Medicaid cuts are likely to worsen mental health care in rural America
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Medicaid cuts are likely to worsen mental health care in rural America
Yahoo is using AI to generate takeaways from this article. This means the info may not always match what’s in the article. Reporting mistakes helps us improve the experience. Across the nation, Medicaid is the single largest payer for mental health care. Medicaid cuts in the massive tax and spending bill signed into law earlier this month will worsen mental health disparities in those communities, experts say. Many will simply forgo care for depression, bipolar disorder and other illnesses that need consistent treatment, they say. The cuts next year would leave 380 rural hospitals at risk of shutting down, an analysis found. The new law creates work requirement exceptions for those with severe medical conditions, but experts say proving those conditions may be convoluted. The exact qualifications and diagnoses for the exceptions haven’t been spelled out, according to a report by KFF, a health policy research organization. It’s so counter to the reality of the situation, Dr. Heidi Alvey, an emergency and emergency medicine physician in Indiana, said.
Yahoo is using AI to generate takeaways from this article. This means the info may not always match what’s in the article. Reporting mistakes helps us improve the experience.
Yahoo is using AI to generate takeaways from this article. This means the info may not always match what’s in the article. Reporting mistakes helps us improve the experience. Generate Key Takeaways
People listen to a sermon before being admitted to lunch at the Hope Center, which assists homeless and addicted residents in Hagerstown, Md. Experts say Medicaid cuts will exacerbate rural communities’ access to mental health care. (Spencer Platt/Getty Images)
Across the nation, Medicaid is the single largest payer for mental health care, and in rural America, residents disproportionately rely on the public insurance program.
But Medicaid cuts in the massive tax and spending bill signed into law earlier this month will worsen mental health disparities in those communities, experts say, as patients lose coverage and rural health centers are unable to remain open amid a loss of funds.
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“The context to begin with is, even with no Medicaid cuts, the access to mental health services in rural communities is spotty at best, just very spotty at best — and in many communities, there’s literally no care,” said Ron Manderscheid, former executive director of the National Association of County Behavioral Health and Developmental Disability Directors.
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Cuts over the next 10 years could force low-income rural families to pay for mental health care out of pocket on top of driving farther for care, experts say. Many will simply forgo care for depression, bipolar disorder and other illnesses that need consistent treatment.
“Not only do you have very few services available, but you don’t have the resources to pay for the services,” Manderscheid said. “That makes the problem even worse.”
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Rural communities are already at higher risk of suicide, with rates almost doubling over the past two decades. Already, rural communities are grappling with a shortage in mental health professionals, making them more vulnerable to losses compared with more urban areas, experts say.
Paul Mackie, assistant director of the Center for Rural Behavioral Health at Minnesota State University, Mankato, studies rural mental health workforce shortages.
“If it [coverage] goes away, what would then be the person’s next option if they already don’t have the resources?” said Mackie, who grew up on a rural Michigan dairy farm. “You can have a rural psychologist or a rural clinical social worker working under a shingle, literally alone.”
Small rural hospitals often provide critical behavioral health care access, he said. One analysis found the cuts next year would leave 380 rural hospitals at risk of shutting down.
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States such as Mackie’s Minnesota, which expanded Medicaid eligibility under the 2010 Affordable Care Act, would suffer significant slashes in federal matches as a result of President Donald Trump’s signature legislation. The law, which includes tax cuts that disproportionately benefit the wealthy, cuts the federal government’s 90% matching rate for enrollees covered under expansion to anywhere from 50% to 74%.
States will have to redetermine eligibility twice a year on millions enrolled under Medicaid expansion. Some Medicaid recipients also will have to prove work history. The new law creates work requirement exceptions for those with severe medical conditions — including mental disorders and substance use — but experts say proving those conditions may be convoluted. The exact qualifications and diagnoses for the exceptions haven’t been spelled out, according to a report by KFF, a health policy research organization.
Not only do you have very few services available, but you don’t have the resources to pay for the services. That makes the problem even worse.
– Ron Manderscheid, former executive director of the National Association of County Behavioral Health and Developmental Disability Directors
“You can’t work when your mental illness is not treated,” said Dr. Heidi Alvey, an emergency and critical care medicine physician in Indiana. “It’s so counter to the reality of the situation.”
