Dr. Dennis Morrison is the Chief Clinical Officer at Eleos and the owner of Morrison Consulting. Previously, he has served as Chief Clinical Officer at Netsmart Technologies, CEO of Centerstone Research Institute (CRI), and CEO of Center for Behavioral Health (CBH).

On December 1, 2025, President Trump signed legislation that, on the surface, should have been cause for celebration across the substance use disorder (SUD) treatment field. 

The SUPPORT for Patients and Communities Reauthorization Act extended critical SUD prevention, treatment, and recovery programs through fiscal year 2030—and industry leaders applauded. The Association for Behavioral Health and Wellness called it essential for providing “the stability and resources needed to respond to an ongoing substance use and mental health crisis.” The American Society of Addiction Medicine praised the extension of loan-repayment programs, opioid-recovery center grants, and minority fellowships.

And yet, underneath all the optimism, there are additional policy changes that are a bit counterproductive—to say the least.

The same administration that signed this expansion also slashed $911 billion from Medicaid—the single largest payer of behavioral health services, covering 60% of all SUD treatment spending. 

At the same time, SAMHSA, the agency responsible for administering these newly reauthorized programs, was consolidated into a new entity with reduced funding and staff. As Dr. Stephen Taylor, president of ASAM, cautioned: “These programs risk being reauthorized in name only if SAMHSA is not fully equipped to administer them.” 

I don’t pretend to have all the answers to this policy paradox. But I’ve learned that organizations rarely get the luxury of clarity before they have to act. The ones that endure moments like this aren’t waiting for certainty. They’re strengthening what they can control—their strategy, operations, and clinical efficiency.

Here’s where I would start.

How We Got Here

Before we dive into the recent policy issues, it’s important to understand the current realities of the system as a whole.

In 2024, nearly 80% of individuals who needed SUD treatment didn’t receive it. Of the 52.6 million Americans who required services, only 10.2 million accessed care.

At the same time, providers are stretched thin. Over half of behavioral health clinicians report moderate to severe burnout, driven in part by documentation burdens and low wages. 

Those documentation burdens are particularly felt in SUD settings, where group therapy is common and requires extensive notes for both the group as a whole and each individual member. 

Meanwhile, clinical complexity continues to rise. Thirty-five percent of Medicaid enrollees have a mental illness, and 24% have a substance use disorder. That significant overlap requires more integrated, coordinated care that can be tough to deliver in a fragmented system.

Synthetic opioids like fentanyl and carfentanil continue to disproportionately affect communities, with carfentanil use seeing a sevenfold increase.

But it isn’t all doom and gloom. Overdose deaths decreased by 27% in 2024. 

This was the landscape heading into December 2025. But the SUPPORT Act story actually began in 2018, when Congress first passed legislation to combat the opioid crisis. It authorized grants, pilot programs, and treatment initiatives—but with an expiration date of September 30, 2023.

For over two years, the industry questioned whether these programs would endure. The 2025 reauthorization passed the House 366-57 in June. The Senate approved it by unanimous consent in September with no revisions, signaling overwhelming bipartisan support, and then they extended the programs through 2030. 

On paper, it was a clear win.

Debbie Witchey, president of the Association for Behavioral Health and Wellness, captured the significance, stating, “The original law created critical tools—like expanded coverage, stronger prevention programs, improved care coordination, and investments in the behavioral health workforce—that communities rely on every day.”

Then, H.R.1—the One Big Beautiful Bill Act (OBBBA)—came into play.

The legislation includes $911 billion in Medicaid cuts over ten years. The Congressional Budget Office estimates 11.8 million people will lose health coverage by 2034, including more than 1.6 million Medicaid enrollees with substance use disorders.

Medicaid accounted for $17 billion in SUD spending in 2019, 60% of the $30 billion spent in total nationwide. And with SAMHSA consolidated into the Administration for a Healthy America, resources and staff have been significantly reduced. 

It’s like the old joke from the early days of Apple’s rise against IBM: “What do you get when you merge Apple and IBM? You get IBM.” So too when you merge behavioral health and SUD into one medical model, they each risk getting lost.

Dr. Sadie Elisseou, a Harvard faculty member who works with veterans diagnosed with substance use disorders, expressed exactly what many of us feel: “Trauma is at the root of many substance use disorders, and trauma-informed care offers solutions for recovery and treatment provisions. If we are looking into a future with fewer resources locally and nationally, I’m not sure that we will be able to address these social concerns, public health concerns, effectively.”

