The Atrómitos Way

#057: When the Safety Net Frays: What HR1 Means for Behavioral Health Access in Washington

• Atrómitos, LLC • Season 5 • Episode 57

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Signed on July 4, 2025, H.R.1 cut roughly $1 trillion in federal Medicaid spending over ten years, in the largest restructuring of Medicaid financing in a generation. Because Medicaid funds about a quarter of all U.S. mental health and substance use treatment, the cuts fall disproportionately on behavioral health. Almost one year after its signing, Michealle Gady sat down with Joan Miller to discuss what the law does, the work-requirement paradox, provider finances, and what to do next.

Joan Miller is CEO of the Washington Council for Behavioral Health, the statewide association of community behavioral health agencies, the state’s behavioral health safety net. She guides the Council’s strategic vision and builds partnerships that promote system improvement, and can speak to both the mechanics of the law and what a cut means in a clinic. Crucially, as Washington is a Medicaid expansion state, she offers key insight into how these deep cuts will directly impact our most vulnerable populations.

Key Takeaways

The impact of H.R.1 on Medicaid and behavioral health services. Medicaid serves as the largest payer for behavioral health services in the U.S., covering a wide range of treatments from crisis services to recovery support. Many behavioral health services are considered “optional,” meaning that during budget cuts, these are often the first to be considered for elimination. Compounding this issue, the new work-reporting rules fall hardest on people whose symptoms make paperwork most difficult to complete.

Cost shift, not reduction. Supporters of H.R.1 argue that it reduces costs and gives states more flexibility. In actuality, any cost reduction has not come from tackling fraud, waste, and abuse, but rather from vulnerable people losing their coverage and from the financial burden shifting to other sources of spending. States will also be required to implement new technological infrastructure to handle the upcoming administrative requirements.

The importance of immediate attention. One of the more concerning aspects of HR1 is the phased implementation of its provisions, some of which won’t take effect until 2027 or later. The delayed implementation could lead to complacency about the repercussions of the bill, which are designed to unfold gradually. By being proactive, advocates and providers can develop strategies to mitigate the negative impacts of HR1, ensuring that as many individuals as possible remain insured and can access necessary care.


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Narrator

Welcome to the Andromeda's Way podcast, where we candidly discuss the everyday challenges facing health and human service providers, including government agencies, philanthropies, and advocates. Cutting roughly $1 trillion, or about 15%, in federal Medicaid spending over 10 years. These cuts have disproportionately fallen on behavioral health, as many services under that umbrella are considered optional and thus the first on the chopping block during budget cuts. On today's episode, Michelle Gady is joined by Joan Miller, CEO of the Washington Council for Behavioral Health, the state's behavioral health safety net. Together, they discuss the impact of these deep funding cuts, policy changes and provider challenges, the work requirement paradox, and perhaps most importantly, what to do next.

Michealle Gady

Welcome to the Andromeda's Way. I'm Michelle Gady. Today we will talk about HR1 and what it means for Washingtonians living with a mental health or substance use condition who are trying to get care. Joan, would you tell us about the work of the Washington Council of Behavioral Health?

SPEAKER_01

Absolutely. Thank you so much, Michelle. So the Washington Council is the statewide professional association of licensed community behavioral health agencies. Our members are providers that serve primarily people who are on Medicaid, who are living with a serious mental illness or a substance use disorder or both. We are a nonprofit organization. We were established in 1979 to provide a unified advocacy voice on behalf of these safety net providers. So the council has a diverse and active membership all across the state. We're in every legislative district. We have agencies that are both in urban areas and rural, both large and small. And our work is focused really on public policy and advocacy. We are active in legislative and rulemaking processes related to behavioral health and healthcare at large. And then we also do a lot of work with our members around improving clinical practice and preparing for Medicaid system transformation, including CCBHCs, which I know we'll talk about a little bit later. And then we also host an annual conference every year where licensed clinicians can earn their continuing education clock hours. It's the largest behavioral health conference in the state, which we're really proud of. So yeah, the council is a great organization with a long history. It's a privilege for me to work on behalf of the behavioral health community. So thank you so much for having me on your podcast.

