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.
Create distinct categories for addiction HPSAs
The Health Resources and Services Administration (HRSA) should create distinct categories for addiction Health Professional Shortage Areas (HPSAs) that are different from mental health HPSAs.[1]
Health Professional Shortage Areas is a designation for an area, population, or facility experiencing a shortage in health care services.[2] HPSAs are currently divided into three groups, which include primary care, dental health, and mental health.[3] More than 163 million people live across 6,546 mental health HPSAs.[4] However,substance use disorder (SUD) is not fully captured by the mental health HPSA designation.[1][4] Treatment for SUD can include counseling, medication, and other support services, which can be provided by SUD professionals and treatment facilities.[5] Unfortunately, HRSA projects workforce shortages of 25,940 full-time equivalent addiction counselors by 2035, resulting in only 81 percent of treatment demands being met.[6] Similar shortages are expected for psychiatrists, psychologists, counselors, and social workers.[6] To address shortages in SUD health professionals, the Health Resources and Services Administration (HRSA) should develop addiction HPSAs.[1]
Topics
Reduce utilization reviews for SUD care
The Centers for Medicare and Medicaid Services (CMS) should encourage the use of case rates for substance use disorder (SUD) care that set a predetermined rate for each level of care once prior authorization has been approved, eliminating the need for further utilization review in levels of care including detoxification, rehabilitation, partial hospitalization, and intensive outpatient services.[1]
Continuous care and treatment improves involvement and outcomes for people with substance use disorders (SUDs).[2] However, the cost for SUD treatment can be expensive, even with health insurance.[3] The use of case rates for SUD care that set a predetermined rate for each level of care once prior authorization has been approved would eliminate the need for further utilization review for each level of care, including detoxification, rehabilitation, partial hospitalization, and intensive outpatient services.[1][4] This would ensure individuals receive continuous care based on their treatment plan and not what is dictated by cost or insurance.[4]
Topics
Pass the Medicaid Reentry Act
Congress should pass the bipartisan Medicaid Reentry Act to connect Medicaid-eligible individuals with access to mental health and substance use disorder (MH/SUD) treatment and resources 30 days prior to release from jail or prison.[1][2][3][5][8][9] In addition, Medicaid services should be maintained for incarcerated individuals who are not adjudicated or convicted of a crime by passing the Due Process Continuity of Care Act.[2][6][7][10][11]
Incarcerated individuals have higher rates of MH/SUD than the general public, and during the first two weeks after release, they are at 129 times higher risk of dying from a drug overdose.[1] Due to the Medicaid Inmate Exclusion Policy, coverage is not continued during incarceration, leaving a gap in coverage and access to care.[3] This exclusion also means that incarcerated individuals who are not adjudicated or convicted of a crime lose access to their coverage.[2][4] Members of Congress have sponsored legislation to ensure that incarcerated individuals under the age of 18 have access to Medicaid coverage.[7] Maintaining Medicaid eligibility for individuals who are not adjudicated or convicted of a crime and allowing coverage 30 days pre-release are essential steps towards decriminalizing MH/SUD.[5] The Medicaid Reentry Act extends Medicaid eligibility to 30 days prior to release. and the Due Process Continuity of Care Act continues Medicaid coverage for individuals not adjudicated or convicted of a crime, the passage of both would improve continuity of care, assist with successful reentry, and save lives.[8][9][10][11]
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Address MH/SUD in the criminal legal system
The White House should launch an interagency council or permanent working group to address behavioral health issues in the criminal legal system. Several issues to address include different funding streams, confusion around jurisdiction on Capitol Hill, and federal legislation and programs that do or could address these issues. Group members should consist of, but are not limited to, the Department of Justice (DOJ), Health and Human Services (HHS), Housing and Urban Development (HUD), and Labor (DOL).[1]
Individuals with mental health and substance use disorders (MH/SUD) are overrepresented in the criminal legal system.[2] Often unable to access the care and treatment they need, these individuals tend to stay incarcerated longer.[3] To address gaps in MH/SUD resources, federal, state, and local groups have taken action. However, this has led to a patchwork response. Congress recognized this fragmentation and has called upon the federal government to coordinate its efforts. This could be accomplished with an interagency council or permanent working group.[1] The Federal Interagency Reentry Council, the U.S. Interagency Council on Homelessness,[1] and the SAMHSA Interagency Task Force on Military and Veterans Mental Health, which bring together federal agencies previously working separately, could serve as models to address behavioral health in the criminal legal system.[1][4][5]
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Expand HPSA bonus payments for psychiatrists
Congress should expand Medicare’s Health Professional Shortage Area (HPSA) Physician Bonus Program to increase bonus payments for psychiatrists who practice in shortage areas.[1]
The Health Resources and Services Administration (HRSA) projects a 20 percent decrease in the supply of adult psychiatrists by 2030.[2] At the same time, a three percent increase in demand is expected.[3] To encourage psychiatrists to practice in Health Professional Shortage Areas (HPSAs), Medicare’s HPSA Physician Bonus Program pays a 10 percent quarterly bonus to physicians, including psychiatrists, who provide Medicare-covered services in health shortage areas across the country.[4][5] However, with growing provider shortages, increased payments are needed to continue to incentivize psychiatrists to provide services to communities facing the highest need. In its 2022 Mental Health Workforce Enhancement Discussion Draft,[6] the Senate Finance Committee proposed such an increase.[1]
Topics
Pass the Immigrants’ Mental Health Act
Congress should pass the Immigrants’ Mental Health Act, which would require Customs and Border Protection (CBP) to develop training to enable its agents and officers to identify mental health challenges and risk factors in immigrants and refugees, provide crisis intervention using a trauma-informed approach, and better manage work-related stress and psychological pressures.[1][2][3]
Immigrants, refugees, and asylum seekers face multiple stressors, such as family separation, poverty, housing insecurity, and unemployment.[4] In addition, about one in three experience depression, anxiety, or post-traumatic stress disorder (PTSD).[4] To address the mental health of those in the immigration system, CBP staff should be trained and MH/SUD experts made available.[1]. However, many immigrants and refugees fear seeking mental health support in fear of it impacting their immigration status.[2] Unfortunately, unaccompanied minors who are required to attend therapy have had their notes shared during court proceedings resulting in the denial of asylum.[5]
In a September 2020 letter, a number of organizations representing medical and mental health providers, including the American Academy of Pediatrics, American Psychiatric Association, American Medical Association, among others, cited the trauma incurred during immigration and immigration detention and their belief that the conditions in CBP custody to be inconsistent with evidence-based recommendations for children and women.
To protect the mental health of immigrants, refugees, and asylum seekers, CBP staff should have training, MH/SUD experts should be available, and it should be prohibited to share confidential information shared in therapy sessions.[1][2][3] Additionally, CBP officers face some of the highest suicide rates of any law enforcement. Between 2007 and 2022, 149 CBP employees died by suicide. The rate of suicide at CBP is almost 28% higher than at any other law enforcement agency. [6][7]
The Immigrants Mental Health Act includes provisions to address mental health challenges among immigrants as well as CBP agents and officers.[1] This includes assigning at least one qualified mental or expert on mental health and substance use disorders (MH/SUD) to each Border Patrol station, port of entry, checkpoint, forward operating base, secondary inspection area, and short-term custody facility. In addition, the act would restrict the sharing of mental health information for use in certain immigration proceedings.[1]