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.
Establish a single global payment for mobile crisis response
Congress should require the Centers for Medicare and Medicaid Services (CMS) to establish a single global payment under the Physician Fee Schedule for mobile crisis response team services for Medicare beneficiaries experiencing a mental health or substance use disorder (MH/SUD) crisis. A bipartisan group of Senate Finance Committee members has supported this important step.[1]
Mobile crisis teams are a critical part of the MH/SUD crisis care continuum. The components of these teams can vary but generally involve response coordinators and social workers who can respond to MH/SUD crises. Research examining the impact of mobile crisis programs has shown they are effective in diverting individuals from emergency departments, reducing the need for hospitalization, and lowering law enforcement involvement for individuals experiencing an MH/SUDcrisis.[2]
Approximately 20 percent of older adults will experience an MH/SUD and access to services may be limited by mobility and transportation.[3] Additionally, many individuals with disabilities under the age of 65 are also eligible for Medicare. Mobile crisis teams are an indispensable part of the 988 Suicide Prevention and Crisis Lifeline, and access to mobile crisis teams is critical for Medicare beneficiaries experiencing an MH/SUD crisis.
Medicare currently covers psychiatric evaluation and depression screenings, which can be delivered in-office or through primary care integration, but does not explicitly cover mobile crisis teams.[4] Given that Medicare Part B has always covered emergency department and ambulance transportation services for physical health emergencies, Medicare should cover mobile crisis teams to ensure these important services are reimbursed and can be scaled to meet rising needs. Advancing parity for MH/SUD crisis services will reduce unnecessary emergency department visits, hospitalization, and law enforcement involvement. Congress should direct CMS to establish a global payment under the Physician Fee Schedule for mobile response team services for Medicare beneficiaries.[1]
Topics
Ensure informed consent for opioid prescriptions
The Department of Health and Human Services (HHS), Department of Labor (DOL), Department of Veterans Affairs (VA), Department of Defense (DOD), the Food and Drug Administration (FDA), and the Office of National Drug Control Policy (ONDCP) should work with stakeholders to develop model statutes, regulations, and policies to ensure informed patient consent before an opioid is prescribed for chronic pain.[1]
Individuals seeking pain-related medical attention, including in the aftermath of surgery, should be fully informed of the risks, benefits and alternatives to taking opioids. While there has been much work completed to inform prescribers and patients about the risks associated with opioid use, a standard informed consent does not yet exist.[2] The Department of Veterans Affairs has developed a patient guide for the “safe and responsible use of opioids for chronic pain” to help Veterans make informed decisions about their care.[3] Additionally, in 2022 the Centers for Disease Control and Prevention (CDC) released a “Clinical Practice Guideline for Prescribing Opioids for Pain” to improve communication between providers and their patients to reduce risks of suffering from an opioid use disorder, overdose, and death.[4] However, a report by the National Academy of Medicine found that while all states have requirements for counseling patients on opioid use before writing a prescription, there are insufficient policies to address standardized prescription practices.[5]
Topics
Expand eligibility for loan repayment programs
Congress should expand funding the eligibility criteria for national and state loan repayment programs to include bachelor-level social workers, health and human services providers, and certified drug and alcohol counselors, while also expanding service delivery location sites to include more home, school, and community-based settings.[1]
Certified drug and alcohol counselors, social workers, and other health professionals work in different capacities to provide mental health and substance use disorder (MH/SUD) care.[1][2] Serious workforce shortages exist among MH/SUD clinicians nationwide.[2]
HRSA’s student loan repayment programs have been leveraged to encourage providers to practice in communities facing behavioral health staff shortages.[3] For instance, the National Health Service Corps (NHSC) Loan Repayment Program (LRP) offers student loan forgiveness for primary behavioral health care clinicians who agree to provide two years of service in areas where communities face limited access to care.[5] Additionally, the State Loan Repayment Program provides grants to states who administer loan forgiveness programs for health professionals who work in shortage areas for two years, including MH/SUD clinicians.[6] Congress should increase funding for both the NHSC and the State Loan Repayment Program.
Unfortunately, the current eligibility criteria for national and state repayment programs typically exclude some bachelor-level health professionals who may play an essential role in expanding access to treatment and recovery services, such as social workers and certified drug and alcohol counselors.[1][4][5][6][7] Furthermore, NHSC does not provide assistance to peer support specialists, which are an integral part of the continuum of care and often better mirrors the communities they serve. Loan repayment programs should be expanded to include a greater range of professionals and peer support specialists degrees to quickly expand the capacity of our nation’s MH/SUD workforce.