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Alvey worked seven years at Baylor Scott & White Health’s hospital in Temple, Texas. As nearby rural critical access hospitals and other mental health centers shut down, the hospital became the only access point for people hours away, she said.
“People who just had absolutely no access to care were coming hours in to see us,” she said. Many had serious untreated mental health conditions, she said, and had to wait days or weeks in the emergency department until a care facility had an open bed.
She’s concerned that Medicaid cuts will only make those problems worse.
Jamie Freeny, director of the Center for School Behavioral Health at advocacy group Mental Health America of Greater Houston, worries for the rural families her center serves. The organization works with school districts across the state, including those in rural communities. Nearly 40% of the state’s more than 1,200 school districts are classified as rural.
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She remembers one child whose family had to drive to another county for behavioral health. The family lost coverage during the Medicaid unwinding, as pandemic provisions for automatic re-reenrollment expired. The child stopped taking mental health medication and ended up dropping out of school.
“The child wasn’t getting the medicine that they needed, because their family couldn’t afford it,” Freeny said. “The catalyst for that was a lack of Medicaid. That’s just one family.
“Now, you’re multiplying that.”
Family medicine physician Dr. Ian Bennett sees Medicaid patients at the Vallejo Family Health Services Center of Solano County in California’s Bay Area. The community health clinic serves patients from across the area’s rural farm communities and combines primary care with mental health care services, Bennett said.
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“When our patients lose Medicaid, which we expect that they will, then we’ll have to continue to take them, and that will be quite a strain on the finances of that system,” Bennett said. The center could even close, he said.
“The folks who are having the most difficulty managing their lives — and that’s made worse by having depression or substance use disorder — are going to be the folks most likely to drop off,” said Bennett, a University of Washington mental health services researcher. “The impacts down the road are clearly going to be much worse for society as we have less people able to function.”
The psychiatric care landscape across Michigan’s rural western lower peninsula is already scarce, said Joseph “Chip” Johnston. He’s the executive director of the Centra Wellness Network, a publicly funded community mental health care provider for Manistee and Benzie counties. The network serves Medicaid and uninsured patients from high-poverty communities.
“I used to have psychiatric units close by as an adjunct to my service,” he said. “And they’ve all closed. So, now the closest [psychiatric bed] for a child, for example, is at least two hours away.”
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Those facilities are also expensive. A one-night stay in an inpatient psychiatric facility can be anywhere from $1,000 to $1,500 a night, he said.
Stateline reporter Nada Hassanein can be reached at nhassanein@stateline.org.
Stateline is part of States Newsroom, a nonprofit news network supported by grants and a coalition of donors as a 501c(3) public charity. Stateline maintains editorial independence. Contact Editor Scott S. Greenberger for questions: info@stateline.org.
Medicaid cuts are likely to worsen mental health care in rural America
Medicaid cuts in the massive tax and spending bill signed into law will worsen mental health disparities in rural communities, experts say. The cuts could force low-income rural families to pay for mental health care out of pocket on top of driving farther for care. Many will simply forgo care for depression, bipolar disorder and other illnesses that need consistent treatment. The law includes tax cuts that disproportionately benefit the wealthy, cuts the federal government’s 90 percent matching rate for enrollees covered under expansion to anywhere from 50 percent to 74 percent. The new law creates work requirement exceptions for those with severe medical conditions, but the exact qualifications and diagnoses for the exceptions haven’t been spelled out, according to a report by KFF, a health policy research organization. Nearly 40 percent of the state’s more than 1,200 rural school districts are classified as classified as rural, including those in Texas, Oklahoma and Arkansas. The group worries for the rural families her organization works with across the state. The family lost coverage during the Medicaid pandemic for behavioral health care during the Great Recession.
Across the nation, Medicaid is the single largest payer for mental health care, and in rural America, residents disproportionately rely on the public insurance program.
But Medicaid cuts in the massive tax and spending bill signed into law earlier this month will worsen mental health disparities in those communities, experts say, as patients lose coverage and rural health centers are unable to remain open amid a loss of funds.
Image © HowLettery – iStock-1474328051
“The context to begin with is, even with no Medicaid cuts, the access to mental health services in rural communities is spotty at best, just very spotty at best — and in many communities, there’s literally no care,” said Ron Manderscheid, former executive director of the National Association of County Behavioral Health and Developmental Disability Directors.
