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.
Reimburse for contingency management
Congress should require Medicare and state Medicaid programs to reimburse for Contingency Management.
Contingency Management is a highly effective approach to treat individuals with substance use disorders (SUDs). It provides small tangible reinforcements such as prizes, vouchers, or small amounts of money to motivate and sustain objectively measured positive changes in behavior (e.g., abstinence or decreased drug use). It takes advantage of the brain’s reward response – the same response that fuels substance use. While Contingency Management treats many SUDs, there is a particularly urgent need to increase its use to treat stimulant use disorder, which lacks other proven effective treatments. One meta-analysis[1][2] found that Contingency Management “has an extraordinarily strong evidence base and is a demonstrably cost-effective technique that has been used for decades to promote abstinence from benzodiazepines, cocaine, tobacco, opiates, alcohol, marijuana, and methamphetamine.”
In addition to Congress requiring Medicare and state Medicaid programs to reimburse Contingency Management, the Centers for Medicare & Medicaid Services (CMS) should educate state Medicaid programs that Contingency Management is THE treatment-of-choice for the nation's stimulant use disorder epidemic. CMS should also establish billing codes and rates for full-value, Office of Inspector General-approved, cash-equivalent, evidence-based Contingency Management, which is the only approach proven to be effective for stimulant use disorder.
Topics
Loosen HIPAA overdose notification restrictions
The Secretary of Health and Human Services (HHS) should use the waiver process established by Section 1135 of the Social Security Act to temporarily modify Medicare, Medicaid, and the Children's Health Insurance Program (CHIP) requirements to augment treatment capacity and loosen Health Insurance Portability and Accountability Act (HIPAA) restrictions to allow notification to families of persons who have overdosed and been revived.[1]
On October 26, 2017, the Secretary of Health and Human Services (HSS) declared a nationwide opioid public health emergency (PHE). This declaration was most recently renewed on April 1, 2023.[2] Section 1135 of the Social Security Act gives the Secretary of HHS the ability to waive certain requirements under Medicare, Medicaid, and the Children's Health Insurance Program (CHIP) during a PHE to ensure health care supplies and services are available.[3] While 1135 waivers have been used for PHEs in the past, they have not been used during the opioid PHE.[4] As a result, regulatory flexibilities that could increase support for millions of individuals with opioid use disorder (OUD) have not been put to use.[5]
Additionally, families can play a crucial role in supporting individuals receiving OUD treatment.[6] However, under the Health Insurance Portability and Accountability Act (HIPAA), families are only notified of an overdose and revival if the individual gives permission, is incapacitated in an emergency as deemed by the provider, or to prevent a serious imminent threat to themselves or others.[7] Outside of these exceptions, families are not notified, limiting their ability to provide support during treatment.[6]
Topics
Fund mobile crisis intervention
Congress should make permanent the recent increase to the Medicaid federal matching rate for mobile crisis team response services, originally passed in the American Rescue Plan Act in March 2021.[1]
Mobile crisis teams (MCTs) are trained health professionals who can provide on-site crisis assistance to people experiencing mental health or substance use disorder (MH/SUD) crises. MCTs can help reduce the reliance on law enforcement and emergency departments and provide more appropriate and effective care for people experiencing a crisis.[2] However, not all states have adequate funding or infrastructure to implement MCTs in their communities.[3] The American Rescue Plan Act (ARPA) of 2021 increased investments in MCTs by authorizing federal Medicaid matching funds for community-based mobile crisis response services. Under this option, states that provide qualifying mobile crisis services under their Medicaid programs will receive an enhanced federal matching rate of 85 percent for the first three years of implementation.[4] The existing option provides a significant incentive and opportunity for states to expand their MCTs and improve their behavioral health crisis response systems. By making the enhanced matching rate for MCTs permanent in Medicaid, Congress will help states grow sustainable MCTs into the fabric of their MH/SUD emergency response.