And so we arrive at the paradox:

  • Expanded mandates with diminished resources. 
  • Reauthorized programs with gutted infrastructure. 
  • Applause-worthy legislation paired with existential financial threats.

Why This Time is Different

I got into community behavioral health in part because it was founded on the promise of comprehensive, accessible care for all. 

I remember when Medicaid expansion felt like a turning point for behavioral health access. Parity legislation was supposed to finally put mental health on equal footing with physical health. (It always struck me as odd that any country would have to pass legislation requiring mental health to be treated the same as medical care, but that’s a discussion for another time.)

Each wave brought expanded promises—and they all eventually crashed into the twin reefs of insufficient resources and lackluster enforcement.

What makes these changes different is the scale and speed of the contradictory health care direction as a whole. 

Previous eras saw a gradual erosion of support or slow implementation of underfunded mandates. This time, the changes are big, fast, and unpredictable—challenging even the best leaders.

And the predicted consequences are already taking shape:

  • Organizations that depend on Medicaid expansion funding will face budget shortfalls before they can fully implement adaptive strategies. 
  • Patients will lose coverage while providers are still applying for newly available grants intended to serve them. 
  • States must prepare to help clients navigate work requirements (80 hours per month) while managing exemptions for “medically frail” individuals—a category that includes those with SUDs—all while operating with reduced federal support.

There is one bright spot, though. The $50 billion Rural Health Transformation Program, which includes CCBHCs, CMHCs, and OTPs as eligible facility types, allocates about $200 million to each state. 

But as Witchey emphasizes: “Now that the framework has been retained, we need to ensure the programs of the SUPPORT Act are appropriated so we can continue to see the gains made.”

The Cost of Waiting

I’ve seen organizations take the “wait and see” approach before. I understand the logic. Why make major changes when regulations might shift? Why invest in infrastructure before final rules are published? Why panic when the details remain unclear?

Here’s why that logic fails this time: In an environment that is exclusively unpredictable, “wait and see” might be prudent, but that’s not what this is. 

The financial cliff is real and approaching fast. 

Medicaid-dependent organizations will experience substantial revenue shortfalls as the cuts phase in. When patients start to lose coverage, uncompensated care will surge. Delayed responses will accelerate staff departures due to uncertainty or downsizing, worsening an already precarious workforce.

The clinical consequences are immediate: 

  • Interrupted care for vulnerable populations, 
  • Increased opioid-related hospital use and overdoses, and
  • Potential reversal of that hard-won 27% reduction in overdose deaths. 

Organizations will be forced into reactive cuts rather than strategic preservation of evidence-based services.

Rural providers will face unique vulnerabilities due to low patient volumes, high fixed costs, and recruiting challenges. Those unprepared to secure Rural Health Transformation funding or SUPPORT Act grants will watch as better-prepared competitors access the resources they desperately need.

Community-based providers who endeavor to provide services regardless of ability to pay will experience a double hit. Clients who once had Medicaid coverage but have lost it in the wake of OBBBA will return as indigent clients needing care—further threatening these organizations’ ability to fulfill their missions while staying afloat financially.

States have until January 1, 2027, to implement work requirements. Organizations that are unprepared to help clients navigate exemptions risk massive caseload churn. And those that fail to adapt reliable compliance systems increase their audit exposure at precisely the wrong moment.

That’s why, even though “wait and see” sounds prudent, it’s actually just slow-motion organizational decline.

See how the Eleos OBBBA AI scanner can proactively alert your providers to patient eligibility changes.

What Leaders Should Do Now

Waiting can’t be your strategy. This moment requires intentional leadership.

A recent 2025 Harvard Business Review article captures the mindset that I believe leaders should be taking now:

“When uncertainty strikes, the default reaction is often to retreat. But courageous leaders don’t wait for clarity—they create it. Courage is not about being fearless; it’s about acting in service of a purpose, even when fear is present.”

One practical framework for doing that is adapted from Govindarajan, Finkenstadt, and Eapen, who describe a strategy of “Strategic Subtraction.” In turbulent environments, resilience often comes not from adding more—but from removing what no longer serves the mission. 