Cuts over the next 10 years could force low-income rural families to pay for mental health care out of pocket on top of driving farther for care, experts say. Many will simply forgo care for depression, bipolar disorder and other illnesses that need consistent treatment.
“Not only do you have very few services available, but you don’t have the resources to pay for the services,” Manderscheid said. “That makes the problem even worse.”
Rural communities are already at higher risk of suicide, with rates almost doubling over the past two decades. Already, rural communities are grappling with a shortage in mental health professionals, making them more vulnerable to losses compared with more urban areas, experts say.
Paul Mackie, assistant director of the Center for Rural Behavioral Health at Minnesota State University, Mankato, studies rural mental health workforce shortages.
“If it [coverage] goes away, what would then be the person’s next option if they already don’t have the resources?” said Mackie, who grew up on a rural Michigan dairy farm. “You can have a rural psychologist or a rural clinical social worker working under a shingle, literally alone.”
Image © JJ Gouin – iStock-1642293566
Small rural hospitals often provide critical behavioral health care access, he said. One analysis found the cuts next year would leave 380 rural hospitals at risk of shutting down.
States such as Mackie’s Minnesota, which expanded Medicaid eligibility under the 2010 Affordable Care Act, would suffer significant slashes in federal matches as a result of President Donald Trump’s signature legislation. The law, which includes tax cuts that disproportionately benefit the wealthy, cuts the federal government’s 90 percent matching rate for enrollees covered under expansion to anywhere from 50 percent to 74 percent.
States will have to redetermine eligibility twice a year on millions enrolled under Medicaid expansion. Some Medicaid recipients also will have to prove work history. The new law creates work requirement exceptions for those with severe medical conditions — including mental disorders and substance use — but experts say proving those conditions may be convoluted. The exact qualifications and diagnoses for the exceptions haven’t been spelled out, according to a report by KFF, a health policy research organization.
Not only do you have very few services available, but you don’t have the resources to pay for the services. That makes the problem even worse. – Ron Manderscheid, former executive director of the National Association of County Behavioral Health and Developmental Disability Directors
“You can’t work when your mental illness is not treated,” said Dr. Heidi Alvey, an emergency and critical care medicine physician in Indiana. “It’s so counter to the reality of the situation.”
Alvey worked seven years at Baylor Scott & White Health’s hospital in Temple, Texas. As nearby rural critical access hospitals and other mental health centers shut down, the hospital became the only access point for people hours away, she said.
“People who just had absolutely no access to care were coming hours in to see us,” she said. Many had serious untreated mental health conditions, she said, and had to wait days or weeks in the emergency department until a care facility had an open bed.
She’s concerned that Medicaid cuts will only make those problems worse.
Image © iStock – Olivier Le Moal
Jamie Freeny, director of the Center for School Behavioral Health at advocacy group Mental Health America of Greater Houston, worries for the rural families her center serves. The organization works with school districts across the state, including those in rural communities. Nearly 40 percent of the state’s more than 1,200 school districts are classified as rural.
She remembers one child whose family had to drive to another county for behavioral health. The family lost coverage during the Medicaid unwinding, as pandemic provisions for automatic re-reenrollment expired. The child stopped taking mental health medication and ended up dropping out of school.
“The child wasn’t getting the medicine that they needed, because their family couldn’t afford it,” Freeny said. “The catalyst for that was a lack of Medicaid. That’s just one family.
“Now, you’re multiplying that.”
Family medicine physician Dr. Ian Bennett sees Medicaid patients at the Vallejo Family Health Services Center of Solano County in California’s Bay Area. The community health clinic serves patients from across the area’s rural farm communities and combines primary care with mental health care services, Bennett said.
“When our patients lose Medicaid, which we expect that they will, then we’ll have to continue to take them, and that will be quite a strain on the finances of that system,” Bennett said. The center could even close, he said.
“The folks who are having the most difficulty managing their lives — and that’s made worse by having depression or substance use disorder — are going to be the folks most likely to drop off,” said Bennett, a University of Washington mental health services researcher. “The impacts down the road are clearly going to be much worse for society as we have less people able to function.”
The psychiatric care landscape across Michigan’s rural western lower peninsula is already scarce, said Joseph “Chip” Johnston. He’s the executive director of the Centra Wellness Network, a publicly funded community mental health care provider for Manistee and Benzie counties. The network serves Medicaid and uninsured patients from high-poverty communities.