Michealle Gady

Thank you, Joan. And I know that you guys just had your conference uh earlier this month. So I appreciate you being here with us and rather than, you know, perhaps on a well-deserved vacation. Yeah, all in due time. That will happen soon. Excellent. So let's start with some basics. Can you tell our audience what is HR1 and what does it change about Medicaid?

SPEAKER_01

So HR1 is a federal budget reconciliation bill. It was signed into law last July by President Trump. Um, and forgive me while I just immediately get a little bit wonky here. But the one thing to know about reconciliation bills is that they cannot be filibustered. So a reconciliation bill can pass the Senate with a simple majority vote rather than meeting that 60-vote threshold that is required to overcome or break a filibuster. So these budget reconciliation bills are supposed to be permitted only for making changes to spending, revenue, or the federal debt limit. And if the bill includes provisions that do not change one of those three things, it would be a violation of what's known as the BERD rule. So, as an example, the original version of HR1 included prohibiting Medicaid or the children's health insurance program from covering gender-affirming care. That provision was ultimately struck by the Senate parliamentarian under the Byrd rule because it was clearly a policy directive. The GOP was very much saying that they did not approve of that policy. But it was not primarily related to spending revenue or the federal debt limit. So it was removed. But at the end of the day, HR1 was a massive tax cut and spending package. And among other things, you know, there were changes to energy policy, changes to the federal student loan program and forgiveness. But what we want to talk about today is that it included the largest cut to Medicaid funding in the history of the program. And primarily those cuts are happening through more administrative burden and more paperwork. So from mandatory work requirements to increasing the frequency of people needing to determine that they're eligible for Medicaid, these savings or cuts are being achieved by making it harder for eligible people to stay enrolled in their Medicaid health insurance plan. The bill also makes changes for how states can finance the non-federal share of Medicaid spending. So just to step back for a minute, you know, Medicaid is a joint federal-state program. It's regulated by the federal government, it's administered by the states. And so each state will appropriate funding for its share of the Medicaid program. And then the federal government will match state spending at a certain percentage. And that's what we call an FMAP, the federal Medicaid assistance percentage. And it varies based on the population or the program. So before HR1, states could fund a portion of their Medicaid share through a provider tax. And this tax would help offset having to use precious, flexible state dollars to fund their share of Medicaid. HR1, however, has banned any new provider taxes and it mandates a phased reduction of current provider taxes. So what this means is that states will need to find a new funding stream to cover the difference. I'm sure many folks are aware that Washington State, like many other states, are facing significant budget deficits that will need to be addressed in the next legislative session. One other thing HR1 did was reduce that FMAP for states that choose to provide state-funded insurance coverage for undocumented immigrants. So again, setting states up for that difficult task of either cutting services or figuring out how to pay for them. And then the last thing I'll mention is that HR1 did not extend the enhanced subsidies that were provided to offset the premiums or health plans sold on the ACA marketplace. So those subsidies have now expired, making insurance on the private market just much more expensive.

Michealle Gady

So how do we help our listeners understand how and why these changes so affect so significantly those with behavioral health conditions and their providers as compared with perhaps other parts of the healthcare system?

SPEAKER_01

Mm-hmm. Yeah. So Medicaid is the largest payer of behavioral health services in the country. And the program pays for an entire continuum of treatment, evidence-based practices, crisis services, recovery supports, whereas commercial plans typically pay for only talk therapy or inpatient care, other hospital-based care. Although I will say there are efforts in Washington State for more commercial billing of some crisis services. But that's the first reason. Medicaid covers a large scope of behavioral health services that other plans don't. And then the second reason is that Medicaid covers a lot of people who need behavioral health services. About 35% of adults enrolled in Medicaid have a mental health issue, including 10% with a serious mental illness. So this is absolutely the population that will experience the most impact from HR1.

Michealle Gady

And so the behavioral health services within the Medicaid program are typically identified as optional. So when budgets tighten, what does that designation mean in practice, both for the program and for the people who are served by the program?

