Policy Shifts Reshaping Mental Health Care with Cathy Gilbert

welcome to Mental Health Evolution, a podcast about what's changing in mental health and why it matters. I'm your host, Rachel Harrison, inviting you into honest conversations with people from all perspectives in the field. Clinicians, tech founders, investors, insurance companies and all the folks in between. Let's explore what's working, what's not, and what's next.

Hello everyone. Welcome back to the Mental Health Evolution podcast where we are talking today about how policy is impacting mental health services, how they're provided, as well as system changes and requirements for different care models. Our guest today, Kathy Gilbert, currently works as a consultant to providers, but she has a history of working in big insurance groups, working with provider network development and operations. She has done a lot of research into different, different policies that are currently impacting our field and we are going to dive more into that today. So I'd like to highlight some information to get us started thinking on this. One of the big policies that will impact the conversation today is the Big Beautiful Bill Act. This is known to be making cuts to Medicaid to SNAP and to Affordability Care act, offering lower cost healthcare options to many Americans. And nami, the national alliance for Mental Illness released this about the bill. Their statement was that they are cutting Medicaid for millions of Americans and they say they're concerned about the mental health care that will not be afforded to millions of people with this bill and will have a far reaching impact. But we're going to dig into that a little bit more. And before this bill there were also some other policies and we might dig into these as well, that 2026 would dissolve the Substance Abuse and Mental Health Services Administration, also known as SAMHSA and the Health Resources Service Administration or hrsa, consolidating them into a new Administration for a Healthy America. As well as additional federal actions impacting access to mental health care include reduced funding for LGBTQ crisis services through 988 Suicide and Crisis Lifeline halting the 1 billion in school mental Health Professional Grants by the Department of Education citing civil rights concerns. And all of this was documented from the apa, which is Psychological association article titled New and proposed policies Affecting Access to Mental Health Care. So that's going to be our focus today is looking at these policies, looking at how they are going to specifically impact mental health care and getting some of Kathy's expertise on this. So Kathy, I just want to say thank you so much for being here.

Oh, nice to be Here, Rachel, looking forward to the discussion.

Awesome. So let's dig in. First, I just want to say all of these changes seem to be moving really fast. I'm wondering from your perspective, is that just how it feels or are things actually moving at a faster pace than they have previously in terms of policy changes for our industry?

I think with the big beautiful bill, things are moving really fast. So for example, I'll be dating myself, but I did my master's thesis on national healthcare in the US in the 90s during the Clinton administration. We finally got it in, you know, in the 2000 teens under the Obama administration. So nearly 20 years later. So it took 20 years for that change when that discussion started, even before then, really. And it felt like, you know, ACA wasn't perfect, but it had a lot of the elements that helped us get to where we needed to be. So. Yes. And now with some of the changes aren't immediate, but things seem to be moving extremely fast because especially behavioral health change is slow. I know it takes a long time.

Yeah.

So yeah, this does feel a lot faster. And I don't think it's still settled yet on how fast some of these changes are going to happen.

So with that, I would love to hear your perspective. How are you looking at these various policies? What do you see as the big things that we need to looking at and addressing in the mental health industry?

One of it is part of it is more general. I see it as just the number, sheer numbers of people losing health care coverage over the next 10 years based on the bill. That's huge. A lot of those that lose coverage, I think will be individuals with mental health challenges. So because of the work requirement and when you think about this in perspective, something else that's happening in the administration is the dismantling of the Department of Education, which funds training programs for persons with disabilities who now have a work requirement. But the training programs may not be there any longer. So I think it's even broader than what people are realizing right now. So that's part of what we have to think about. Plus there's in the mental health world for people under ACA coverage or Medicare or Medicaid, all, all three of those are significantly impacted by this bill. Those are the, those are usually our most vulnerable populations, the people that could use the additional supports. So if they're losing coverage, programs are curtailed. Not just in mental health, though that population is going to struggle even more so looking for innovative ways to continue to deliver those services, make sure people have the right Supports and try to keep the support systems, those safety net systems intact.

I mean, when you think about the

whole perspective, that's my big concern.

Well, yeah, but, but I think about providers with that, whether it's a nonprofit organization. Right. That might also be losing grant funding or whether it's a practice, a medical practice. Those typically aren't people that have the means to pick up the slack here.

Right.

Or provide services for free or low cost even. I mean. Right, yeah, right, yeah.

