Rural Hospitals on the Front Lines of Behavioral Health Coverage Gaps
Shannon Werb, CEO of Array Behavioral Care, explains how uncertainty around Affordable Care Act (ACA) subsidies and Medicaid eligibility threatens to disrupt behavioral health care first—fueling treatment gaps, increased emergency department use, and mounting strain on hospital systems, especially in rural areas.
Key Takeaways
- Coverage instability hits behavioral health first: Even brief lapses in insurance can interrupt therapy, medication access, and crisis support, quickly destabilizing patients with high and ongoing care needs.
- Hospitals absorb the downstream impact: Coverage loss drives higher uncompensated care and prolonged behavioral health boarding in emergency departments, creating significant operational and financial pressure, particularly for rural hospitals.
- Integrated and virtual care are critical to continuity: With demand rising and workforce shortages persisting, permanent telehealth flexibilities and upstream, integrated care models are essential to preventing crises and reducing emergency department (ED) utilization.
How would a lapse in ACA subsidies or Medicaid eligibility most immediately affect access to behavioral health services?
Shannon Werb: Behavioral health patients often feel coverage instability first. They typically have higher care needs and rely heavily on public programs. Even short gaps in coverage can disrupt care; therapy pauses, medication delays, and loss of crisis support happen quickly. If ACA subsidies expire or Medicaid eligibility tightens, millions could become uninsured. Even added paperwork or reverification requirements risk breaking continuity of care, regardless of exemptions for mental health or substance use services.
What specific pressures do you anticipate hospital systems—particularly in rural areas—facing if coverage gaps widen?
Werb: Hospitals will likely see more uncompensated care and longer emergency department boarding times for behavioral health patients, which often already exceed medical boarding times and strain already stretched EDs. When coverage lapses, the ED becomes the default access point, creating ripple effects across the system.
For rural hospitals, where resources are limited and psychiatric specialists are scarce, this can intensify staffing challenges, disrupt patient flow, and threaten financial stability.
How does coverage loss become a leading barrier to behavioral health treatment, and who is most at risk?
Werb: Loss of coverage makes cost an immediate barrier. Therapy visits, medications, and follow-up appointments are often delayed or discontinued. Those most at risk include individuals with serious mental illness, substance use disorders, and low or fixed incomes. These conditions require consistent, ongoing treatment to maintain stability.
What kinds of treatment disruptions are most likely, and how might they contribute to higher relapse rates or emergency department utilization?
Werb: Common disruptions include missed therapy sessions, interruptions in medication management, and delays in post-discharge follow-up. For example, gaps in medication can trigger withdrawal or destabilization, accelerating crises. Over time, these interruptions compound; symptoms worsen, relapse becomes more likely, and patients return to the ED. Without reliable outpatient support, care becomes reactive and crisis-driven.
Beyond the policy debate, what broader trends in behavioral health care should health systems and payers be preparing for right now?
Werb: Demand for behavioral health services continues to rise, while workforce shortages and capacity constraints persist. Systems must shift care upstream, engaging patients earlier and in community settings to prevent escalation to ED visits. This approach should be anchored in an integrated care model that meets patients where they are—before discharge from the hospital, in outpatient settings, and even in their homes—to ensure continuity and reduce gaps in treatment.
The extension of telehealth flexibilities, including Drug Enforcement Administration (DEA) prescribing allowances and Medicare provisions through at least 2025, supports this shift. But temporary measures are not enough. These flexibilities need to become permanent to sustain access, enable virtual and hybrid care models, and ensure continuity of care, especially in rural areas. Without permanent policy changes, gains in access and reductions in ED boarding risk being reversed.