SPEAKER_01

So, yes, there are there are some services that the federal government requires states to include in their Medicaid program. So the Affordable Care Act ensures that all Medicaid health plans offer what are known as essential health benefits, things like labs and x-rays, hospital services, mental health counseling, family planning. And then there's a whole category of optional services a state may choose to include. Most people will probably not be surprised by the list that includes things like dental and vision and prescriptions or case management. And so for Washingtonians, there's good news and bad news. Apple Health, which is the name of our state's Medicaid program, includes many of the optional services in its benefits package. We have prescription services, vision, dental. But because they are optional when budgets tighten, it is often one of the first places lawmakers will look. So much of state spending is mandatory. Things like K-12 education, collective bargaining agreements, lawsuit settlements. And our state has a suite of optional Medicaid services that could come under scrutiny. I do believe, however, that our state is doing everything and its power to keep as many people and services covered as possible, and they are working furiously to mitigate the impacts of HR1. So for the person receiving care, I am hopeful that the designation between mandatory and optional continues to be invisible to them, and we won't be in a position where we'll have to ask restrict access to some care.

Michealle Gady

So for many of these, the provisions in HR1 don't take effect until 2027 or later. Why do we need to be paying attention to this now rather than treat it as a problem for later?

SPEAKER_01

Well, I mean, first I'd say that I think the rolling effective dates for the different provisions of HR1 were designed in part so we would forget that it was the one big beautiful bill that caused the problems we're going to see later. It was not an accident that many provisions are going to go into effect after the November midterms. This was an extraordinarily political bill. That said, you know, we see what's going to happen. And so now we have the, we don't, we can't wait. We we need to work now to prepare and strategize and work with our state and providers to keep as many folks insured as possible.

Michealle Gady

So let's talk about one of the provisions you identified, which are the work requirements. So beginning in 2027, just about six months from now, many adults that are covered through the Medicaid expansion will need to document 80 hours a month of work or school activity or community service. So who to whom do these requirements apply? And who is meant to be exempt?

SPEAKER_01

So I'm going to be blunt again. I believe that these work requirements are intended to functionally repeal one of the Affordable Care Act's key policy priorities, which was Medicaid expansion. So, you know, for those who who don't know or don't recall, prior to the Affordable Care Act, you could not be eligible for Medicaid simply because you had a low income. In order to be eligible, you had to fit into a categorically needy criteria. And there were three of them. You had to be elderly, meaning you were 65 or older. You had to have a dependent child or children, or you had to qualify as permanently and totally disabled or legally blind. So we had what we called the aged, blind, and disabled population covered by Medicaid. And then we had a population of folks that received their health insurance from their employer. But at the time, there was this large group of individuals who were uninsured because they did not have access to employer provider coverage and/or they could not afford a plan under the private insurance market. And this was the group that the ACA aimed to cover. And so without getting into all the details of the original ACA and the subsequent challenges, it went up to the Supreme Court. At the end of the day, the ACA allowed states to expand their Medicaid programs to individuals whose income was up to 138% of the poverty line without having to meet one of those categorically needy criteria. And in the states that did that, that expanded Medicaid to that population, we saw drastic reductions to the uninsured population. So now going back to HR1, that piece of legislation exempts that age-blind disabled population from the new work requirements. The work requirements apply only to those low-income adults 19 through 64 who are eligible for coverage under the ACA's Medicaid expansion provision. And what's most frustrating to me about this is that this population, for the most part, is working. But we're back to that sort of pre-ACA situation where they are working jobs that don't offer employer-sponsored health plans, don't pay enough to afford a private plan. And that that was the whole reason why we gave them the Medicaid expansion lifeline. And for the folks that aren't working, it's almost always because they face some significant barrier to employment, such as caregiving responsibilities or transportation issues. And HR1 didn't address any of that. So we are putting in place just extraordinary and unnecessary barriers and red tape for folks that we know are eligible for coverage. And so instead of outright appealing Medicaid expansion, which would be deeply unpopular and again, would need to be able to survive a filibuster, HR1 just makes it harder for this group of enrollees to keep their health insurance.