“I used to have psychiatric units close by as an adjunct to my service,” he said. “And they’ve all closed. So, now the closest [psychiatric bed] for a child, for example, is at least two hours away.”
Those facilities are also expensive. A one-night stay in an inpatient psychiatric facility can be anywhere from $1,000 to $1,500 a night, he said.
Medicaid cuts threaten health care access in rural America
Michael Shepherd is an assistant professor of health management and policy at the U-M School of Public Health. His research focuses on what he calls the “rural health spiral,” how worsening health outcomes in rural areas can create a cycle where problems rarely get solved. Shepherd: Cuts to Medicaid threaten institutions that serve the broader rural public, even those with employer-sponsored or private insurance. He says 80% of rural hospitals that have closed since the Affordable Care Act have been in Republican states that failed to expand Medicaid. It’s not just that people on Medicaid may lose benefits—everybody may lose access to health care, and many people will lose their jobs, he says. It can have very different outcomes depending on state-level decisions, he adds. It’s important to know about the broader impact of these cuts, and people who aren’t on Medicaid should know about it, too, Shepherd says. The cuts would dramatically increase closure rates. These cuts would disproportionately harm rural communities.
Shepherd, assistant professor of health management and policy at the U-M School of Public Health, studies the politics and policies surrounding rural health disparities, including rural hospital closures, the opioid epidemic and Medicaid policy. His research focuses on what he calls the “rural health spiral,” how worsening health outcomes in rural areas can create a cycle where problems rarely get solved and support for government solutions decreases over time.
He recently co-authored an op-ed examining how proposed budget cuts would disproportionately harm rural communities. Here, Shepherd discusses what these proposed changes could mean.
How important is Medicaid for rural communities?
Medicaid is incredibly vital for rural people, not only those who benefit directly, but for the survival of rural health care institutions that serve everyone. Twenty-three percent of rural Americans are insured by Medicaid, compared to 19% nationally. About half of rural children are covered by Medicaid, and it pays for over half of rural births.
Rural hospitals, mental health clinics and doctors’ offices depend heavily on Medicaid reimbursements. Cuts to Medicaid threaten institutions that serve the broader rural public, even those with employer-sponsored or private insurance.
What happens when rural hospitals lose Medicaid funding?
Take McNairy County, Tennessee. In 2016, they lost their regional hospital, mostly because the state didn’t expand Medicaid. When it closed, residents had to drive 45 minutes to an hour for care. If you’re on Tennessee Medicaid, you can’t cross the state border to Mississippi for covered care—you have to use in-state options that are even farther away.
Research shows that when a rural hospital closes, patients travel, on average, 20 miles farther for common care and 40 miles farther for specialized care. Every additional mile increases your health care risk for emergencies like strokes or heart attacks. Studies also show rural hospital closures lead to significant increases in mortality, and birthing outcomes and obstetric care suffer following closures.
How do Medicaid cuts affect people who aren’t on Medicaid?
Hospitals in rural communities are often the largest employers.The health care sector can supply as many as 10% of the jobs in a rural community. Most rural areas don’t have large employers beyond their public schools or hospitals.
If a hospital closes, you’re talking about increasing unemployment, lowering incomes and people leaving the community to find work elsewhere. It’s not just that people on Medicaid may lose benefits—everybody may lose access to health care, and many people will lose their jobs.
Even community mental health providers are very Medicaid-dependent. If you withdraw Medicaid benefits, people won’t be able to access their mental health providers because those clinics rely on federal funding and Medicaid clients to stay open.
What does research show about states that expanded Medicaid versus those that didn’t?
States that expanded Medicaid saw rural hospital closures drop to close to zero, while non-expansion states experienced continued spikes. My research shows that roughly 80% of rural hospitals that closed since the Affordable Care Act have been in Republican states that failed to expand Medicaid.
According to the Center for Healthcare Quality and Payment Reform, over 300 rural hospitals currently face “immediate risk” of closure—and that’s without these proposed cuts. Rural hospitals operate on shoestring budgets and stay open primarily because of Medicaid reimbursements. These cuts would dramatically increase closure rates.
Why do politicians support cuts that could harm their own constituents?
