abuse and Mental Health Services Administration (SAMHSA) are not expected, there are still hurdles ahead for behavioral health providers.
Opportunities for Growth in Behavioral Health Care
One of the key positives highlighted during David’s speech was the continued expansion of opportunities for Medicaid providers in the behavioral health space. In particular, she emphasized the impact of the Centers for Medicare and Medicaid Services (CMS) granting waivers that allow providers to bypass the Institute for Mental Disease (IMD) exclusion rule. The IMD exclusion typically prevents Medicaid from reimbursing for care in inpatient facilities with more than 16 beds, which has long been a barrier for larger treatment facilities that serve people with severe substance use disorders or mental health conditions.
Previously, these waivers were only available for substance abuse treatment, but in November of 2019, CMS granted the first mental health IMD exclusion waiver. This marks a significant step forward in expanding access to care for individuals who need inpatient services. According to David, these waivers are part of a broader trend in which CMS continues to approve the expansion of community-based benefits and initiatives aimed at reforming the behavioral health delivery system.
With bipartisan support from both sides of the political spectrum, the opioid epidemic remains a top priority for policymakers, which further emphasizes the need for ongoing reforms and better support for those struggling with addiction. However, David stressed that the expansion of Medicaid benefits must be coupled with efforts to remove eligibility barriers. While expanding access is an important step, any program that imposes eligibility restrictions—such as work requirements—ultimately undermines the goal of increasing access to care.
The Double-Edged Sword of Flexibility in Medicaid
A critical issue in 2020 will be the increased flexibility granted to states under the Trump administration’s Medicaid reforms. This flexibility allows states to implement policies that could either expand access to care or restrict it, depending on how the policies are shaped. Work requirements for Medicaid beneficiaries, for example, have emerged as one of the more contentious issues in recent years. Under these requirements, individuals must verify their employment status, or show that they are training or actively looking for work, in order to maintain Medicaid coverage.
While some states have used this new flexibility to expand access, others have imposed work requirements that have led to reductions in Medicaid enrollment. David pointed to Arkansas as an example, where 18,000 people lost their Medicaid coverage after the implementation of work requirements. The majority of those who lost coverage did so not because they failed to meet the work requirements, but because they failed to report whether they had met the requirements or qualified for an exemption. The administrative burden associated with these requirements can be overwhelming, especially for individuals who are already facing significant health challenges, such as those with mental health or substance use disorders.
The National Council for Behavioral Health has been actively working to reverse these work requirements, and David noted that the organization is also advocating for the elimination of similar requirements for other federal assistance programs, such as the Supplemental Nutrition Assistance Program (SNAP).
Other Challenges Facing Providers in 2020
While David’s outlook for Medicaid expansion and other reforms remains positive, she acknowledged several pain points that could make 2020 a challenging year for behavioral health providers. One of the most pressing issues is the continued shortage of behavioral health professionals. The workforce shortage has been a chronic issue in the field, and it’s unlikely to improve in the near future unless more efforts are made to support the training and retention of skilled professionals.
To address this, the National Council has been advocating for programs such as loan forgiveness for behavioral health workers and legislation that would allow clinicians to operate at the top of their licensure. For instance, the Mental Health Access Improvement Act, which would enable licensed professional counselors and marriage and family therapists to bill Medicare directly for their services, has gained significant support. This bill has seen an increase in co-sponsors in the current Congress, a sign that advocates have made significant strides in educating lawmakers about the importance of supporting the behavioral health workforce.
David’s remarks on the Mental Health Access Improvement Act were met with applause from conference attendees, illustrating the widespread support for the bill among those in the field. However, the primary challenge to passing the legislation remains the cost. As David noted, lawmakers must be convinced that the investment in improving access to mental health care through expanded billing opportunities for behavioral health professionals is worth the cost.
The Opioid Epidemic and Other Substance Use Disorders
Another challenge that David raised in her speech was the continued focus on the opioid epidemic, which has received a significant amount of attention and funding in recent years. While it is undoubtedly important to address the opioid crisis, David cautioned that other substance use disorders are often falling through the cracks in the process. As much as policymakers have prioritized opioids, other forms of substance abuse are still rampant, and providers need more support to address these issues as well.
Moreover, David pointed out that the opioid crisis has been largely funded by grants, and there is a lack of consistent, non-grant funding flowing into addiction treatment programs. This is a problem that behavioral health providers need to address, as grants are often time-limited and do not provide the long-term stability that is needed to build sustainable addiction treatment programs.
Looking Ahead: The Future of Behavioral Health Care
Despite the challenges ahead, David and other policy experts at the National Council remain optimistic about the future of behavioral health. The ongoing efforts to expand access to care, remove eligibility restrictions, and improve the behavioral health workforce will continue to shape the landscape in the coming years.
As 2020 unfolds, it’s clear that behavioral health care will continue to be a central focus in healthcare policy discussions. While uncertainty remains around funding and regulation, the optimism shared by experts like Rebecca Farley David highlights the importance of advocacy and collaboration in addressing the mental health and addiction crises that continue to affect millions of Americans. By working together, policymakers, providers, and advocacy organizations can help ensure that behavioral health gets the attention and resources it deserves in the year ahead.