Michealle Gady

And so kind of building on that, the medical frail exemption, which is meant to include people with serious mental illness and substance use disorders, you know, it sounds protective on its face, but what concerns do you have about how it will work in practice, particularly given the recent interim final rule that was released?

SPEAKER_01

Yeah, so much that that interim final rule is quite disturbing, in my opinion. Our state has been working hard this past year to streamline the implementation of work requirements and ensure they have a plan in place to easily and quickly identify Medicaid expansion enrollees who would qualify for a medically frail exception. And, you know, we were, of course, relieved to see that mental health and substance use disorders were included in that short list in HR1. The bill didn't provide an actual definition for medically frail. And we have been waiting for this rule to come out. You know, I don't work for the state, but my understanding is that CMS had been providing guidance to states about the medically frail exemption. And states had been expecting that people with certain serious diagnoses would just automatically qualify. And again, they were states were building infrastructure to be able to match Medicaid applications to existing medical records. So the exemption could be identified automatically. We wouldn't have to ask for, you know, a letter from a provider or do some type of attestation. You know, it would be automatic with the technology. And then earlier in this month, CMS released their rule and they have turned the medically frail exemption determination into a two-pronged approach. So the first one is do they have the diagnosis? And the second prong is does the diagnosis significantly impair their ability to meet the work requirements? And the rule goes so far is to cite the example that those living with HIV and AIDS or cancer would likely qualify for a medically frail exemption, but only if their illness is serious enough that they cannot work. And so I, you know, I just don't know what enrollees, providers, and states will need to show or document to prove that second prong, you know, especially for mental health and substance use diagnoses, which can often result in episodes of care, you know, certain times in their lives where they're unable to work. So I am I'm very concerned that in practice this exemption is just going to be one more way to cut off access to people who need and deserve health care and are in fact legally eligible for the program.

Michealle Gady

And so, you know, thinking about that, the the level of documentation that is going to be required in order to meet the exemption strikes me as something that is potentially very difficult for the patients that your providers serve. So you know, it leads to the question of are we at risk of ultimately disenrolling thousands of people who are actually exempt from this requirement, but because they can't meet the paperwork requirements, they're they're falling out of compliance. Yes. You guys have an estimate for how many folks you expect to ultimately lose coverage?

SPEAKER_01

We don't. I mean, there's a lot, you know, KFF and the CBO, there's a lot of organizations that are are doing the the data crunching to come up with that estimate. Um, but you know, we know it's going to be significant. I mean, you know, I I recently underwent an endeavor to sign my son up for summer camps, which required a level of organ organizational skill and persistence that I don't think even law school prepared me for. So it it's it's really hard for me to imagine someone who might be experiencing, you know, a housing issue or hallucinations and paranoia to be able to figure out how and when to submit the redetermination paperwork on time. You know, but I know providers are working hard to help their patients out. You know, as a Medicaid expansion state, we've had to do something similar before, which was a whole lot of outreach and engagement to make sure people knew that they were eligible for Apple Health and to help them enroll. And so we're working to reinstitute those processes so we can help current Medicaid enrollees keep their coverage. You know, and I do want to say one more thing about this because I don't want to give the impression that work is not an important goal or value. You know, in fact, we know that employment in school and volunteering, you know, engaging with your community is actually incredibly important for people's mental health. There is tons of literature demonstrating that having a purpose and a routine and community connections can be very helpful to people working toward recovery. Unfortunately, there are many nonpartisan analyses that have been done, including by the Congressional Budget Office, that show Medicaid work requirements do not significantly increase employment, but they do increase the uninsured rate. And that's the outcome we're trying to prevent.

Michealle Gady

For folks with behavioral health care needs specifically, what does it mean when you have a gap in health insurance coverage? Why is continuity so critical for the treatment for folks with behavioral health conditions?

