“Unrealistic” expectations: How Colorado’s Behavioral Health Administration has struggled to get off ground

With less than six months before Colorado’s new Behavioral Health Administration is supposed to take over regulating the state’s mental health and addiction treatment providers, people working in the industry are concerned that they’re running out of time.

The agency, which has only existed since 2022, recently pivoted from lawmakers’ original plan of running all behavioral health programs to more of an organizational role, getting other agencies to work together. It also had to ask lawmakers for extra time to write rules this year, but providers are still worried they won’t have enough time to implement them.

And the nascent BHA has seen a spurt of staff resignations earlier this year, followed by Gov. Jared Polis’ replacement of the agency’s first commissioner, Dr. Morgan Medlock, after just 15 months on the job. Since then, Medlock’s successor and the BHA’s advisory board have had a sometimes-contentious relationship.

State Sen. Jim Smallwood, a Parker Republican, said during a legislative hearing earlier this year that he’s skeptical the system can become more nimble while mental health programs remain dispersed among agencies — and that he and others voted for a unified system when they approved the 2021 bill that created the BHA.

“I’m disappointed the vision I was sold is not coming to fruition,” he said.

Despite the challenges that have played out in recent months, there’s still a strong desire to make the BHA work. Multiple administrators, advisory committee members and advocates spoke about the current process as a rare opportunity to fundamentally reshape the state’s mental-health system in a way that better meets Coloradans’ needs.

The Colorado Health Access Survey found about 24% of residents said they had “poor” mental health in 2021, and about 14% said they thought they needed mental health care but didn’t get it because of cost, difficulty getting an appointment, or other factors.

“What happens if we miss our moment to do big, transformational work?” asked Dr. K. Ron-Li Liaw, chief of mental health at Children’s Hospital Colorado and a member of the BHA’s advisory committee.

The bill to create the agency came out of a task force to address problems with treatment access and affordability, as well as a workforce shortage. The initial idea was that all of the state’s mental health and addiction programs would move under the BHA, allowing it to close gaps and streamline care. Agency staff told lawmakers this spring that that wasn’t going to be possible, though, and might not be desirable even if it were.

Instead, the BHA’s role will be to coordinate programs, ensure quality services and leverage funds for behavioral health, rather than leaving each department to figure out how to fund its part of the system, Deputy Commissioner Summer Gathercole told a Senate committee in April.

She said staff spent about a year researching the idea of moving all programs in-house, and learned it took significantly more time and money than expected in other states that followed through. They also didn’t find much duplication of programs that could be streamlined, she said.

Sen. Rhonda Fields, the Senate Health and Human Services Committee’s chairwoman and an Aurora Democrat, said she has concerns about the change in direction, though she voted to advance a bill extending the deadlines and allowing some programs to remain in place instead of moving under the BHA.

“The whole vision was that you couldn’t go through any wrong door,” she said during the April hearing.

Julie Reiskin, the executive director of the Colorado Cross Disability Coalition, said in May that the timeline and expectations the legislature set for the BHA were “unrealistic” from the beginning and forced the agency to move too quickly. Conflicts, stumbles and an inability to form relationships fully with outside groups were a consequence, she said.

“I think everyone was moving at such a fast pace,” she said, “and whenever you move at that pace, you’re going to get a lot of miscommunication, a lot of problems, it’s not going to work. It’s not anyone’s fault. It was set up for failure to start.”

Providers worry delay won’t leave them enough time

The challenges became more visible this spring, when BHA leadership had to ask the legislature for extra time to get up and running, through a bill that pushed back multiple deadlines.

The original bill called for the agency’s regulations to be ready by April, but now they won’t take effect until January. Providers said they still aren’t sure they will have enough time to prepare, though, and some advocates complain they feel left out of the process because of the need for speed.

It’s not that the BHA hasn’t accomplished anything over the last year. Medlock told members of a House committee in late March that the agency had administered about $48 million in grants to close gaps in care, held town halls with the public and meetings with providers, laid out the blueprint oversee local services and managed newer programs, including I Matter, which offers free therapy sessions to youth.

Even though stakeholders have been discussing problems in the system and possible solutions for about three years, it became clear early this year that the BHA needed to take more time to gather public comment, which required later deadlines, interim Commissioner Michelle Barnes said. That process restarted in April, she said.

