Despite Uncertainty, Policy Expert Optimistic About 2020 Behavioral Health Outlook

As 2020 approaches, behavioral health providers are staring down the barrel of financial and regulatory uncertainty. While they may not know exactly what to expect, policy experts at the National Council for Behavioral Health are optimistic about the behavioral health landscape in the year ahead.

“[A government shutdown] seems extremely unlikely this year,” Rebecca Farley David, vice president of policy and advocacy at the National Council, said. “The other thing I can say with a fair bit of certainty is that we’re not going to see major cuts to mental health and addiction programs funded by SAMHSA.”

David made those comments Tuesday during a keynote speech at the Community Behavioral Healthcare Association (CBHA) of Illinois’s 47th Annual Conference, where she offered a national perspective on fiscal year 2020, which began Oct. 1, though a federal spending bill has not yet been passed.


Like the National Council, CBHA is a not-for-profit trade organization representing behavioral health providers. While the National Council has more than 3,300 member organizations across the country, most of whom are safety net providers, CBHA represents community behavioral health organizations across the state of Illinois.

In her speech, David highlighted a number of positives behavioral health providers — especially those reimbursed by Medicaid — will be able to take advantage of in the year ahead.

For one, the Centers for Medicare and Medicaid Services (CMS) is expected to continue granting waivers allowing providers to get around the IMD exclusion rule, which typically prevents Medicaid from paying for beneficiaries to stay in in-patient facilities with more than 16 beds.


While such waivers were previously only available for substance abuse treatment, CMS granted the first mental health IMD exclusion waiver in November.

On top of that, CMS continues to approve the expansion of community-based benefits and delivery system reform initiatives, while elected officials on both sides are prioritizing the opioid epidemic.

But despite David’s bullish outlook, she acknowledged that those positives come with pain points.

“It’s great to expand access to benefits on the one hand,” she told conference attendees. “But if you are imposing eligibility restrictions, like work requirements that result in people being eliminated from the program, you have not achieved that expansion of access to care that you really wanted.”

2020 pain points

Work requirements for Medicaid beneficiaries are the result of increased flexibility CMS has given states under the Trump administration, David explained.

Rather than using the flexibility to expand access to Medicaid beneficiaries, some states are restricting access by implementing such requirements.

“Flexibility can be a double-edged sword,” David said. “This is very much a tension at the heart of regulatory policy that we have seen both in the last several years and that we anticipate seeing into the future.”

Work requirements generally necessitate beneficiaries to verify employment — or that they’re training or searching for a job — before they can receive Medicaid coverage. There are some exemptions.

While there have been a number of legal challenges in an attempt to stop such requirements, beneficiaries in some states have already felt the negative effects.

“In the states where [work requirements] have been implemented, we have seen massive reductions of Medicaid enrollment,” David said.

She pointed to Arkansas as an example, noting that 18,000 people lost Medicaid coverage there following the implementation of work requirements.  

“The majority of them [lost coverage] not because they failed to meet the work requirements, but because they failed to report whether or not they had met the work requirements or qualified for an exemption,” David told conference attendees. “What you see is a loss of eligibility based on what could be any number of factors: Failure to understand how the reporting requirements work or lack of knowledge that someone might be exempted from the work requirements by nature of having a disability.”

The National Council continues to work to overturn work requirements for Medicaid — as well as those recently proposed for the SNAP program.

Work requirements are just one pain point providers could see in the year ahead, David said.

She also acknowledged the focus on opioids at the expense of other substance use disorders falling through the gaps, the lack of new non-grant money flowing into addiction treatment and mental health and the worsening workforce shortage.

To address the lattermost, the National Council continues to advocate for behavioral health worker loan forgiveness programs and for legislation that would allow clinicians to operate at the top of their licensure.

One example of that is the Mental Health Access Improvement Act, which would allow licensed professional counselors and marriage and family therapist to bill Medicare directly for their services.

Mention of the act earned David a round of applause from CBHA conference attendees.

“We have seen an explosion of new co-sponsors for this bill in the current Congress, which is a testament to the education efforts that constituents are doing with their legislators,” she said. “The main obstacle is the cost that it will have, so we keep working to identify an offset and convince members of Congress that that this is a cost worth paying.”

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