Medicaid Reforms in the One Big Beautiful Bill Act and Mental Health Care

Medicaid is the nation's largest payer of mental health and substance use disorder care. As a result, federal policy changes can have far-reaching consequences for people with mental health conditions and substance use disorders. The recently enacted One Big Beautiful Bill Act imposes Medicaid work requirements, increases income-verification frequency, and establishes new cost-sharing practices for many services. The potential harms are especially acute for adults with a serious mental illness. For these adults-many of whom already face significant cognitive, motivational, and social challenges-these burdens interact with symptoms in ways that can magnify coverage loss and harm eligible individuals who are not the target of efforts to reduce the Medicaid-eligible population. The work-requirements statute exempts people who are medically frail, which, the statute indicates, involves people with a disabling mental disorder. Behavioral health conditions often involve fluctuating symptom severity and variable engagement in care, and the systems that treat them are often plagued by inconsistent diagnostic coding and insufficient documentation in administrative datasets. Addressing these complexities will pose important implementation challenges.