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.
Pass the HCBS Access Act
Congress should pass the Home and Community Based Services (HCBS) Access Act, which would make HCBS a mandatory benefit within Medicaid and ensure eligible older adults and individuals with disabilities can choose between home care and institutional care.[1][2]
Older adults and individuals with disabilities may require long-term care.[2] An estimated 11 million Americans qualify for long-term services and supports (LTSS).[3] Those who qualify for LTSS may have a range of physical or mental health or substance use disorder (MH/SUD) needs which require intensive caregiving. Qualified individuals face two paths to long-term care: institutional care in a facility or care provided through HCBS.[2] HCBS provide significant support to those who require long-term care, including home health aides, case management, adult day care, and more, while allowing patients to remain at home.[4]
While most states currently offer HCBS waivers, many who qualify for LTSS find themselves on long waiting lists for a waiver, and when care is needed immediately, eventually turn to institutional care despite preferring to remain at home.[2] Individuals with a MH/SUD that requires long-term care should not feel forced into institutional facilities when they would prefer to remain at home and can do so with better outcomes.[5] Congress should pass the HCBS Access Act, which would require Medicaid to allow all eligible adults to choose between receiving care at home or another facility.
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Apply the federal Parity Law to all health coverage
The Mental Health Parity and Addiction Equity Act (MHPAEA) should apply to all health coverage in the United States. Existing major gaps in MHPAEA’s protections include Medicare Fee-for-Service, Medicare Advantage, Medicaid Fee-for-Service, TRICARE, and the Indian Health Service (IHS).[1][2][3] Additionally, the federal government should strengthen MHPAEA’s existing protections by finalizing its proposed rule released in July 2023.
The Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA or Parity Law) requires equity in coverage between mental health and substance use disorder (MH/SUD) and medical/surgical benefits.[4][5] When passed in 2008, the MHPAEA applied only to group health plans and group health insurance.[4][5] However, in 2010, the Affordable Care Act (ACA) amended the law to include the individual health insurance market.[4][5] While the MHPAEA has significantly improved access to MH/SUD coverage for millions of Americans, several gaps persist. Tens of millions of Americans who receive health coverage through Medicare, fee-for-service Medicaid, TRICARE, and the Indian Health Service (IHS) are not covered by the Parity Law, leaving individuals with health insurance through these programs open to discrimination.[5][6][7] Parity protections shouldn’t apply only to a subset of Americans based on the type of insurance they have. Everyone deserves to receive equal coverage of mental health and addiction treatment services.[6]
In addition to expanding the MHPAEA’s applicability, the existing regulatory rules need to be updated and strengthened. In July 2023, the Departments of Health, Treasury and Labor issued a proposed rule that would require health plans to act when there are disparities in consumers' ability to access care, require data reporting to evaluate plans' compliance, and would create new rules regarding "network composition" to address whether individuals can access care within plan networks.[8] The administration should work quickly to finalize the proposed regulation and implement these new protections.
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Ensure access to MOUD and MAUD
Congress should enact the critical insurance protections to ensure access to medications for opioid use disorder (MOUD) and medications for alcohol use disorder (MAUD) as a new section within the Public Health Service Act (42 U.S.C. § 300gg et seq).
Congress should amend the Public Health Service Act to include the following additional insurance protections that increase access to MOUD and MAUD, which have been proven to save lives.[1] Specifically, Congress should ensure the following protections are codified:
- Health plans and issuers may not exclude coverage of any Food and Drug Administration (FDA) approved medication for the treatment of substance use disorders (SUDs) if such medication is medically necessary according to the most recent National Practice Guideline on the Use of Medications for the Treatment of Addiction Involving Opioid Use established by American Society of Addiction Medicine (ASAM).[1]
- All FDA-approved medications for the treatment of SUDs should be placed on the lowest tier of a health plan or issuer’s prescription drug formulary.[1]
- Health plans and issuers may not impose step therapy requirements on MOUD/MAUD before coverage is approved.[1]
- Health plans and issuers may not exclude coverage for any prescription medication approved by the FDA to treat SUDs and any associated counseling or wraparound services because such medications and services were court-ordered.[1]
While the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) improved access to MH/SUD treatment and services, patients still encounter obstacles in accessing care, including MOUD/MAUD.[2] Many barriers may impact the availability of these medications including stigma, the availability of prescribers, and insurance benefit designs.[2] MOUD/MAUD have been proven to be an effective treatment for MH/SUDs, but it can be costly for people who are uninsured or underinsured.[3] Having quality health insurance coverage can make treatment more affordable and accessible.[4] Given the recent increases in overdose deaths and alcohol use, Congress should ensure health insurance coverage provides access to critical SUD medications.