“What we found is that a lot of stakeholders wanted to take two steps back and get into the muck, into the details,” she said.

Since then, staffers have focused on meeting with smaller groups rather than holding large town halls, so people have more time to speak, Gathercole said.

Rep. Judy Amabile, a Boulder Democrat who’s been involved in the BHA’s formation and launch, said in early May that advocates had begun to hear growing concerns “that things weren’t going well with the BHA.”

“We were hearing that the policies that they were putting forward or the ideas they were putting forward were not what people thought was going to happen,” she said.

Specific concerns were raised about stakeholding meetings with providers and advocacy groups, she and others said. At an early April meeting of the state’s board of human services, advocates from Mental Health Colorado and Colorado Cross Disability Coalition both vented frustration to the board about the rulemaking and stakeholding process.

“Just because you are in a room with somebody and you talk and they talk, it doesn’t mean your concerns are going to be addressed in the work that gets done,” Amabile said. “And it’s perfectly reasonable to think, ‘I heard you, but I disagree,’ or, ‘I heard you and what you’re saying is in the minority and most people are telling me something else.’ But no one ever had that conversation.”

Vincent Atchity, president and CEO of Mental Health Colorado, said in an interview in April that frustration from advocates centered around the feeling a “completed product” was being handed to advocates who felt shut out of the process.

He called that approach “mystifying” but didn’t ascribe blame to Medlock or any other person. But he said he was glad that the governor’s office was “reasserting control over something that really needs to be successful.”

The extra time for public comment leaves a tight turnaround to finalize the regulations governing providers that are scheduled to take effect on Jan. 1. In a Senate committee hearing about the bill in late April, Atchity said Mental Health Colorado opposed giving an extension to finish the rules, both because providers would need time to digest the new regulations and because the current system isn’t serving patients well.

“The well-being and lives of Coloradans are at risk today and every day,” he said.

The goal is for the agency to be “fully operational” by July 2024, which involves setting up agreements with other state agencies, creating standard contracts with providers and developing a strategic plan, Gathercole said. Regional entities to monitor the availability and quality of care in different parts of the state won’t come online until July 2025, though.

The work ranges from hiring people to run the BHA’s information technology to coming up with a way to put more “teeth” into contracts and make sure providers offer quality services, Barnes said. The Colorado State Board of Human Services also has to approve all of the new regulations before they can take effect, she said.

“It’s a heavy lift,” she said. “I feel like this is a moment when all of the stars are aligned to make big changes in behavioral health.”

At this point, it’s not clear how oversight will work. Staff are working with providers and people who use their services to determine how to measure quality and enforce it, Gathercole said.

“It’s the first time in decades that we started from scratch,” Gathercole said.

The timeline to set up an agency was “exceptionally aggressive,” said Edie Sonn, senior director of external affairs at the Colorado Behavioral Healthcare Council. An agency that’s supposed to coordinate that many programs is going to have hundreds of pages of rules, and despite staff’s best efforts, they can only draft those so quickly, she said.

“I think they — I mean all of the BHA staff — were given an impossible timeline… and they were under inordinate pressure,” she said.

The rules are written now and will go before the state human services board in September, and most likely will be approved in November, Sonn said. But that doesn’t give providers much time to read and understand them before they take effect in January, let alone to train their staff and change their record-keeping, she said. The BHA has said it won’t enforce most rules until April, with the exception of situations that threaten patients’ health or safety.

Rick Doucet, CEO of Community Reach Center, said that the delay gives providers some “breathing room,” but the timeline’s still unfeasible. The center offers behavioral health care in Broomfield and Adams counties.

“You can’t completely throw out a system and replace it in a year,” he said.

Turnover and board friction

The Behavioral Health Administration also has had to deal with turnover at the top. Its first commissioner, Medlock, left in April under circumstances that weren’t publicly explained. The governor’s office simply announced that Barnes was taking over “effective immediately.”

Efforts to reach Medlock for comment on this article were unsuccessful, but she told the Colorado Sun she had a conflict with Polis’ chief of staff, didn’t receive support from other cabinet members and saw her day-to-day responsibilities stripped away over time.

After Medlock’s departure was announced, advocacy groups signaled their support for the move.