This gets at what we call “accountability” in political science—whether voters can connect policy outcomes to the politicians responsible for them. There’s a lot of research that shows voters often struggle to assign responsibility correctly, especially when policies have complex, delayed effects.
What I found in my research is that even when state Republicans chose not to expand Medicaid—which ultimately led to worse outcomes for rural hospitals—voters blamed Democrats and the Affordable Care Act for their experiences. This creates what I call the “rural health spiral,” the worse things get, the less rural people trust government solutions, which leads to support for politicians who are less likely to use government to fix problems.
My research shows this pattern where Republicans can actually benefit politically from decisions that make things worse for their voters, while Democrats get penalized despite passing policies that objectively help similar communities. It’s a function of our federal system, where national policies can have very different outcomes depending on state-level decisions, but voters often assign credit or blame to the president’s party regardless.
What would you want people to know about the broader impact of these cuts?
Even people who aren’t on Medicaid should be alarmed. If you live in a rural community, you’re likely to lose access to health care yourself if these cuts happen, regardless of whether you have Medicaid.
What’s remarkable is that Medicaid is popular across party lines. Survey data shows that 61% of Republicans, 71% of Independents and 83% of Democrats see Medicaid as important to their communities. These cuts aren’t what people are demanding.
Medicare and Medicaid cuts are big but not beautiful – The Washington Post
At least 17 million Americans will lose their Medicaid and Affordable Care Act coverage. People in vulnerable populations are more likely to go to the emergency room for nonemergency care. In rural areas where hospitals rely heavily on Medicaid dollars to continue operating, facilities might close and exacerbate the problem. States will also have the unfunded burden of dealing with all of the additional vetting of the Medicaid expansion population. They have a fiduciary duty to act in the best interests of the country, which includes its viability for future generations of Americans. They front-loaded tax cuts to provide benefits to many Americans before the midterm elections while back-loading some cuts until after the elections. They seem to have designed the “One Big Beautiful Bill” to ensure some benefits to some people before the midterms. They also have written the bill so that some benefits will be available after the election, ensuring their own political fortunes. It’s a mistake to say, “We all going to die.” The same is not necessarily true of corporations or countries.
People in vulnerable populations, including those who lack health insurance, are more likely to go to the emergency room for nonemergency care. The article stated that 40 percent of D.C. residents are covered by Medicaid. What will happen when some of them lose that coverage? In rural areas where hospitals rely heavily on Medicaid dollars to continue operating, facilities might close and exacerbate the problem. The patients left behind might crowd the hospitals that remain, or they might be forced to forgo medical care altogether.
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Make America healthy again indeed.
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Randy Rosso, Arlington
Cuts will increase cost
One of the sections of the “One Big Beautiful Bill” is intended to rationalize Medicaid and save money, resulting in at least 17 million Americans losing their health coverage.
However, the cuts to Medicaid will actually increase spending on health care for two reasons. First, studies have shown that uninsured people are less likely to seek preventative care, and are also more likely to delay or go without receiving the care they need because of the expense. But as a result of the delay or loss of care, the conditions of those who are ill or injured will probably worsen, requiring more intensive and costlier treatment.
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Second, as their conditions worsen, those affected will predictably seek care at community hospital emergency rooms, which are required to provide treatment for patients regardless of whether they have insurance. This is one of the most expensive avenues for medical care, far exceeding the cost of a visit to a doctor’s office. So, the combination of the higher cost for a more advanced disease, combined with a very expensive venue for treatment, will drive overall health care costs even higher.
Ken Lefkowitz, Medford, New Jersey
The writer is author of “Medicare for All: An Economic Rationale.”
In his July 7 op-ed, “Why the GOP’s Medicaid cuts are less than meets the eye,” Ramesh Ponnuru played down the loss of Medicaid coverage resulting from the Republican budget law. First, Ponnuru suggested states such as New York and California might subvert their work requirements without acknowledging the states that will implement the requirements to deny coverage. He also glossed over the tremendous impact that slashing the federal return from provider taxes will have on health care and state budgets.
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Ponnuru also did not mention that providers may be denied reimbursement that they might have been paid under prior law that provided a longer window for retroactive Medicaid coverage. Nor did he mention that the enormous deficit spending in the bill that will trigger massive Medicare cuts over time because of the Statutory Pay-As-You-Go Act of 2010. States will also have the unfunded burden of dealing with all of the additional vetting of the Medicaid expansion population. This work will fall to state agencies that are short-staffed and might have antiquated information technology systems.
