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

More than one in five U.S. adults is estimated to live with a mental health condition (57.8 million in 2021), and almost half of adolescents will experience a mental health condition in their lifetime.[3] Crisis services are a critical part of a community’s response to MH/SUDs, because these services can help divert people away from emergency rooms, psychiatric hospitalization, and interventions by law enforcement.[4] For instance, crisis stabilization services can provide short-term observation by MH/SUDprofessionals in a non-hospital environment.[4]

The Behavioral Health Crisis Services Expansion Act would establish national requirements for MH/SUD crisis services and expand health insurance coverage for these services, including within Medicare, Medicaid, ACA health plans, employer-sponsored coverage, the Veterans Administration,  TRICARE, and the Federal Employee Health Benefits Program.[2][3] The bill would also provide funding and technical assistance for communities to deliver behavioral health crisis services and establish an expert panel that will make recommendations to improve coordination and integration between 911 dispatchers and 988 Crisis and Suicide Prevention Hotline call centers in cases involving MH/SUD crises.[2][3]

LGBTQ+ youth often experience discrimination and a lack of acceptance that can negatively affect their mental health, increasing their risk for MH/SUDs. Many are unable to receive needed services, and data relating to the most effective treatments and supports for individuals who belong to multiple, frequently marginalized groups is too often limited.[1][2][3]. Black and Native communities are experiencing increased suicide rates, and communities of color are broadly experiencing an increase in drug overdoses.[4] People of color are estimated to be underdiagnosed with MH/SUDs and face additional barriers to accessing care.[4] To advance health equity, our country must provide culturally competent – and congruent – high-quality and affordable healthcare services for underserved communities. Additionally, we must fund foundational and applied research that includes members of diverse communities to ensure that clinical interventions are effective across communities.[5][1]

States have a multitude of complicated Medicaid eligibility requirements, with many states having a $2,000 asset test (for a single person) to qualify and maintain eligibility in Medicaid, an amount established in 1989. For SSI, which assists low-income older adults and individuals with disabilities, the $2,000 asset test is the strictest limit of any federal program. This very low asset test penalizes savings, makes it extraordinarily difficult to weather emergencies, and also constrains family members from helping their loved ones with disabilities achieve economic security.[1] The asset tests also lead to churn in and out of these programs if individuals temporarily exceed the limit. Because the tests have not been indexed to inflation, each year they apply to more individuals, including those with mental health conditions, including autism and substance use disorders. If the current $2,000 SSI asset limit were adjusted to account for inflation, it would be $10,000 today. The Center on Budget and Policy Priorities, in its analysis of proposals to increase the SSI asset limit to $10,000 (as has been proposed on a bipartisan basis in the Savings Penalty Elimination Act)[2], to $100,000 (which would be consistent with limits of recently created tax-advantaged saving accounts for individuals with disabilities), and to eliminate the SSI asset test altogether, estimates that all would meaningfully increase SSI participation while not ballooning programs costs.[3][4] There is a growing movement to raise or eliminate such asset tests, with California ending its Medicaid asset test in 2024.[5]

The United States remains one of only two major countries that does not provide paid time off for short-term illnesses nor paid leave for family and medical needs.[3] A quarter of the private sector workforce and 9 percent of the public sector workforce lack paid sick leave.[4] The lack of paid sick leave is associated with workers reporting higher levels of psychological distress.[5] A universal paid sick leave policy, which could be used by individuals with mental health and substance use disorders, would reduce preventable emergency department visits and result in cost savings of $1.1 billion annually, including $500 million for public health insurance programs like Medicare and Medicaid.[3]

Disparities exist by race and ethnicity for access to and use of paid leave. Black and Hispanic workers have lower rates of paid family and medical leave access and use than their White, non-Hispanic counterparts.[6] Research has shown that paid parental leave policies greatly improve maternal mental health; these policies give mothers time to recover from childbirth and to care for their child and enhances families’ economic security.[7] One study found increasing the length of maternity leave from under eight weeks to eight to twelve weeks showed a large improvement in mental health– increasing the length of leave by one week could reduce depressive symptoms by 6 to 7 percent.[8] A longer paid leave policy allows parents to take time off without the risk of economic ruin to bond with their children. Despite these benefits, data from the Bureau of Labor Statistics found that less than one in four workers had access to paid family leave in 2021.[9]

Congress should pass the Healthy Families and the FAMILY Acts to mitigate these disparities and provide paid leave for workers.

An estimated 1.8 million LGBTQ+ youth seriously consider suicide each year, and they are more than four times more likely to attempt suicide than their peers.[1] In 2021, nearly 70 percent of LGBTQ high school youth reported feeling persistently sad and hopeless, compared to only 35 percent of their heterosexual peers.[2]

Accurate data is necessary to address the growing LGBTQ+ youth suicide crisis. Sexual Orientation and Gender Identify (SOGI) data enables those working with LGBTQ+ youth to better understand the health and safety risks among these youth, informs policy change [3] and helps policymakers and leaders understand the full extent of the discrimination the LGBTQ+ community faces.[4] Data informs decisions in public health by tracking better, faster, and more actionable insights.[5] SOGI data will also increase awareness around the LGBTQ+ health crisis, reducing stigma and lowering suicide rates.

The Administration, Congressional leaders, and federal agencies recognize the importance of this data. In June 2022, the White House released Recommendations on the Best Practices for the Collection of SOGI Data on Federal Statistical Surveys, emphasizing the vital role of federal surveys in supporting evidence-based policymaking.[6][7] In June 2023, the LGBTQ+ Data Inclusion Act was reintroduced in both the U.S. House and Senate. The bill would require voluntary questions on sexual orientation, gender identity, and related characteristics in government surveys to help lawmakers and federal agencies address LGBTQ+ issues.[4][8][9][10] In 2022, the bill passed the U.S. House.

More than 391,000 children are in foster care, and more than 600,000 children are served by the foster care system annually.[4] Mental health and substance use needs are the largest unmet health need for these children.[5] Nearly 80 percent of children in foster care have significant challenges [6] and are much more likely to have worse mental health than their peers.[7] The long-term effects are substantial - compared to the general adult population, adults previously involved in the foster care system are five times more likely to experience post-traumatic stress disorder and seven times more likely to have a SUD.[6][8]

Annual screenings are critical components of prevention and early intervention of MH/SUDs.[9] Early identification and treatment lead to better outcomes in overall health and may lessen long-term disability.[10] HHS and CMS should guide states in meeting the critical need for children to receive MH/SUD screenings and necessary treatment immediately when entering the foster care system - before, during and after placements - and when emancipating from foster care.[1][3][11] There is also a lack of data about MH/SUD interventions specific to youth in foster care.[12] HHS and CMS should provide technical assistance to states in collecting and reporting data about the children in foster care screened and treated for MH/SUDs.[1][2]