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

Amidst attacks on LGBTQ+ individuals by many state and local governments across the country,[1] President Biden signed an Executive Order on Advancing Equality for Lesbian, Gay, Bisexual, Transgender, Queer, and Intersex Individuals on June 15, 2022.[2] The Executive Order directs federal agencies to take steps to protect LGBTQ+ individuals from unlawful discrimination and eliminate disparities that harm them and their families, including safeguarding health care access and suicide prevention programs and supporting LGBTQ+ children and families in the foster care system. The Executive Order is consistent with the Supreme Court’s decision in Bostock v. Clayton County (2020), which held that Title VII of the Civil Rights Act of 1964 prohibits discrimination on the basis of sexual orientation or gender identity in employment. It also builds on the previous Executive Order of January 20, 2021, which extended the Bostock ruling to other federal laws that prohibit sex discrimination.[3]

Approximately two-thirds of LGBTQ+ people have reported experiencing discrimination in their lives, which can negatively impact their mental health, increasing their risk of depression, anxiety, suicidal thoughts, and self-harm.[4] According to the National Survey on Drug Use and Health (NSDUH), LGBTQ+ adults are more likely to experience mental health and substance use disorders (MH/SUD) than heterosexual adults.[5] LGBTQ+ youth are also at a higher risk of harassment, abuse, homelessness, and suicide.[6] Research has shown that lesbian, gay, and bisexual individuals living in states with comprehensive legal protections have higher self-rated health than those in states without these protections. The federal government should use all tools at its disposal to protect LGBTQ+ individuals from these continued assaults.

Individuals with intellectual and developmental disabilities (IDD) are at an increased risk for developing other mental health or substance use disorders (MH/SUDs).[2] IDD usually develops or presents in early childhood, and early diagnosis and intervention can lead to better outcomes.[3] To aid in early diagnosis, in 1994, Zero to Three developed a guide known as the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (DC:0-3), which was most recently updated in 2021 (DC:0-5).[4] With over 42 million children receiving coverage from Medicaid and CHIP, a recent survey asked states if their policies required or recommended the use of DC:0-5 or DC:0-3R.[5] However, only seven states require the use of the diagnostic classification, and only eight states recommend its use.[5] The use of age-specific diagnostic systems should be required for payment and utilization review purposes to improve access to needed care.[1]

The United States has the highest maternal mortality rate of any high-income country.[4][5][6] Mental health and substance use disorders are one of the leading causes of pregnancy-related death,[6][7][8] and are the most common complications of pregnancy and childbirth, impacting 800,000 women annually.[9] Low-income, Black, and other marginalized families are disproportionately affected.[10][11] Significantly, Black women experience maternal death at a rate 2.5 times higher than white women.[11]

The bipartisan Moms Matter Act, one of the thirteen bills within the Black Maternal Health Momnibus Act,[4][12] would invest in programs supporting moms with maternal health conditions and substance use disorders and provide critical funding to grow and diversify the maternal mental and behavioral health workforce.[1][2][3] It would make critical investments in the social determinants of health, including housing, transportation, and nutrition, that contribute to high maternal mortality among Black women, Veterans, incarcerated people, Native Americans, and other people of color.

Research shows that income insecurity among children and adults can significantly contribute to mental health disorders.[3] The Earned Income Tax Credit (EITC) provides qualified low to moderate-income workers and families with a tax break that varies with specific criteria, like income, marital status, number of children or dependents, and disability.[4] Pre-COVID-19 pandemic data demonstrate that the EITC lifts people above the poverty line—more than 5.5 million people, including nearly 3 million children.[5] In the 2021 tax year, 31 million workers and families received about $64 billion in EITC thanks to expanded eligibility criteria passed by Congress as part of the American Rescue Plan Act.[6]

The Worker Relief and Credit Reform Act (WRCR Act) would build upon the ARPA expansions and change the EITC criteria to better reflect the current economic conditions of students, workers, caregivers, and the elderly.[1] Proposed reforms include recognizing caregiving and higher education as work, expanding the eligibility age range, and providing taxpayers with assistance, safeguards, and educational and outreach programs.[1] Congress should pass the WRCR Act to lift more people out of poverty, improving the mental health individuals and families.

Previously incarcerated individuals receive inadequate assistance and resources as they re-enter their communities, which puts them at increased risk for being rearrested.[1] Many states ban incarcerated individuals from eligibility for public assistance programs that provide access to food or affordable housing.[1][3] Without access to these programs, recidivism and substance use is higher.[1] Congress should prohibit states from restricting access to previously incarcerated individuals.

Substance use is a leading cause of death in pregnant women and contributes to birth-related complications, including preterm labor. Pregnant people with SUDs often lack access to prenatal and postpartum health care. Additionally, many substance use treatment programs do not accept pregnant clients and/or Medicaid beneficiaries, while maternity care providers often do not have experience with SUDs. These gaps lead to a lack of  evidence-based SUD care for pregnant and postpartum individuals.

The MOM model addresses gaps in care for pregnant and postpartum Medicaid beneficiaries with opioid use disorder. The MOM model provides coordinated and integrated physical health care, behavioral healthcare, and wrap-around services. State Medicaid agencies implement the model with community providers, including hospitals and Medicaid managed care organizations. The MOM model includes services such as well-woman care, medications for opioid use disorder, prenatal and postpartum care, labor and delivery, and neonatal/ infant care.

CMS should expand the coordinated, wraparound care provided in the MOM model to pregnant Medicaid beneficiaries who have other SUDs, such as alcohol use disorder and stimulant use disorder, for which coordinated care is beneficial.[1]