Because the other concern is how are states going to be able to manage the cuts in what the federal government portion on the Medicaid dollar. It's a pre significant portion for most states of what dollars come from the federal versus the state match to fund the Medicaid safety net programs. I'm concerned that there will be rate reductions in how providers are reimbursed. Not a total loss, but rate reduction. So will they be able to cover costs in mental health? The other thing I worry about is, you know, mental health in the medical world, in the healthcare world has been one of the lowest reimbursed areas historically. It has not kept up with other specialties. And if those rates are reduced yet again, that's not sustainable.

Where do you think the rate reduction is going to come from?

I think it's got to be a combination. There's a lot of a combination of public and private dollars, which is, you know, kind of where ACA wants a combination of looking at the legislation and being able to understand it. I get really concerned about this. It feels like almost a slash and burn mentality instead of really looking and evaluating program specific specifically and looking how to improve those. I mean, honestly, everybody in the healthcare world has concerns about, you know, broad waste and abuse, which is part of what they were trying to get at with some of the requirements they put in. Yeah, but 99.9% of people that go into behavioral health in the healthcare world aren't going into it for the money. No, they're going into it because they care. And so when they talk about all the slash and burn because they're going to save because people are abusing the system, I'm like, where are you seeing that? It's so small comparatively. So yeah, I'm not sure there's so much that remains to be seen on these, on all the pieces of this bill. It's like they cancel. Like I said, they canceled. You know, they're cutting this and requiring work. They're also cutting into training programs. Okay, does it work when you have individuals who need support and that's a large improvement. The mental health. My husband actually was a vocational rehab counselor. He's since retired and he worked with that population helping them get jobs. That program that he worked in was founded through the Department of Education and he worked with the individuals with disabilities to help them get jobs, many of them with mental health challenges.

Yeah, I hear you that it's going to have a bigger impact than just what we see. Yes. People are losing medical coverage and what else does that impact? I even think about, you know, society impact. Right. If people are getting support with mental health concerns and able to walk into a clinic or whatnot, that that prevents a lot of maybe maladaptive behaviors or other places where that's going to come out and affect our communities. So I'd like to talk about your consulting work. What types of clients do you work with? And I'm curious what you're seeing with them with this policy. Like what kind of conversations are you having? What are you telling people that they should be thinking about? What does that look like?

Well, I work with a lot of clients in the digital health space, so either virtual care or hybrid, which they also may offer in person care in some markets. So a combination of those and plus a couple more traditional behavioral health settings. Most of my clients are in some way tied to behavioral health. So I have a few that are more in the allied therapies, though occasionally something different. But for the most part in behavioral health, which is where my. Where my career has been is primarily behavioral health. I started out as a social worker, so I had that going all the way back to early career.

I know that piece. Yeah, that's cool.

So. So in what I'm telling them, one of the things, there is a piece of the legislation that actually is good for virtual care providers and it could be good because that may be where some things move so that people can have affordable and health insurance coverage. Is there was a provision during COVID that waived allowed health plans or employee self employed employee self insured employer groups to allow virtual care or telehealth to be covered without having to meet the deductible and or pay the coinsurance copay could be waived for telehealth visits. They love to deal with preventative care and they waive that. There is a provision in the big bad beautiful bill that does make that permanent that allows allows benefits to not require deductible to be met to pay for virtual care visits. So in all of that there's a positive. Yeah, I was trying to find some. So that's good. But there's another issue that's not addressed in that bill or that act now that there's a requirement in mental health and substance use for an in person visit every six months or a year when implementing telehealth that expires September 30th. Congress is not acted to change that yet. So that combat you need, you kind

of need both you kind of do.

So we're waiting to hear on that other piece. But it is good especially for individuals that have those high deductible plans which a lot of companies have gone to to make at least some insurance affordable to members. So that's one piece of maybe good in the legislation. And since I work with a lot of digital providers that's we're excited about that piece. That's good news because some of those are programs and programmatic where their payment structure is for a program and somebody with a high deductible health plan. Those high deductible health plans have deductibles of 2,500 to $5,000. So if you're going for care it's a lot Unless you have something nature it's a long time to your health plan kicks in.

That is a long time.

Yeah. When you think about in perspective. I mean it's across all health services that you receive but still that's a big deductible and it allows for more services to be paid out of health savings accounts. So without impacting health savings accounts. So seems like a positive for employers and employees with coverage and having that covered basically from day one.

