Alignment for Progress: A National Strategy for Mental Health and Substance Use Disorders
It’s time for a meaningful national conversation about mental health and substance use care. We must remove the barriers to equitable and available coverage for these conditions so people can get the help they need.
Welcome To The National Strategy
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How Content Is Organized and How Best to Search/Sort the Recommendations
The National Strategy recommendations are organized by category, with impacted populations and topical areas providing additional nuance and the ability to narrow a search. We have also included the option to search recommendations by the relevant House and Senate committees of jurisdiction.
Recommendation Selection Methodologies and Criteria
After conducting a thorough review of the federal policy landscape, The Kennedy Forum team created this first-of-its-kind compilation of policy recommendations needed to transform our mental health and substance use systems. The recommendations have been sourced and vetted from numerous organizations, advocates, and experts across the country in order to capture a robust set of recommendations for lawmakers and federal agencies to act on.
All National Strategy Recommendations
These featured recommendations are highlighted based on their importance in beginning the national movement towards better care for everyone.
Expand National Health Service Corps eligibility
The Health Services and Resources Administration (HRSA), within the Department of Health and Human Services, should educate mental health and substance use disorder (MH/SUD) professionals about Public Service Loan Forgiveness for work in the criminal legal system.[1] Congress should expand National Health Service Corps (NHSC) eligibility to local and county corrections and a wide range of SUD treatment and recovery support professionals and make permanent the Fiscal Year (FY) 2018 NHSC expansion of eligible participating sites to include SUD treatment facilities.[1]
An increasing number of individuals with mental health and substance use disorders (MH/SUDs) are involved with the criminal legal system, where there is a scarcity of health professionals who can provide MH/SUD care.[1][2] An estimated 44 percent of individuals in jail and 37 percent in prison have a mental health condition and 63 percent and 58 percent, respectively, have an SUD. Sixty-three percent of these individuals don’t receive the treatment they need in prisons and less than half receive treatment in jails.[3][4] One way to incentivize MH/SUD professionals to work in the criminal legal system is by expanding loan forgiveness and repayment programs.[1]
Licensed clinical social workers and professional counselors; health service psychologists; marriage and family therapists; psychiatric nurse specialists; physicians with a specialty in psychiatry, including child and adolescent psychiatrists; nurse practitioners; and physician assistants who specialize in mental health and psychiatry who work in the criminal legal system are eligible for Public Service Loan Forgiveness.[5][6] In Fiscal Year (FY) 2018, Congress expanded National Health Service Corps (NHSC) eligibility to include SUD treatment facilities and additional MH/SUD health professionals.[1][7] However, this expansion is not permanent and does not include eligibility for local and county corrections and MH/SUD treatment and recovery support professionals.[1][7][8] Education and permanent expansion of loan repayment and forgiveness programs is necessary to increase the number of MH/SUD health professionals in the criminal legal system.[1]
Topics
Eliminate out-of-state licensure requirements
To address the continued need for provider flexibility and remove federal barriers to meeting workforce demands, Congress should permanently eliminate the out-of-state licensure requirements under Medicare and Medicaid. Congress should also direct the Department of Health and Human Services (HHS) to convene a working group representing state health profession licensure boards to identify barriers to participation in state licensure compacts and develop a framework or model application for reciprocity to facilitate provider approval to practice across state lines.[1]
In response to the COVID-19 pandemic, the Centers for Medicare and Medicaid Services (CMS) temporarily waived requirements that out-of-state Medicare practitioners be licensed in the state where they are providing services.[2] CMS also released guidance stating that state Medicaid agencies could use Section 1135 waiver authority to permit providers located out of state to provide care to another state’s Medicaid enrollee impacted by the COVID-19 emergency.[2] These changes were particularly helpful in enabling mental health and substance use disorder (MH/SUD) providers to meet increasing demand for services around the country throughout the pandemic. While the public health emergency has officially ended, the need for increased flexibility to maintain the capacity of providers has not. Congress should amend the Social Security Act to allow licensed providers participating in Medicare, Medicaid, and CHIP to provide services across state lines.
In May 2023, the Health Resources and Services Administration (HRSA) Office for the Advancement of Telehealth released new resources on interstate licensure.[3] These resources include the latest guidance on how to practice telehealth across state lines legally while encouraging the uptake of licensure models that increase access to health care. As part of this ongoing work, HHS and HRSA should convene stakeholders to identify remaining barriers to participating in interstate compacts and develop a framework for overcoming those obstacles.