SPEAKER_01

Yeah, I mean, even a brief gap in coverage can have tremendous consequences for someone receiving behavioral health care. You know, for individuals on medication, antipsychotics, for example. Losing access to that medication can easily cause decompensation. They also lose many care coordination services that keep them connected to housing supports or a physical health care provider. For many people with a behavioral health condition, their behavioral health agency, their behavioral health provider, is really their primary care provider. It's their health home. It's where they go to get services for any type of need, whether it's, you know, mental health, SUD, you know, help with social determinants of health, just it, it's a whole person setting. And so you lose your Medicaid and you lose access to a lot of that. And then another component of HR1 is that if an individual is denied or disenrolled for Medicaid due to the work requirements, then they are also ineligible to apply for an insurance plan on the ACA marketplace exchange. And so that gap in health insurance could very well last a long time.

Michealle Gady

So what would you identify as a particularly well-designed process in the state of Washington to address some of these concerns as the state is required to enforce work requirements?

SPEAKER_01

I mean, I think a well-designed system would prioritize prevention, early intervention, and accessible, affordable outpatient care. It would not create so many barriers to accessing health insurance that people can ultimately only receive care in the emergency room, which is, of course, more expensive and more traumatic.

Michealle Gady

So let's think about the math as it relates to the providers, which are the providers that you work with really are safety net providers. You know, they are often not reimbursed for the full cost of delivering care. So how does HR1 change the financial picture for the behavioral health safety net providers in the state? Yeah.

SPEAKER_01

Well, of course, we're still waiting to see how it all plays out. You know, HR1, again, didn't actually cut services or programs or the expansion population altogether, which would be a lot easier to quantify in, you know, a financial budget. But because my members' revenue is pretty much 85 to 95% dependent on Medicaid reimbursement, any reduction to the number of Medicaid enrollees will affect their financial picture. And again, as you mentioned, they are safety net providers who pretty much serve anyone who walks in the door. So we will probably continue to see our patients when they lose their Medicaid, and that will increase the uncompensated care that we provide.

Michealle Gady

So you mentioned at the beginning of our conversation the provider taxes and the impact of HR one on those. In practical terms, what does that mean for a clinic's ability to, for example, hire a therapist or keep a crisis line staffed?

SPEAKER_01

So I think this is gonna be more of a trickle-down effect for behavioral health providers. I believe most of the provider taxes in our state are allocated to hospital services. So I know hospitals are really, really worried about this provision. But as I mentioned before, if the state can't make up the gap in funding as the provider tax phases down, then they will likely need to reduce Medicaid coverage or lower Medicaid payment rates to providers or hospitals. And any cuts to Medicaid will certainly exacerbate workforce shortages, making it harder for community behavioral health to pay their therapists a competitive salary to keep crisis line staffed 24-7. You know, with the implementation of 988, many of our crisis lines have been able to move from a primarily volunteer staff to actual paid employees who are able to pick up that line. And so we might see a trend again towards utilizing lower level credentials or volunteer services.

Michealle Gady

So changing gears just a little bit, um, the council's been a strong advocate for the CCBHC model and its prospective payment approach. Does the does HR1 make that model more important or more difficult to sustain or both?

