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

People with mental health and substance use disorders (MH/SUDs) are disproportionately represented in the criminal legal system—an estimated 44 percent of those in jail and 37 percent of those in prison have a mental health condition (compared to 20 percent of the general population). Furthermore, 63 percent of individuals in jail and 58 percent in prison have an SUD.[2]

Food insecurity, just one barrier formerly incarcerated individuals face upon reentry, is significantly and positively associated with psychological distress.[3] Research has found that formerly incarcerated individuals, and the children of currently incarcerated individuals, are twice as likely to experience food insecurity.[4] Federal law[5] imposed a lifetime ban on Supplemental Nutrition Assistance Program (SNAP) and Temporary Assistance for Needy Families (TANF) benefits for individuals with a previous drug felony conviction, though states have the flexibility to remove or modify the ban.[6] While most states have done so for at least one of the programs, some states still restrict or completely ban food assistance under SNAP, cash assistance through TANF, or both for individuals with a drug-related felony conviction.[6][7] Research suggests that SNAP participation reduces psychological distress, including decreasing the association between food insecurity and depression.[3]

Passing legislation that prohibits states from enforcing restrictions or bans on federal food assistance programs to formerly incarcerated individuals would decrease food insecurity for those individuals and their families, reducing one barrier to reentry, and decreasing an important risk factor for mental health and substance use.

Across multiple generations, communities of color and low-income communities have been negatively impacted by discriminatory transportation public policy decisions.[2][3] For example, decisions made over decades about the placement of highways  contributed “to the residential concentration of race and poverty and created physical, economic, and psychological barriers” as the construction displaced primarily Black households, churches, schools, and businesses.[4] The Bipartisan Reconnecting Communities Act intends to reconnect and revitalize neighborhoods divided by the construction of the Interstate Highway System, empowering communities to reverse the legacy of the construction’s harm.[5] The Biden Administration’s American Jobs Plan included $20 billion for a similar program to “reconnect neighborhoods cut off by historic investments and ensure new projects increase opportunity, advance racial equity and environmental justice, and promote affordable access.”[6]

Centuries of racism, including the construction of the Interstate Highway System, negatively impact all aspects of the Social Determinants of Health[7] (e.g., safe housing and transportation, economic stability, access to quality education, healthcare, and food, and clean air and water)[8]), all of which influence community mental health. Numerous studies have tied air pollution (including small particulate matter, nitrogen oxide and nitrogen dioxide – which are associated with vehicle exhaust) to higher levels of stress and increased risk of depression, schizophrenia, bipolar disorder, personality disorder, and even suicide.[9]

Passing the Reconnecting Communities Act and supporting similar efforts is the first of many steps necessary to reconnect and revitalize communities through infrastructure investments.

The United States is facing a severe housing crisis, especially in high-cost, high-demand areas where the supply of housing has not kept up with population and job growth. According to a report by the National Low Income Housing Coalition, there is a shortage of 7.3 million affordable and available rental homes for extremely low-income renters nationwide.[1] The lack of affordable housing negatively impacts the economy, the environment, and the well-being of millions of Americans. One way to address this crisis is to increase the production of housing near transit, which can provide multiple benefits, such as reducing traffic congestion, greenhouse gas emissions, and transportation costs, as well as improving access to jobs, services, and opportunities.[2]

However, many local governments have imposed restrictive zoning and land-use regulations that limit the availability of housing and drive up housing costs, wasting critical resources.[3][4] These local barriers increase homelessness and the number of unsheltered individuals living on the streets, including a disproportionate number of individuals with mental health and substance use disorders (MH/SUDs), leading to worsening health outcomes and criminal legal system involvement. A recent landmark study by the Benioff Homelessness and Housing Initiative at the University of California San Francisco showed that high housing costs and low incomes were the primary factors driving homelessness. Having one or more MH/SUD prior to homelessness was a key contributing risk factor, and individuals’ mental health and substance use worsened after they became homeless, yet they had little access to treatment.[5]

Congress, DOT, and HUD should tie federal transportation and housing funding to housing production to incentivize local governments to reform exclusionary zoning and land-use policies that drive up housing costs, increase homelessness, and disproportionately impact individuals with MH/SUDs who are at significantly higher risk for homelessness, which can cause further deterioration of the conditions.