Finally, loan repayment programs should also expand the types of sites in which health professionals may work in order to be eligible to receive loan forgiveness.[1] For instance, HRSA’s Substance Use Disorder Workforce Loan Repayment Program allows loan recipients to work at community mental health centers, private practices, and school-based clinics.[7] However, there are no approved home-based settings or sites.[7] Additionally, NHSC programs do not currently specify that crisis programs be eligible sites. HRSA should align eligibility with Substance Abuse and Mental Health Services Administration (SAMHSA) guidelines for crisis services, which include a range of facilities such as call centers, mobile crisis response teams, and crisis receiving and stabilization facilities.[8]
Topics
Develop comprehensive diversion plans
Senate and House appropriators should include in the annual Commerce, Justice, Science, and Related Agencies spending bill a requirement that as a condition of receiving certain Department of Justice funding, local criminal legal systems, including law enforcement and juvenile justice programs, should be required to develop comprehensive diversion plans with health systems and mental health and substance use disorder (MH/SUD) providers in their communities.[1] Additionally, efforts to universally screen and assess individuals at arrest, sentencing, and all points across the criminal legal system continuum for MH/SUD should be expanded to inform connections to appropriate treatment and services.[2]
Individuals with MH/SUD are disproportionately involved with the criminal legal system, and jails and prisons have tragically become major providers of MH/SUD services.[3] As a condition of receiving DOJ funding, state and local governments should be required to support efforts focused on expanding interventions that divert people with a MH/SUD away from the criminal legal system and into treatment.[3][4] This includes working with health care systems and community MH/SUD providers to develop diversion plans[1][5], and expanding efforts within the criminal legal system to improve screening of individuals for MH/SUD.[2]
Topics
Pass a 10 percent set aside for crisis services
Congress should pass a 10 percent set-aside for crisis services in the Mental Health Block Grant to address gaps in vital crisis services across the United States. At present, the set-aside stands at 5 percent, which falls short of effectively meeting the growing demand for mental health support, including in moments of mental health and substance use disorder (MH/SUD) emergencies.
Under the Consolidated Appropriations Act of 2021 and the Coronavirus Response and Relief Supplemental Appropriations Act of 2021, the Substance Abuse and Mental Health Services Administration (SAMHSA) was directed by Congress to set aside 5 percent of the Mental Health Block Grant (MHBG) allocation for each state to support crisis systems.[1] The MHBG is a grant program designed to provide comprehensive community health services to individuals MH/SUDs.[2]
The COVID-19 pandemic underscored the urgency of prioritizing MH/SUD services, and many states have struggled to meet the surging demand for crisis services. A permanent 10 percent set-aside ensure states allocate the resources needed to build up critical MH/SUD crisis services. This is equivalent to $165 million, with a funding level of $1.653 billion for the MHBG.[3] A robust crisis response system not only helps individuals navigate immediate challenges but also serves as an avenue for ongoing care and recovery.
Topics
Make mobile crisis services mandatory under Medicaid
Congress should make mobile crisis services mandatory under Medicaid. At a minimum, these services should be made a permanent state option available to states eligible for enhanced federal Medicaid match funding.[1]
Mobile crisis teams are a critical part of the mental health and substance use crisis care continuum. The components of these teams can vary but generally involve response coordinators and social workers who can respond to mental health crises. Research examining the impact of mobile crisis programs has shown they are effective in diverting individuals from emergency departments, reducing the need for hospitalization, and lowering law enforcement interventions for individuals experiencing a mental health crisis.[2]
Since the launch of the Crisis Assistance Helping Out On The Streets (CAHOOTS) program in Oregon, more than 35 states have implemented mobile crisis programs using various Medicaid authorities, including waivers and demonstrations.[3] Mobile crisis teams are an indispensable part of the 988 Suicide Prevent and Crisis Lifeline, and states across the country are seeking to build out capacity to ensure the availability of an in-person response for 988 callers who need it. To expand the availability of these programs, Congress created a new state option under Medicaid with an enhanced federal matching rate of 85 percent for mobile crisis services as part of the American Rescue Plan Act (ARPA) of 2021.[2] Congress also provided funding to support state planning grants to ease implementation and support take-up of the new option.[4]
This new option is only temporary and expires in 2027. Given that physical health emergency services are covered by all state Medicaid programs, Congress should make mobile crisis services a mandatory Medicaid benefit. At minimum, Congress should make the the state option with the 85 percent federal matching rate permanent.[1]