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

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 TakeawaysThe 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.Atrómitos Knowledge Hub Promo--This podcast is a production of Atrómitos, a woman-owned boutique consulting firm creating 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.Want to know more about the firm behind the podcast?Atrómitos, LLC Website: https://atromitosconsulting.comFollow us on LinkedIn: https://www.linkedin.com/company/atromitos-llc/Subscribe on YouTube: https://www.youtube.com/@atromitosllcGet Emails: https://atromitosconsulting.com/atromitos-way/#subscriberIn addition to our podcast, we've developed additional resources to improve your understanding of both long-standing and emerging issues important to leaders in the health and human service provider, government and philanthropic sectors.Our articles, policy briefs and infographics provide you with information you can use to reach your organization’s goals. Atrómitos Way Podcast Website: www.atromitosconsulting.com/atromitos-wayFollow us on LinkedIn: www.linkedin.com/showcase/the-atrómitos-wayArticles: https://atromitosconsulting.com/atromitos-way/progress/White Papers: https://atromitosconsulting.com/atromitos-way/unlocking/