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Improve mental health screenings for the incarcerated
Evidence-based screening, assessment, and treatment, including psychosocial and pharmacological treatments, should be adopted in jails and prisons. Correctional officers should be trained on de-escalation and safety measures in situations involving an inmate in a mental health crisis. To improve the care within jails and prisons, the Department of Justice (DOJ) should issue guidance and model policies and practices for state and local governments, as well as implement such policies and practices within federal facilities.[1]
The number of incarcerated individuals with mental health and substance use disorders (MH/SUD) continues to increase, and conditions in correctional facilities are known to only exacerbate MH/SUD.[2] Screening and assessment, treatment, and case planning is critical to identifying and meeting individuals’ MH/SUD needs and help with reentry upon release.[3] Correctional officers need training on MH/SUD and how to assist individuals experiencing a mental health crisis.[4] Policies and practices should be developed and implemented to improve the ability of correctional facilities and staff to screen, assess, and treat individuals experiencing an MH/SUD crisis.[1]
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Ensure consumer protections in all health plans
Congress should oppose expansions of any type of health plan that does not have to provide the consumer protections offered by the Affordable Care Act (ACA) or the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA).
In 2023, two bills were introduced in the U.S. House that would expand telehealth-only plans and association health plans (AHPs). As introduced, these bills did not include critical protections for individuals with mental health and substance use disorders (MH/SUD).[1][2][3]
Telehealth-only health plans would limit – or fail to cover altogether – in-person MH/SUD services. While telehealth is a critical delivery mechanism for MH/SUD services that should be covered at parity with in-person services, restricting in-person services through telehealth-only plans will limit access to critical in-person care. Key levels of care (e.g., inpatient) are fundamentally in-person services, while other services may be most effectively delivered in-person (due to the nature of the service or the needs/preferences of the individual). These “excepted benefits” plans should not be expanded.[4]
AHPs are offered by organizations like trade associations or professional groups and are exempted from ACA standards, such as requiring coverage of MH/SUD services and preventing discrimination against individuals because they have (or previously had) an MH/SUD.[5] AHPs also threaten to raise premiums and undermine the stability of higher-quality health plans that serve the majority of Americans by peeling off younger and healthier enrollees who are less expensive. Similarly, short-term limited duration plans, which do not have to follow ACA rules or MHPAEA, should be defined as plans lasting three months or less. These plans offer inadequate coverage and should not be allowed to undermine full-year plans.
Congress should reject any health plans that do not offer strong MH/SUD coverage, are allowed to discriminate against individuals with MH/SUDs, or are not subject to MHPAEA.
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Develop telehealth data best practices
Congress should fund research through the National Institutes of Health on the efficacy of mental health and substance use disorder (MH/SUD) services provided via telehealth, with outcomes studied by service type (e.g., crisis response) and demographic groups, including underserved communities.
Nearly one-third of all MH/SUD visits occurred via telehealth in the second quarter of 2022 – a 45-fold increase from the start of the COVID-19 pandemic.[1] Even after the worst of the pandemic passed, many providers maintained some type of virtual care with the option for hybrid services. However, data and best practices for telehealth are lacking.[2] To effectively measure the effects and outcomes of services delivered via telehealth, Congress should fund data collection and research on best practices in telehealth for MH/SUD services. Based on this information, the Department of Health and Human Services should issue guidance on best practices in providing MH/SUD telehealth services and work to establish standards for digital platforms and data collection. Best practices should be broken down by age and include criteria for determining, with patient input, the best method of service delivery (e.g., audio, video, in-person).