My state of New Hampshire is among those that might lose over 7.5 percent of their federal Medicaid funding. Unfortunately, Ponnuru neglected to acknowledge the impact on human lives, including in my state, that are imperiled.
Brendan Williams, Pembroke, New Hampshire
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The writer is president and CEO of the New Hampshire Health Care Association, a long-term care trade association.
The dangers of kicking the can
Though Sen. Joni Ernst (R-Iowa) recently responded to the looming Medicaid cuts in the “One Big Beautiful Bill” by saying, “We all are going to die,” the same is not necessarily true of corporations or countries. Corporate boards have a fiduciary duty of loyalty, requiring them to act in the best interests of the corporation, including its solvency and continuity over time, not in their own personal interest. Similarly, the president and Congress have a fiduciary duty to act in the best interests of the country, which includes ensuring its viability for future generations of Americans.
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But the president and Republican legislators seem to have designed the “One Big Beautiful Bill” with their own political fortunes in mind. They have cynically front-loaded tax cuts to provide benefits to many Americans before the midterm elections while back-loading some benefit cuts until after the midterm elections. They have also written the bill so that some benefits to taxpayers, such as higher caps on state and local tax deductions, are set to expire after President Donald Trump leaves office so that another president will be under pressure to extend them or take the blame.
Since we are all going to die, while the country (hopefully) continues to exist, the president and Republican legislators should be thinking not only about their own personal interests in getting reelected but also about the interests of citizens who are not yet born. We should work to ensure our country is better, not worse, for our children. Future Americans deserve a country that is both fiscally solvent and environmentally sustainable. One searches in vain for provisions in this bill to meaningfully address these long-term crises. Rather, the bill is rapidly advancing both days of reckoning by expanding the federal deficit and cutting back support for green energy.
Chris Gerrard, Rockville
Threats to mental health care
I am a mental health therapist living and working in rural Maine. I’ve spent years helping families navigate a broken health care system, and I’ve seen firsthand what happens when access to care depends on Zip code or, worse, income. That’s why the recent proposals to slash funding for Medicaid aren’t just bad policy. They’re dangerous.
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That program is a lifeline. In my community, it covers everything from a child’s therapy to a senior’s insulin. About 1 in 5 Americans rely on Medicaid, and in the rural areas of my state, that percentage is even higher.
Many of my clients have no other form of insurance. Without Medicaid, they wouldn’t be able to walk into my office. Without Medicaid, their parents or grandparents wouldn’t afford the medication keeping them alive. These are not exaggerations; these are daily realities of our community members.
Supporters of the cuts argue they’re necessary to reduce the national debt. But we need to stop pretending that the burden of fiscal responsibility should fall on the backs of our most vulnerable citizens.
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Medicaid and Medicare are not just health programs; they keep small-town hospitals open. When we gut these programs, we’re not just cutting care; we’re threatening the livelihoods of health providers, closing clinics and driving our communities even further into crisis.
Also, we are experiencing a mental health emergency among young people. The Centers for Disease Control and Prevention has reported that suicide is the second-leading cause of death among people ages 10 to 34. Medicaid funds a significant share of youth mental health services. Stripping that support now would be like taking water away during a house fire.
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Some argue that charities could fill the gap. But they cannot replace coordinated, consistent care. We’re not talking about a gap to be filled; we’re talking about a canyon.
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So, what’s the alternative? Instead of cutting funding, invest those funds in smarter, more targeted ways. Close loopholes in Medicare Advantage plans that prioritize profits over care and health outcomes. Increase Medicaid eligibility in states that still haven’t opted in to the expansion. Boost funding for telehealth, which has proved especially effective in rural regions. These are policy moves that save lives and even money in the long run.
We can build a system that works — one that treats health care as a right, not a privilege reserved for the healthy and wealthy. But we can’t get there by ripping out the foundations that hold people up.
Our community members need us. Do not cut Medicare and Medicaid. Expand and protect them. When we protect health care, we protect dignity, safety and life itself.
Lisa Dezso, Pittsfield, Maine
The writer is a doctoral student in prevention science and a practicing mental health therapist.