Alignment for Progress: 
A National Strategy for Mental Health and Substance Use Disorders

Continuity of Operations Plans (COOPs) clearly outlines how an organization will continue to perform its essential functions during a disaster or emergency.[2][3] While critical to ensure workers can get back to work quickly and safely, these plans often fail to address employees’ mental health needs.[3] Essential workers are at an increased risk for job-related trauma and for developing mental health conditions and substance use disorders.[4] As recommended by the National Action Alliance for Suicide Prevention’s “Action Plan for Strengthening Mental Health and the Prevention of Suicide in the Aftermath of COVID-19,” including plans to address employee needs related to mental health, emotional stress, and trauma support in COOPs can help improve the overall health of essential workers during a crisis.[1]

Individuals involved in agricultural work or farming often encounter many challenges that may impact their mental health. Challenges related to volatile agricultural commodities markets, weather and even climate change can contribute to the stressors on farmers and agricultural workers. At the same time, there is often a shortage of healthcare providers to address the needs of agricultural communities. The American Psychological Association notes that rural areas experience shortages of mental health care providers and stigma around mental health.[2]

The FRSAN program connects farmers, ranchers, and other agriculture workers to stress assistance programs and resources. Through FRSAN, state departments of agriculture, state extension services, and non-profits receive funding to establish helplines, provide suicide prevention training for farm advocates, and create support groups for farmers and farm workers. Under the Farmers First Act, departments of agriculture across many states and non-profit organizations are provided the necessary funding to establish helplines, suicide prevention training for farm advocates, and support groups.[3] Congress should prioritize reauthorizing this important program serving the mental health needs of farming communities.

FQHCs frequently serve socially and economically marginalized communities. FQHCs must report on quality measures associated with mental health and substance use disorders (MH/SUDs), including depression screenings, brief alcohol interventions, and depression remissions.[1][2] However, they are not required to use the Center for Medicare and Medicaid Services’ (CMS) core quality measures for publicly funded health plans.[3][4] Clinical experts have raised concerns about the efficacy of existing FQHC reporting requirements, particularly in addressing disparate health outcomes in marginalized communities.[1] HHS should mandate that FQHCs align with CMS’ core measures to address health disparities. Implementation of these reporting requirements should be appropriately funded. [1]

The Department of Health and Human Services should assist in elevating the standards of MH/SUD care that are generally accepted by MH/SUD clinicians by examining peer-reviewed scientific studies and medical literature, recommendations from nonprofit clinical specialty associations, recommendations from federal agencies, and drug labeling approved by the U.S. Food and Drug Administration.This database of generally accepted standards of care could be utilized by federal and state insurance regulators in their enforcement of the Mental Health Parity and Addiction Equity Act (MHPAEA) and other health coverage requirements. The Department of Health and Human Services should further identify guidelines and criteria that are consistent with generally accepted standards of MH/SUD care to help improve the quality of MH/SUD service delivery and coverage. The Department could consult with the New York State Office of Mental Health, which has put out “Guiding Principles” for clinical review criteria for mental health services and a “Best Practices Manual for Utilization Review for Adult and Child Mental Health Services. In its reviews, OMH found that no health plans’ submitted criteria met these Guiding Principles.[1][2]

Currently, the lack of such a definition weakens MHPAEA’s protections, especially for autism spectrum disorders. Federal regulators have made clear that health plans must define MH/SUDs consistent with generally recognized independent standards of current medical practice, such as the DSM or International Classifications of Disease (ICD), unless state law defines otherwise. This generally results in individuals with autism being protected under MHPAEA, given that autism is defined as a mental health condition in the DSM and ICD. However, at least one state – North Carolina – defines autism as a physical health condition, not a mental health condition, and MHPAEA’s protections do not apply to fully-insured plans in the state. In their 2022 report to Congress, the Departments of Labor, Health and Human Services, and Treasury have requested that Congress define MH/SUD[1], and the Promoting Clarity in Mental Health and Substance Use Disorder Treatment Act was introduced later that year, which would tie the definition of MH/SUD to the DSM and ICD[2].

Congress established the CCBHC model as a Medicaid demonstration under Section 223 of the Protecting Access to Medicare Act of 2014. The original 10 CCBHC demonstration states will be graduating from the demonstration over the next few years and will need to seek a state plan amendment or an 1115 waiver to maintain their already-implemented CCBHC models. Additionally, other states that seek to establish the CCBHC model outside of the demonstration will also need to apply through a state plan amendment or waiver. The lack of a federal CCBHC definition creates a risk that states and their CCBHCs may not have consistent models, affecting both outcome data and the quality of care provided.

The Bipartisan Safer Communities Act of 2022 allows for 10 new states to join the CCBHC Medicaid demonstration every two years. Having a standard federal CCBHC definition gives states the ability to continue their existing CCBHC models and will expedite efforts for states implementing the CCBHC model by having clear guidance for state plan amendments and 1115 waiver. This will also support fidelity to the CCBHC model that Congress established and continues to support.[1]