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

The Family Educational Rights and Privacy Act (FERPA) (20 U.S.C. § 1232g; 34 CFR Part 99) protects the privacy of student education records and applies to all schools that receive funding from the DOE.[1]

The updated May 2023 CMS guide for delivering Medicaid school-based services introduces an extremely challenging FERPA requirement that threatens to negatively impact schools’ ability to bill Medicaid.[2] As a part of the cost settlement model, local education agencies (LEAs) are reimbursed, in part, based on the percentage of Medicaid-enrolled students at the LEA, also referred to as the Medicaid Eligibility Ratio (MER). The CMS guidance states: “The MER is a ratio of Medicaid-enrolled students (per FERPA who have parental consent to release information to Medicaid) at each LEA (or other claiming entity) divided by the total number of enrolled students.” The addition of FERPA as a requirement will significantly reduce the MER for most districts, resulting in a major decrease in school funding.[2]

However, the FERPA statute itself does not require consent to be included in the MER. Current FERPA regulations allow states a pathway where FERPA consent is not required for the MER. The current guide, as written, would not allow states to follow this pathway.[2][3]

CMS should clarify in writing - through the TA center or other means -  that the requirement to have the free care numerator include only those students who are both Medicaid enrolled and have FERPA consent is not meant to supersede the allowable FERPA exceptions. The DOE should also provide State Education Agencies guidance that audits of the school Medicaid program conducted by the Office of the Inspector General (OIG) fall under the audit exception to FERPA. The DOE should clarify that for the purposes of audits, school Medicaid is considered an education program and LEAs are free to release information to auditors.[3]

Absent this action, Congress should ​update the FERPA statute to allow for school Medicaid exceptions that clearly allow: (1) LEAs to disclose all necessary information to the state Medicaid agency for the purposes of determining Medicaid enrollment; (2) LEAs to provide all necessary information to OIG in the event of an audit – including individual education plans (IEPs); and (3) LEAs to submit necessary billing/claiming information to the Medicaid agency without FERPA consent. The free and reduced lunch exceptions to FERPA set a precedent for this approach. [3]

Firearms are a leading cause of injury and death among children in the United States. According to the Centers for Disease Control and Prevention (CDC), 2,281 children under the age of 18 died from firearms in 2020, with 721 of these deaths classified as suicide and 121 classified as unintentional. About 43 percent of child suicides involve the use of a firearm.[1]

One of the main risk factors for firearm-related injury and death among children is the accessibility of firearms in their homes. The 2021 National Firearms Survey found that guns are stored unlocked in almost half of households with both firearms and children, and that these unlocked guns are stored loaded in about 15 percent of these households.[2]

A majority of states, including states from across the political spectrum, have enacted child-access or secure storage laws.[3] To prevent children from firearm injury and death, Congress should pass legislation to establish federal statutory requirements to regulate the storage of firearms on residential premises such as the Safe Guns, Safe Kids Act, which would require firearms on residential premises to be safely and securely stored if a minor would reasonably have access, and would hold the owner of the firearm liable if a minor were to obtain and use the firearm in an unlawful way.[4]

Lack of employment opportunities for youth in low-income and other marginalized communities contributes to negative outcomes such as lower adult earnings and increased risk of criminal legal system involvement and early mortality. Among teenagers 16 to 19 years old, the unemployment rates were highest for Black youth, Hispanic/Latino youth, and Asian youth.[1] Similarly, American Indian/Alaska Native youth were less likely to be employed than other youth.[2]

Youth employment programs provide employment for youth who work at selected employers during the summer, and often include job readiness training and other supports. These programs have been shown to reduce youth violence by providing opportunities to learn interpersonal skills from positive role models and mentors and to improve confidence and self-control through work experience. Researchers found that summer employment offered to youth through the One Summer Plus (OSP) in Chicago resulted in 43 percent fewer youth violent crime arrests.[3] Another study of a youth employment program in New York City found increased earnings for youth and decreased incarceration and mortality.[4]

While youth employment programs drive positive outcomes, they unfortunately often lack the resources to address the oftentimes significant mental health needs of the youth they serve. A recent survey of youth programs found that 90 percent or more reported observing anxiety or depression among youth, and 60 percent of programs believed more than half of their youth needed mental health services. Yet 64 percent did not have a process for screening or monitoring youth’s mental health needs, and 89 percent were unable to provide quality mental health training to staff.[5] Youth employment programs face challenges related to limited and unstable funding, insufficient capacity and quality (including related to helping address youth’s mental health needs), and lack of coordination and evaluation.