Anything that you think is important for solo and group practice owners to be aware of maybe you know you're talking about working with a lot of virtual folks but even folks that are seeing clients day to day, what are your thoughts for them?

You know they need to just be aware of monitoring coverage especially if they participate with Medicaid and ACA plans that to be aware and maybe support their their patients in that recertification and and reminding them and helping them to maintain their coverage. I think that's one piece of also to monitor for watch for changes and how coverage changes because I think benefit plans are going to change a little bit. So monitoring for what services are covered. I think basic mental health services, I mean they're the standard codes are going to continue to be covered. But one of the things I noticed is there's a mandate under a number of the ACA plans for a minimum level of co payment elections. I think it was something like $35. So CO payments may change. There may actually be times when you were used to there being no copayment. Now there's a co payment. So really being aware, continuing your eligibility checks and benefit verifications, you know, most of those are electronic and sometimes it's hard to keep track of, but just keep reverifying. That I think is going to be really important. The other thing I noticed which I think is critical, especially if they participate with some of the Medicaid plans, they used to be that for Medicaid in most states when people were getting enrolled, they, they could retroactive up to three months coverage. They've reduced that to one month in that bill. So when you're used to as people are in, you know, getting enrolled in Medicaid, especially if that's a population that you see, you know, if somebody's applied they would retroactive it and it takes them time to process. So sometimes that three months gave them time to get it processed and they retroactive it back to the application date. Now they're only going to be able to go back a month. Ye which can make a difference, significant difference. Because I'm concerned about application processing taking longer with the. And that would also impact those redeterminations of eligibility. Every six months those get delayed, somebody could lose coverage, it could take a while. Then they, they would only be able to retroactive it back a month to reinstate coverage. Yeah, potentially.

What is your recommendation for how often to check for eligibility and if there are changes?

I mean you should ask the patient at every visit and I think that's pretty standard. But I would almost check monthly just to, you know, make sure nothing changes. And that's about how often things kind of change on a Medicaid role. And even if somebody's employed and changes jobs usually at least covered till the end of the month.

So that's true. That's true.

So figuring out a way to kind of do some re verification, you know,

on a regular basis, that's good, that's good concrete advice. I like that. So you're not backpedaling or caught unaware or those kinds of things.

Right. Because you know those individuals may be individuals that aren't going to be able to pay that bill.

Right.

So I mean that's, you know that that would be one of the things I would really look at and you know, I'm also concerned about from the health plan perspective, them being able to maintain networks because if you're in a market where you can stay with just commercial and private insurance or private pay it's going even make access more challenging for those individuals that don't have that available to them.

Yeah, I see that too. Definitely makes all of that challenging. We are about out of time for this episode and I'm wondering if you could highlight one critical piece of information for people to know. What would be your top line policy takeaway that folks should know about?

Oh, there's so many points. Yeah. Pay attention to what the changes are. Watch those communications from the health plans you participate with. So because they're going to be telling you how they are implementing the requirements of the changes. So my takeaway from all of it as things settle out and health plans figure out what's going on and even the state Medicaid associations really watched for those notices. Not just what's in the news, but watching for those direct notices that plans do send out. And I know it's easy to ignore those because you can get bombarded. But I think in this time of fast change my especially for small individual and group practices, really pay attention to those notices as things are settling and they'll tell you what changes are and coming in coverage and how they're. Because it could change some processes. It could, you know, change could mean rate changes could mean a whole variety of things. So I think when things are moving this fast, it's really critical to watch for those notices or try to monitor the payer websites because that's where they're going to put stuff. I love that would be my.

I do. Yeah. Because with information we can make better decisions. So.

Right.

That's great.

Right. Because you don't know exactly. It's going to be Medicaid is going to be slightly different in each state. Each state's impacted differently and and help plan changes. Each plan is going to have to fig out how they're going to account for the changes. I mean Elevance and Centene in the last week have come out with the restatement of earnings. I'm sure it's coming from United. It's going to be coming from all the major players who are involved in aca, Medicare and Medicaid, which all of the major players are.

Yeah. Yeah. Well Kathy, thank you so much for being here and sharing in this conversation about policy changes for the mental health industry. Your perspective has been awesome and thanks for the concrete takeaways too. So we will wrap up this episode and we'll hope to hear you back next time.