There are numerous federal, state, and local agencies working to improve MH/SUD outcomes in the country. However, these agencies often work in their own lanes, siloed in goals, data, and metrics. Federal agencies overseeing state and local government programs often do not have the ability to access key data and metrics relevant to agency efforts or share across agencies, and state and local programs often do not have the data systems capacity to manage information on their programs. This leads to programs and initiatives that operate in silos, independently of each other, and a wide inability of the government to collect data on mental health and addiction programming outcomes, conduct research, share information, or tailor programs that build on the lessons learned from previous programs and grants. Today’s information and cloud-based technology opens up new opportunities to allow valuable data to be protected and shared across federal agencies. An integrated data systems approach can address these challenges, and improve cross-agency coordination, data collection and research, and program outcomes.

In 2016, the 21st Century Cures Act (Cures Act) effectively made sharing electronic health information an expected norm in health care. The Cures Act took nearly seven years to implement a common general health data format, but there has not been a similar effort to define MH/SUD common data needs.[1] In August 2022, CMS proposed rules to improve Medicaid and Children’s Health Insurance Program (CHIP) quality reporting across states. The proposed rule would make it mandatory for states to annually report on three different MH/SUD measure sets, including core sets for children’s health in Medicaid and CHIP, mental health and addiction measures in adult health in Medicaid, and health home quality measures in Medicaid.[2] CMS should finalize its proposed rule to make it mandatory for states to annually report MH/SUD measures for adults, children, and health homes.

Additionally, all agencies providing MH/SUD funding – including the Substance Abuse and Mental Health Services Administration (SAMHSA), the Health Resources and Services Administration (HRSA), and CMS –should work to create and use a core MH/SUD data model, leveraging previous data modeling efforts undertaken by SAMHSA and CMS as part of the 21st Century Cures Act. These agencies should use one common data collection portal and require all community block grants to include common core data reporting elements in tracking and reporting. To support this effort, HHS should reestablish its HHS Data Council, chaired by the Office of the National Center for Health Information Technology, and extend its responsibility to include data management.

The Centers for Disease Control and Prevention should also update the NVSS in its existing NVSS modernization efforts by adding new MH/SUD statistics records, including national statistics at the city and county level, and provide timely data updated monthly. These standards have not been updated since 2003. Future phases could include progress reporting and dashboard creation. Each NVSS report could be linked to the community-block grants, as well as link services to payers, HRSA, SAMHSA, and state and local health agencies, so that the value of the investment can be tracked.

The MTSS framework is an evidence-based prevention system consisting of three tiers of intensity for instruction, intervention, and support for students needing academic, social, and emotional support. Tier 1 supports are preventive supports and programming for all students and may include screening for additional areas of need. Tier 2 supports are small group, targeted standardized academic interventions or mental health supports using validated intervention programs for students identified as at-risk. Tier 3 supports are intensified and individualized interventions for students not responding to Tier 2 through instruction and supports that are intensified and individualized based on student needs.[1]

States and districts across the country have adopted MTSS as a governing framework for school-based mental health, but there is little consistency in how this framework is defined and implemented across states and districts. This results in programming that is implemented with varying fidelity to best practices. States and districts should be following a consistent set of MTSS-aligned best practices for mental healthcare delivery, but it is difficult to do so without federal guidelines that outline standard definitions and best practices for each tier of the MTSS framework.[2]

The DOE should create clear, standardized definitions of best practices for each tier of the MTSS framework, a certification program that recognizes districts that have implemented these best practices, and collect and publish federal dashboards to report on key mental health performance metrics and MTSS adherence, and build a federal resource library of professional and adult learning content on youth mental health.[2]

To mitigate common confusion over whether Tier 1 supports, which are inherently preventative, fit under “prevention” under Medicaid’s EPSDT coverage mandate for youth (note: the “P” stands for “Prevention”), CMS should clarify that Tier 1’s preventative supports and programming are indeed within the scope of “prevention” under EPSDT.

Additionally, the DOE should establish a permanent position for school-based Medicaid services at the DOE that can support state education agencies in implementation. Absent this action, Congress should require DOE to do so.

Congress should double OAA funding of supportive services (Title III B), as well as increase funding for Native American Aging Programs (Title VI) and the research, demonstration, and evaluation center for the Aging Network (Title II). According to the U.S. Census, by 2035, older adults will outnumber children in the United States.[1] This increase in the older adult population will also increase the need for funding and services for aging. The current federal funding for older adults will not keep up with the growing older population.[2] OAA funding of supportive services is particularly important to prevent and address mental health and substance use challenges among older adults. Social isolation among older adults increases hospital and nursing facility spending, leading to an estimated $6.7 billion in additional annual costs to Medicare.[3] Adults over the age of 75 have among the highest suicide rates of any group.[4]

President Biden’s 2024 budget proposed a historic $3 billion for the Administration for Community Living.[5] This increase will be vital to the most urgent priorities: services, prevention, and workforce.