Mental Health Colorado, which a few weeks before had raised concerns publicly at a board meeting, told Polis in an April 20 letter that the group was grateful for his “continuing commitment to transforming the state’s behavioral health landscape” and that they supported Barnes’ appointment as interim commissioner. Barnes had been serving as executive director of the Colorado Department of Human Services.

In a separate statement sent in response to a request for comment about the leadership change, Eagle Valley Behavioral Health Executive Director Chris Lindley said he applauded the governor’s office for “continuing the difficult work of bringing change to behavioral health care in Colorado” and that he looked forward to working with Barnes in the future.

The commissioner’s job wasn’t the only one to see some turnover. According to records obtained by The Denver Post, 10 BHA staffers resigned between December and March. Nearly all of them did so in a six-week span between late January and March 9.

The announced departures included Gathercole, the BHA’s chief of staff and division director of strategy planning and engagement, along with several analysts and individual program managers and directors. Gathercole rescinded her resignation at some point during the five weeks between submitting the letter and her planned departure and continues to work at the BHA.

In an interview, Barnes declined to comment on Medlock’s departure or the other turnover beyond saying it’s “always unfortunate” when a leader leaves, but that the BHA has retained sufficient talent.

Not everyone welcomed the change in leadership. During a meeting of the BHA’s advisory board in late May, 17 out of 44 people who were participating virtually had changed their names or posted images with slogans like “Justice for Medlock” or “More than Diversity.” The conversation with Barnes quickly moved on to a general feeling of not being heard or included, however.

Bob Dorshimer, CEO of Mile High Behavioral Healthcare and co-chair of the advisory committee, said the group didn’t always agree with Medlock, but felt like she and staff were listening. Now, the process is moving faster than the advisory committee can keep up with, because it’s still organizing itself, he said.

“Don’t march too far forward without us,” he said.

Rob Archuleta, chief innovation officer at addiction treatment provider Crossroads Turning Points and a member of the board, said during the meeting that he felt like the BHA staff were doing their best to include people who received services or worked in the field, but he’s frustrated by the timeline and the sense they haven’t been able to address important issues.

“I understand we have a deadline, but it doesn’t make me feel hopeful about the future,” he said.

The legal requirements that apply to a state department also have created friction. Nonprofit groups aren’t required to make their board meetings public, while state agencies must.

Racquel Garcia, executive director of the addiction recovery-focused HardBeauty Foundation and co-chair of the advisory group, wanted to meet with Barnes and another board member in late May, and said she felt ambushed by the requirement that the meeting be livestreamed. By law, an agency head meeting with two board members constituted a public meeting, but Garcia felt it undermined her goal of building relationships and rallied supporters to either speak or post slogans to back her up.

“Don’t dismiss my humanity,” Garcia said when Barnes responded to criticism. “You can acknowledge you were wrong.”

Jeremy Pavlik, a recovery coach with HardBeauty who said he is in recovery from heroin addiction, said he felt Barnes and the BHA staff weren’t part of the community because many of them didn’t live with a mental illness or addiction.

“Making decisions about us if you aren’t one of us, that enrages me,” he said. “I think everybody should be required to have lived experience.”

Barnes acknowledged the frustration some feel with the process, which involves collecting feedback, writing regulations and getting the Colorado Attorney General’s Office to sign off on them.

“As a state agency using taxpayer dollars, we have different rules and accountability than a nonprofit or an individual,” she said.

In an interview later, Garcia said she thought a disconnect remained between the board and the agency’s leadership, and felt like a “token” person of color. Still, the advisory group will get its work done and focus on building a system that works for everyone, she said.

“For far too long we were sitting on the outside, so we want to do it well,” she said. “Things are not OK, and we have to move forward.”

“It’s in how we implement these things”

Liaw said Colorado has an unusually complicated system, with seven regional accountable entities administering Medicaid in different counties, on top of all of the state agencies involved in mental health. She said she was speaking on her own views as a health care provider and committee member, not for Children’s Hospital Colorado.

While it’s good to involve stakeholders in creating the agency, the work is also incredibly complex, Liaw said. While she has a good grasp of some aspects of the system because of her work as a doctor and administrator, she said she isn’t familiar with the details of some of the laws that shape it, and that advisers need time to get up to speed.

Recently, some members asked for guidance on their role as an advisory group, Liaw said. She compared much of the last year to a “two-minute drill” in football, without the benefit of having played the full game.