Topics
Require CMMI to advance behavioral health integration
Congress should require the Center for Medicare and Medicaid Innovation (CMMI) to advance behavioral health integration by adding support for adopting behavioral health integration as one of the types of opportunities the CMMI must consider when developing new demonstration models or revising existing models. [1]
In 2017, the Centers for Medicare and Medicaid Services (CMS) began paying physicians and non-physician practitioners separately for supplying patients with Behavioral Health Integrated Services (BHI).[2] These services involve a closer partnership between treating primary care and MH/SUD providers, which has proven beneficial to patients and has evolved into the Collaborative Care Model (CoCM). The CoCM has been demonstrated effective by more than 90 randomized-controlled trials and can help to more effectively utilize limited MH/SUD provider capacity.[3] CMMI is responsible for testing alternative payment models. Given the demonstrated success of BHI/CoCM payment models at improving care and improving delivery efficiency, CMMI should be required to consider these models when developing new demonstration models or revising existing ones.[1][4] In 2022, the Senate Finance Committee’s bipartisan Mental Health Care Integration workgroup recommended such a requirement.[1]
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Pass the Servicemembers Mental Health Improvement Act
Congress should pass the Servicemembers Mental Health Improvement Act as stand alone legislation or part of the National Defense Authorization Act (NDAA), which would establish a mental health task force within the Department of Defense (DoD), including DoD and non-DoD mental health experts, to examine mental health matters across the department and provide recommendations to improve mental health services in the Armed Forces. [1][2]
Over 456,000 active military members from 2016 to 2020 were diagnosed with at least one mental health/substance use disorder (MH/SUD).[3] In 2020, over 5.2 million Veterans experienced a MH/SUD.[4] These numbers likely underestimate the number of military personnel with a MH/SUD, as it is estimated that 60 percent do not seek treatment[3][5], with stigma an important abarrier to mental health care for military personnel.[6] Individuals often fear they may be perceived as weak or could losie their job.[6] Other barriers include the lack of awareness of potential treatment options and an inability to take time off. [6] Congress and the Department of Defense (DoD) must take action to improve mental health services for military personnel. [1][2]
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Develop quality measures to assess care integration
Congress should require the Centers for Medicare and Medicaid Services (CMS) to develop Medicare quality measures that assess the degree to which clinician practices integrate mental health and substance use disorder (MH/SUD) and primary care.[1]
Despite effective MH/SUD treatments being widely available, many individuals with MH/SUD do not receive needed treatment, in part due to historically siloed MH/SUD and physical health systems.[2] Integrating MH/SUD and physical health services is essential to improving access to care, as well as patient outcomes.[2] In 2017, the Centers for Medicare and Medicaid Services (CMS) began paying physicians and non-physician practitioners for supplying patients with Behavioral Health Integrated Services (BHI).[3] These services involve a closer partnership between providers, which has proven beneficial to patients and has evolved into the Collaborative Care Model (CoCM). This model has been demonstrated effective by more than 90 randomized-controlled trials and can help to utilize limited MH/SUD provider capacity more effectively.[4]
Quality measures are used by CMS to measure and track a range of outcomes and processes in order to determine the ability to provide effective, timely, safe, efficient, patient-centered, and equitable care based on related quality goals.[5] There are currently no quality measures tied to quantifying or monitoring the degree to which clinical practices integrate MH/SUD.[6] Congress should pass language included in the Senate Finance Committee’s 2022 Mental Health Care Integration Discussion Draft, which would require CMS to develop Medicare quality measures that assess BHI efforts undertaken by clinical practices.[1][7]
Topics
Fund the Veterans Health Administration
Congress should appropriate additional funding to the Veterans Health Administration (VHA) to increase the number of mental health and substance use disorder (MH/SUD) providers, decrease wait and travel times, and attract culturally competent providers that serve the unique needs of the nation’s Veterans.[1][2]
The Veterans Health Administration (VHA) effectively integrates mental health and substance use disorder (MH/SUD) and physical health care, has expertise in conditions that disproportionately affect our Veterans such as post-traumatic stress disorder and depression, and understands military culture. Accordingly, investing in the VHA is critical to serving Veterans’ unique needs. While the premise of the Veterans Choice Program, which allows Veterans to get mental health care from non-VA professionals, is commendable, only about 13 percent of private mental health providers are able to provide culturally competent and evidence-based care, according to the National Alliance on Mental Illness.[3] Therefore, it is critical that Congress take steps to ensure that Veterans Choice Program-participating professionals demonstrate military cultural competency and increase rates to attract culturally competent providers.[3]