Here’s how to put that in action:

  • Eliminate what no longer adds value. Cut activities, steps, or rules that don’t serve a clear function. For example, clinical programs that don’t add value but have simply “always” been part of the organization’s DNA should be terminated or at least paused. 
  • Substitute complexity with simplicity. Swap out high-maintenance tools or workflows with simpler options that meet the same need. This is where AI can shine, especially when it comes to supporting clinical documentation for group therapy.
  • Consolidate overlapping functions. Merge tasks, systems, or touchpoints into integrated solutions. The old “we’ve always done it that way” is the target here.
  • Hide complexity behind clean interfaces. Keep systems powerful under the hood, but conceal nonessential details so users only see what they need, reducing overload while keeping functionality intact. Do EHRs and other user-intensive tools work the way you need them to, or is it time to have a conversation with your vendor about optimization?
  • Suspend features or services that aren’t needed now but may return. This preserves flexibility and avoids burning bridges. Though this may be unpopular with stakeholders, it’s important to bring them into the conversation about why their pet program is being stopped, even temporarily.

I also gave a quick overview of Strategic Subtraction in a recent webinar I hosted with Dominic Miller, LCSW, MPA.

Dr. Denny Morrison, Eleos Chief Clinical Officer, shares insights for behavioral health and SUD organizations around the concept of “Strategic Subtraction.”

Catch the full webinar for more H.R.1-related guidance, or grab the highlights on the blog.

Where Strategy Meets Clinical Execution

Assuming you don’t adopt a “wait and see” strategy, the next practical question is:

Where should leaders focus first?

Unfortunately, of the three most common environments leaders face—predictably good, predictably bad, and unpredictable—we are in the latter, which is harder to manage than the first two. That unpredictability makes it even more difficult for leadership teams to maintain clinical quality while ensuring financial viability.

The good news is that many of the same tools that improve clinical quality can also drive operational efficiency. It’s not an either/or proposition. In times like these, strengthening core clinical processes is a financially strategic act in itself.

Rethinking the Intake

Improvement often begins with uncomfortable truths. 

One of ours in SUD and behavioral health is that we are terrible at intakes (and I can say that because I led a behavioral health center). 

Much of the problem with intakes stems from externally imposed requirements from payers and other stakeholders that demand data, data, and more data collected at the initial point of contact with a new client. But the result of this is higher no-show rates, not for the intake itself but for the second session. 

Provider organizations have little control over whether someone shows for an intake. We often don’t know why someone scheduled an appointment and didn’t show up. What we do know is that, unless they were a returning client, they don’t know much about us. And if someone does show up for an intake, they will get to know us and, based on that encounter, decide whether to come back. 

Though the research is sparse, personal experience and feedback from my peers typically put second-appointment show rates around 50%. It seems clear that, generally speaking, we aren’t making a stellar first impression.

What do you call it when half of a population doesn’t show for treatment, and a clinician now has to document that missed encounter and probably do a discharge summary? 

Waste. (Sorry if you thought I had an amusing punchline up my sleeve. 😅)

One of my favorite sayings is one I learned while working in an SUD program: “If you always do what you’ve always done, you’ll always be what you’ve always been.” 

The SUD community is nothing if not committed to life-altering changes, but managers seem to adopt a position of learned helplessness when they think about intakes. 

I believe when a problem seems insolvable, we must step up a level and address what assumptions we are making about the problem. 

One critical point for intakes is: “We have to get paid for the intake session.” Do you? Really? What would happen if you abandoned that assumption?

From a Clinical Perspective

On the clinical side, you’d likely find that the care provided in that one session had improved. That probably sounds odd, but bear with me. 

Talmon (1990) found that about 20% of people who seek therapy only need or want one session. So, what would the intake look like if you knew it would be the only session you had with the client? 

Many SUD providers already practice from a Motivational Interviewing perspective that honors client autonomy and agency. If you assume the intake may be the only session, the focus shifts: Deliver value (as defined by the client) now. 

Instead, we often document as if the client will remain in treatment for weeks—and then feel surprised when they don’t.

From a Financial Perspective

From a purely financial standpoint, I suspect you would find that you’ve actually saved money. 

If half of second appointments never occur, you are spending clinical and administrative time documenting intakes and writing discharge summaries for clients who fail to return. Reducing documentation burden and redesigning the intake encounter could eliminate significant waste.

From a Personnel Perspective

When it comes to your team, you’d probably find that you have happier providers.

Few things frustrate clinicians more than completing lengthy intake documentation only to prepare a discharge summary for someone they saw once. Reducing unnecessary administrative burden improves morale—and in a workforce crisis, morale matters.