SPEAKER_01

So I think it's going to make the CCBHC model more important than ever. I think CCBHCs are going to be crucial to serving people who lose their Medicaid or their marketplace coverage. You know, as CCBHC, a certified community behavioral health clinic, is intended to be sort of a behavioral health corollary to FQHCs, the federally qualified health centers who do primarily primary care services. But CCBHCs, you know, provide a comprehensive suite of services. There's nine services required by the federal government. They are required to serve anyone who walks in the door, regardless of age, residence, or ability to pay. And the perspective payment approach you mentioned is essential to making that CCBHC model work because it allows providers to actually get paid the cost of care. And also that PPS is different for each CCBHC because it is based on what the clinic's community actually needs. So if a clinic anticipates that its payer mix is going to change because of HR1 and that it will include more uninsured in individuals and less Medicaid enrollees, that cost can actually be factored into their PPS rate. So there is a little bit of good news in Washington state, as we were recently selected to join the federal CCBHC demonstration. And this is going to give us the opportunity to prove, as other states have, that if you pay a comprehensive behavioral health provider, a bundled rate, a rate that is based on the services their community actually needs, and based on how much it actually costs to deliver those services in that particular community, it's going to result in lower clinician turnover rates and better health outcomes for the people we serve. So CCBHC is a really one of the few areas where I'm just feeling truly, truly optimistic. SAMHSA just released the no-foos for a new round of grant funding for individual clinics to begin building up CCBHC services. We have two bipartisan pieces of legislation in the House and the Senate that would codify that prospective payment into the Medicaid program. It would make CCBHCs an eligible Medicare provider type, which is incredibly important. We know the geriatric population has a lot of behavioral health needs that are not being taken care of. And the bills would also allow primary care services to be built into the clinic's bundled rate. Right now it includes primary care monitoring and sort of care coordination, but it doesn't provide the funding for a behavioral health agency to bring a primary care provider on staff. And these current bills that are introduced in Congress would allow us to do that. So yeah, I mean the federal CCBHC demo was started more than a decade ago. And so I am I'm just really pleased that with everything else going on, we still seem to have bipartisan support to keep this model moving nationwide.

Michealle Gady

So let's talk about behavioral health access in rural Washington. Is there any particular risk for populations in rural Washington as a result of HR1? And do you think that the rural health transformation program, that those funds will do anything to meaningful meaningfully address the potential risk in the rural areas?

SPEAKER_01

Yeah. So the rural health fund is a drop in the bucket. It it really is. We have $50 billion that will be allocated to the states over the next five years. I think there are projections that are showing HR1 is going to result in like a $137 billion cut. So I mean, just math alone, we know it's it's not enough. Washington state did receive $181 million for the first year. A little over $20 million of that is allocated for initiative six of our plan, which is to expand and sustain Washington's rural health behavioral health system. And, you know, again, we're gonna put those dollars to good use, including supporting our rural CCBHCs, but the rural health fund will in no way offset the impacts of HR1. And then, you know, to get to the first part of your question, rural communities are particularly at risk because Medicaid is a critical program sustaining the health and well-being of small communities all across the country and in Washington state. And in fact, Washington's fourth and fifth districts, encompassing some of our most rural counties in the state, have the highest Medicaid expansion population. HR1 is going to affect those two districts the most. And we're already starting to see that trend in places like Yakima now that those enhanced subsidies have expired. And, you know, agricultural workers have very, very high suicide rates. It's almost three and a half times the general population. So we absolutely should be expanding access in our rural communities. And unfortunately, the rural health fund isn't going to be enough.

Michealle Gady

So, you know, Washington was among the first states to expand Medicaid, you know, over a decade now. So, which places us among the states facing, I think, among the deepest reductions. So, how would you describe the scale of that challenge here in Washington?

SPEAKER_01

Yeah, it's it's pretty enormous. You know, again, most of the provisions of HR1 uh are targeted to the Medicaid expansion population. And so while, you know, the 10 states who have not expanded Medicaid still have to grapple with, you know, changes to the ACA marketplace and the phase down of provider taxes. They don't have the heavy lift of implementing, documenting, and monitoring the work requirements or redetermining eligibility every six months. And, you know, I don't, I don't see Washington state actually ever rolling back Medicaid expansion. Like you said, it's been more than 10 years. It is ingrained in our system. But I do think HR1 makes it really challenging for the 10 remaining states to expand their Medicaid programs, which again was the Affordable Care Act's, you know, primary driver for reducing the uninsured population in this country.

Michealle Gady

So supporters of the law argue that it reduces costs and gives states more flexibility and offsets the impact with the rural health fund. How do you respond to those arguments?

SPEAKER_01

Well, you know, it reduces costs by making it harder for poor people, struggling families, folks living with a disability to keep their health insurance. We are not reducing costs by tackling waste, fraud, and abuse. We are kicking people off of their health insurance because they couldn't complete their paperwork correctly or on time. I also emphatically disagree that it gives states more flexibility just based on what's been going on in the past year since this law was signed. If anything, it does the opposite by requiring states to implement all sorts of new technology infrastructure to handle all of these upcoming administrative requirements. And then finally, like we talked about with the rural health fund, it won't even meaningfully offset the impact of rural communities, never mind the entire state or country.