Topics
Ensure tribal representation on task forces and commissions
Tribal representatives must have the opportunity to serve on federal task forces and commissions seeking to address the opioid epidemic. The Department of Health and Human Services (HHS) Pain Management Best Practices Inter-Agency Task Force and the National Committee on Heroin, Opioid, and Pain Efforts (HOPE) must include tribal representation.[1]
According to the CDC, American Indians and Alaska Natives have the second-highest rate of opioid overdose in the country compared to other racial and ethnic groups.[2] For these challenges to be considered, representation of tribal leaders is needed. Yet representation is lacking on federal opioid and pain management task forces and commissions.[3]
The Comprehensive Addiction and Recovery Act (CARA) of 2016[4] led to the creation of the Pain Management Best Practices Inter-Agency Task Force. The Task Force convenes to propose updates to best practices and issue recommendations on managing chronic and acute pain with the goal of addressing the opioid epidemic.[5] The Task Force does not include tribal representation; only public comments from the Indian Health Service (IHS) were included in their latest report.[6]
Similarly, the IHS National Committee on Heroin Opioids and Pain Efforts (HOPE Committee) established five workgroups that aim to foster tribal relationships to address the increasing crisis facing their communities. Although the workgroups include IHS experts, they also fail to mandate tribal leader representation.[3]
Topics
Fully implement the 988 suicide and crisis lifeline
The Substance Abuse and Mental Health Services Administration (SAMHSA) should continue to fully implement the 988 number, with response driven by healthcare systems, not public safety systems.[1] Enhanced training should be provided to counselors answering 988 calls, and coordination between 988, 911, and all services within the continuum should be strengthened.[2] Clinically staffed crisis response should be integrated within 911, and training provided to 911 operators in identifying mental health needs and linking callers to mental health crisis response services.[1] Congress should provide the funding necessary to scale up 988 to meet the high – and increasing need. Funding should be at least $946 million a year – and should grow over time. Of this amount, $100 million is needed for state Mental Health Crisis Response Grants, $836 for the 988 Suicide & Crisis Lifeline program, and $10 million for the Behavioral Health Crisis & 988 Coordinating Office at the Substance Abuse and Mental Health Services Administration.[3]
The 988 Suicide and Crisis Lifeline, formerly known as the National Suicide Prevention Lifeline, was created to help address the increasing rates of suicide and overdose in the United States.[4] 988 offers 24/7 access to trained counselors via call, text, and chat, who provide support and resources, if needed. Efforts to improve cultural competency training for Lifeline counselors are ongoing.[5] In the fall of 2022, the 988 system set up a program to connect high-risk LGBTQI+ youth to counselors that could meet their needs.[4] Yet, access to a robust crisis services system for those who call does not yet exist.
In May 2023, the Department of Health and Human Services (HHS) announced more than $200 million in funding for 988, which provides opportunities to improve multiple aspects of local responses. These include making enhancements to the 988 workforce, improving services for vulnerable populations, ensuring access to culturally competent support centers, and allowing for systemic follow-up and enhanced coordination of crisis stabilization among emergency services.[2][6]
While this is an important step, more action is needed to implement the 988 system and establish effective care interventions to provide help to those in crisis when they need it most.
Topics
Expand states’ capacity to provide MH/SUD services under Medicaid
Congress should incentivize states to expand their capacity to provide mental health and substance use disorder (MH/SUD) services under Medicaid, which will improve equity. For example, Congress should authorize a planning grant or demonstration program to provide participating state Medicaid programs with additional federal funding to expand or improve the capacity of MH/SUD participating providers.[1]
Medicaid is the single largest payer of MH/SUD services in the United States, with 40 percent of the nearly 14 million beneficiaries requiring some form of MH/SUD treatment in 2020.[2] However, Medicaid beneficiaries are disproportionately more likely to encounter MH/SUD services through visits to emergency departments during a crisis, indicating barriers to access.[3] This is, in part, due to a shortage of MH/SUD providers who accept Medicaid.[4] Planning grants provided by the Centers for Medicare and Medicaid Services (CMS) have been used to assist states in building out MH/SUD crisis services, including mobile crisis response.[5][6] Congress should incentivize increased state Medicaid program innovation and their capacity to provide MH/SUD services with additional federal funding attached to these or new planning grants.[1]