From a Customer Service Perspective

Lastly, you’d likely find clients more satisfied when you minimize the documentation load placed on them (which, frankly, is to meet our needs, not theirs). 

People seeking services are taken aback and disappointed when we ask a lot of questions that, to them, seem irrelevant. What if we avoid that in the first session, focusing on their presenting problem (as they see it), and then setting the expectation that there will be some necessary “paperwork” to complete if they decide to come back? If they don’t want another session, make it easy for them to say “no thank you” when you ask whether they’d like to schedule one. Give them your business card and tell them, “Feel free to contact me if I can help.”

There is a power dynamic at work here, which shows up in this little folie à deux. It happens when both the clinician and the client know the client isn’t coming back for the second session, but they both agree to schedule it anyway.

In a resource-constrained environment, improving long-standing processes like intake is both a clinical upgrade and a financial safeguard.

Reducing Documentation Burden Without Sacrificing Quality

I know I’m preaching to the choir when I tell an audience of SUD providers to use group versus individual therapy whenever possible. 

Group therapy is clinically equivalent to individual therapy for most problems—and more efficient. It allows organizations to extend access and maximize clinician capacity.

The downside of groups is the documentation burden. While individual appointments have a 12-15-minute documentation burden per note, group providers face an exponentially greater burden with a group note plus individual notes required for each participant. What looks operationally efficient on the schedule can become administratively overwhelming after hours.

Until recently, technology improvements largely benefited individual sessions. Ambient AI dramatically reduced documentation time—with many providers reporting 70–80% time savings.

Now, similar efficiencies are becoming possible for group documentation. If you apply even a fraction of that improvement to the documentation demands of group care, the time savings are substantial—and the impact extends well beyond convenience.

Reducing documentation burden:

From there, it’s a domino effect. Better documentation at the point of care leads to improved compliance. Layer in AI-driven auditing that reviews 100% of notes before submission, and organizations reduce denials, mitigate audit risk, and strengthen financial performance.

How to Navigate The Road Ahead

Like many aspects of American healthcare policy, this one cannot be reduced to simple solutions. Context, implementation, and countless other factors matter.

There are tactical challenges, like:

  • What does the law say?
  • What does it change?
  • What is the timeline for the various changes? 

Use trade associations for support, especially those that actively advocate on the Hill. Poll your network to get ideas and opinions from peers.

These are necessary steps to work out for any strategic planning. But tactical clarity alone is not strategy.

Defining your organization’s specific strategic plan is beyond the scope of this blog. What I can offer is a set of decision-making lenses—drawn from Harvard Business Review—that may help leaders navigate turbulent conditions.

Consider asking:

  • What decision today will still make sense a year from now? This question pushes you beyond short-term pressure. It invites you to prioritize decisions that align with long-term values and direction, helping you move from reactive to resilient.
  • If this decision became a case study in leadership, what would it teach? Use this to test not just the logic of your decision, but its message. What example are you setting? What does it say about your team’s character and culture? Will it build trust, respect, and confidence?
  • What if this isn’t the storm—what if it’s the climate? Stop waiting for volatility to pass. If disruption is the norm, ask what needs to change permanently—in your systems, culture, and strategy—so you can endure, not just survive.
  • What’s the cost of waiting? Delaying may feel safe, but inaction carries hidden risks. This question reframes the moment and urges you to act with intention before momentum is lost.

We are clinical organizations. Strengthening core clinical processes in alignment with strategic goals is not optional—it is foundational. 

That may mean pausing programs that no longer align with the organization’s direction. It may mean challenging long-held assumptions. It may require investment in technologies that improve documentation, compliance, and care delivery—even when the instinct is to freeze spending.

These challenging times require thinking differently, not about programs or service lines but about what business you are in and, more importantly, what business you should get out of.

I found this line from the above-mentioned Strauss Einhorn article to capture this well:

“In today’s perma-crisis world, waiting for stability is like waiting for a train that’s never coming.”

It’s not an exaggeration to say that we have seen more unpredictability coming out of Washington—and in some cases, state governments—than ever before. I do not see this changing anytime soon, so “perma-crisis” is probably where we will be for a while. 

The current policy paradox will challenge leaders of all ilk, but times like these also provide opportunities for those willing to meet the moment and take risks that push beyond the status quo.

Want to learn how Eleos helps SUD providers reduce documentation burden while improving outcomes and positioning organizations for value-based contracts? Request a demo of our purpose-built AI platform.

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