Michealle Gady

So I um, you know, just to follow up on that, I think about HR one not as a cost reduction, but as a cost shift bill, that it really is shifting the financial burden from Medicaid to other sources of spending, either at the federal or state level or both. Thoughts on that?

SPEAKER_01

Yeah, absolutely. I mean, I think it is, you know, important to remember that HR1 also was a massive tax cut bill. They are taking these savings from Medicaid and are extending tax cuts for the extreme wealthy. So it definitely is a cost shifting in that way.

Michealle Gady

So, where do you see the most meaningful opportunities for the state to act? And, you know, where are the limits of what Olympia can realistically do in order to backfill this loss in funding?

SPEAKER_01

So, I mean, the number one thing the state can do right now is try to keep as many people insured as possible. Even if there comes a time, I hope it doesn't happen, but even if we do eventually have to look at the optional benefits and Medicaid, we need to keep as many people on some kind of health plan and connected with as many of their providers as possible. And, you know, the primary, I think, limitation for our state is that we don't have enough state revenue to mitigate all the fiscal impacts of this bill. Our our state legislature is required to pass a four-year balanced budget. Our state has one of the most regressive tax structures in the country. Although we did pass, you know, a wealth tax, a millionaires tax last session, it doesn't go into effect until 2029. And frankly, a lot of that revenue is already spoken for. So the next revenue forecast is actually in the next couple of days, we expect it on June 27th. And that's going to give us a better understanding of what position Olympia is in and what we're going to be able to backfill.

Michealle Gady

If you had a handful of minutes with the legislator in Olympia, what would you ask them to protect first as they look to the future?

SPEAKER_01

Yes, this is where my mind has been since the end of the last legislative session. We used to, we used to get a nice break in policy during the interim where we could, you know, take a vacation and it it just seems like that doesn't happen as much anymore. Interim is just as busy as we get ready for the next session. But first and foremost, I would ask them to not cut behavioral health Medicaid rates, just no cuts to behavioral health rates. And during the Great Recession, behavioral health was one of the first spending categories to be cut. Again, there's a lot of optional spending that our progressive state chooses to take advantage of. But we're still digging out of that hole that they put us in during the Great Recession. And I think the state legislature recognizes that. I also think that maybe the only silver lining that came from COVID is that it really helped to reduce some of the stigma around needing behavioral health supports. I think isolation and illness had a way of helping people understand that their mental health matters. And so, you know, last session we made we made it through without any cuts. And I'm hopeful that that will happen again next year because I do think people are aware that it is a short-sighted decision to make, that it will actually cause worse health outcomes and be more expensive in the long run. And then my second ask, and you know, I do try to not have a long list of asks. So I will I will keep it to two. Um, but the second one would be to continue funding the C C BHC model. Um we are very fortunate to have been selected for the federal demo that comes with an enhanced FMAP for the next four years. And so we are starting off the demo with two clinics. Um, they will begin being paid their PPS starting on January 1st. But over the course of this four-year demo, we should fund as many CCBHCs as possible to take advantage of bringing in those additional federal dollars. And then we need to have some kind of planning process or vision for how to make sure CCBHCs become a permanent part of Washington's Medicaid program after the demo ends. So those would be my two big asks.

Michealle Gady

I think those are exactly the right ones. So thinking about the providers for behavioral health providers who might be listening, what are the two or three things that they should be doing to prepare for what's coming?

SPEAKER_01

So, first, they need to ramp up eligibility assistance if they haven't already. Um, we all need to be doing, you know, I've said this a few times now, anything we can to help make sure our patients are able to comply with the work reporting requirements. We've got to help them navigate this paperwork so they don't lose the coverage they're entitled to. They also need to start collecting all the data that they can, all the stories, all the data so they can be used in future advocacy efforts. And then the third thing I would say is to support your staff. And if you're a clinician or a peer, take care of yourself. There is a lot of change, and all the data and modeling is showing that it's going to have a very negative impact on the people we serve. And so we need to help mitigate burnout and compassion fatigue so the helpers can continue making a difference in their communities.