Congress has contributed to these challenges by allowing WIOA, the primary federal funding source for youth employment, to expire in fiscal year 2020. As a result, WIOA programs have relied on short-term extensions through annual appropriations bills. Congress should reauthorize WIOA and increase investment levels, particularly given the unprecedented mental health challenges youth are facing in the aftermath of the COVID-19 pandemic.[6] Furthermore, Congress should dedicate funding to increase the availability of mental health services and supports among youth employment programs.[5]

Approximately 600,000 people are released from prison each year. Within five years, three-quarters will have been re-arrested.[4] Formerly incarcerated individuals face many challenges, including difficulty accessing employment, education, housing, and health care.[4][5] For people with mental health conditions, the reentry process is especially difficult and, as a result, they have a higher recidivism rate.[6] These individuals are at an increased risk for experiencing barriers to employment and housing, and often struggle to access mental health services.[6] One-stop shop reentry programs can lower recidivism by improving access to critical support services.[1][2][3]

There are approximately 450,000 Veteran renter households who have extremely low incomes but receive no rental assistance.[1] According to a 2023 U.S. Department of House and Urban Development’s (HUD) Mandatory Affordable House Program report, many Veterans have the “worst case housing needs.”[3] This means they fall below the federal poverty line, spend more than half of their income on substandard housing, and receive no housing assistance.[3] Joint programs such as the U.S. Department of Housing and Urban Development and the U.S. Department of Veterans Affairs Supportive Housing (HUD-VASH) initiative are well positioned to provide assistance to Veterans with both their housing and health needs. Specifically, HUD-VASH is designed to assist homeless and extremely low-income Veterans and their families by providing rental assistance, along with clinical and case management services to improve access to health care, mental health treatment, substance use counseling, and other supportive programs.[2] To provide Veterans with housing security and address this population’s health needs, Congress should approve the $13 billion in funding requested in the President’s Fiscal Year 2024 Budget Proposal to help expand and sustain critical programs such as HUD-VASH.[1]

Mass shootings in the United States are not only a threat to public safety, but also a source of widespread fear and anxiety that affects the mental health of millions of Americans. More than 50 percent of teenagers worry about a shooting occurring in their school, which is associated with heightened anxiety and fear. A large majority of Americans report fears of mass shootings, with one in three avoiding certain events and places.[2]

One of the factors that contributes to this fear is the availability and use of assault weapons and dangerous hardware that facilitate and increase the lethality of mass shootings. Assault weapons are semi-automatic firearms that can fire more rounds in a shorter amount of time and cause more damage than other kinds of guns.[3] High-capacity magazines generally hold more than 10 rounds of ammunition and allow shooters to fire more shots without reloading, increasing the potential for casualties.[4] Researchers found that the federal ban on assault weapons and high-capacity magazines from 1994 to 2004 reduced the likelihood of mass shooting deaths by 70 percent for the ban period and estimated that 314 out of 448 would have been prevented in the 12 years before and after the ban.[5]

Other conversion devices, such as silencers and bump stocks, can also enhance the deadly potential of firearms. Silencers, which are devices that suppress the noise of gunshots, can hinder the ability of law enforcement or bystanders to locate and respond to an active shooter.[6] Bump stocks, which are devices that enable semi-automatic rifles to fire at a nearly automatic rate, were used by the shooter in the 2017 Las Vegas massacre that killed 58 people and wounded hundreds more.[7]