Michealle Gady

For someone enrolled in Medicaid or a friend or family member who supports them as their caregiver, what should they understand in order to protect their coverage? What are the things that they need to start thinking about and being ready to do?

SPEAKER_01

So honestly, you know, I only have some pretty basic advice at this point because the details and mechanisms around implementing some of this stuff is still really unclear and unknown. But the first thing I I would say is they should understand that if you have Apple Health Insurance, then you are on Medicaid. And every state calls their Medicaid program something different. I think that was intended to reduce some of the stigma around being poor and needing a government handout. But as we have come to find out, many people who are on Medicaid don't always know that because the plans are branded as Apple Health. You know, why would they know when everything they get says Apple Health on it? So that's the first thing. You know, make sure you know where you're getting your coverage from. And then also keep your address up to date. The Healthcare Authority, which is our state Medicaid agency, is going to communicate changes as they receive more guidance from the federal government. And you want to make sure to the extent that you can that these notices get to you. And then lastly, don't hesitate to reach out to your providers. They are here to help you navigate this stuff.

Michealle Gady

And then to advocates, behavioral health advocates, what would you tell them in terms of where they can make their voice heard in a way that will make a real difference?

SPEAKER_01

So I do think contacting and meeting with your senators and representatives makes a real difference. I have been in public policy for a long time. They really do want to hear from their constituents. You know, prior to my role in the council, I was a nonpartisan staffer down in Olympia for the Senate Human Services Committee. And it was not uncommon for senators to come into my office and say, I just met with a constituent. I need you to draft a bill to solve the problem. They they really do care. They want to hear from you. And it's a lot harder for them to decide to cut a program or a community service if, you know, they have constituents asking them not to. So last two questions.

Michealle Gady

If a listener takes away one thing from our discussion, what would you want it to be?

SPEAKER_01

Well, I mean, I don't feel like this was sort of the most optimistic, uplifting conversation I've ever had. Um, but I think the one thing I'd like people to take away is that even when things happen that are really hard or that feel out of our control or that make us feel a little bit helpless, you know, we always have the option to keep doing the next right thing. So do the next right thing. You know, take take care of your neighbors and your communities. We are in this together.

Michealle Gady

So finally, how can people follow the council's work and stay informed as implementation moves forward with HR1 as well as the rest of the work that the council does?

SPEAKER_01

Well, you can follow us on LinkedIn. You can attend our annual conference in June. We also have a national association, the National Council for Mental Well-being. We rely on them a lot for information about what's going on at the federal level. So they're a great organization to follow as well. Um, and if you are a behavioral health agency that isn't a member of the council, you can always feel free to reach out to me and I'll tell you more about the work we do.

Michealle Gady

Thank you, Jan. I really appreciate you being here with us today. What this conversation makes clear, at least to me, is that Medicaid is the foundation of behavioral health care. And when it is cut, behavioral health is where the damage lands first. The new work and reporting requirements that take effect January 2027 and by design will fall hardest on the people least able to meet them, including those living with serious mental illness or substance use disorder. For Washington, an expansion state, that means lasting pressure on the providers and the coverage people depend on. So the full consequences will take time to surface, Joan, as you mentioned, post-election. But the direction is really already set. And what happens between now and 2027 will determine how much of that harm is allowed to occur. This has been the Adramatus Way. We thank you for listening.

Narrator

Thank you for listening to this episode of The Adromata's Way. This podcast is a production of Adromatus, a woman-owned boutique consulting firm that creates a better way for our health and human services provider clients to achieve their goals by strengthening internal operations, enhancing financial stability, and evaluating public policies. Please follow the show and leave a review. You can find previous episodes and more content on our website, Adromatas Consulting dot com slash Adromatas Dash Way. That's A-T-R-O-M-I-T-O-S. We'll see you next time.