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.
Pass the Democracy Restoration Act
Congress should pass legislation such as the Democracy Restoration Act to ensure that individuals with criminal convictions who have been released from incarceration are able to vote in federal elections.
Voting is a fundamental right. Yet, a disproportionate number of incarcerated individuals within state prison systems experience mental health and substance use disorders (MH/SUD). According to the U.S. Department of Justice’s Bureau of Justice Statistics, an estimated 43 percent of state prisoners had a history of mental health conditions (with many more undiagnosed).[1] And the National Institute on Drug Abuse has noted that approximately 65 percent of prisoners in the U.S. have a SUD.[2]
Therefore, state restrictions that prevent voting in federal elections after release disproportionately affect individuals with mental health and substance use disorders (MH/SUD).[1][2] Twenty-six states deny individuals with past criminal convictions the right to vote in federal elections. The Democracy Restoration Act would grant formerly incarcerated individuals the right to vote in federal elections and notify individuals with past criminal convictions about their right to do so. Notifications to these individuals occur during sentencing and upon release from a correctional facility.[3][4] States that continue to deny individuals with past criminal convictions thereby discriminate against individuals with MH/SUD.
Congress should pass the Democracy Restoration Act to dismantle barriers against formerly incarcerated individuals who disproportionately experience MH/SUD. These millions of Americans with MH/SUDs should not be disenfranchised in federal elections due to discriminatory state laws.[5]
Topics
Study Medicaid payment rates for MH/SUD services
Congress should require a U.S. Government Accountability Office (GAO) report comparing Medicaid payment rates for mental health and substance use disorder (MH/SUD) services and medical or surgical services across a sample of states.[1]
Medicaid beneficiaries are disproportionately more likely to experience a MH/SUD than those with private insurance.[2] However, Medicaid beneficiaries access MH/SUD services at lower rates than those with other insurance types.[3] One reason for the disparate access to care may be inadequate reimbursement within state Medicaid programs that disincentivizes providers to accept Medicaid patients.[4] Research shows Medicaid reimbursement rates for MH/SUD remain extraordinarily low, with some providers not having seen increases in rates in 30 years, causing experienced providers to be less likely to accept it and compounding an existing shortage of providers.[4][5] To sufficiently understand this problem and how to address it, Congress should direct the GAO to conduct a study examining Medicaid payment rates for both MH/SUD and physical health services across a sample of states to determine whether MH/SUD services are being reimbursed adequately. In late 2022, a bipartisan group of Senate Finance Committee members supported requiring such a report.[1]
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Ensure coverage for respite centers and clubhouses
Congress should ensure that both Medicare and all state Medicaid programs cover psychosocial rehabilitation support services such as respite centers and clubhouses, which offer individuals with mental health conditions (usually a serious mental illness) a physical place where they can engage in a therapeutic community. The Department of Health and Human Services should ensure that psychosocial rehabilitation support services are covered under the Affordable Care Act’s Essential Health Benefits requirement for individual and small group health plans (i.e., Qualified Health Plans).
Clubhouses are operated by members and staff and provide a range of services and supports, including primary and psychiatric services, care management, home and community-based services, and employment and education supports. This cost-effective approach helps members reclaim their agency and dignity, while improving outcomes and reducing hospitalizations and costs.[1][2] The clubhouse model has existed for more than 65 years, and a meta-analysis of the clubhouse model found evidence that clubhouses are an important component of rehabilitative services for individuals with serious mental illness.[3] Clubhouse International, an international network of clubhouses, has quality standards and offers accreditation, which 80 percent of clubhouses have achieved.[4] Clubhouses have been shown to reduce hospitalization, incarceration, and costs.[5]
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Create HCPCS codes for tech-based treatments
The Centers for Medicare and Medicaid Services (CMS) should fast-track the creation of Healthcare Common Procedure Coding System (HCPCS) codes for Food and Drug Administration (FDA)-approved technology-based treatments, digital interventions, and biomarker-based interventions. The National Institutes of Health (NIH) should develop a means to evaluate behavior modification apps for effectiveness.[1]
Digital tools such as software-driven applications, wearable devices, as well as detective or biomarker-based interventions can be leveraged to identify needs, assess care, and deploy substance use disorder (SUD) treatments.[1][2][3] An example of such a technology are “devices that transmit findings from smartphones directly into the medical record.”[1]
No independent regulatory agency, such as the Food and Drug Administration (FDA), is charged with consistently examining all mental health and substance use technology or applications. While the FDA may review certain apps (e.g., those that may require a prescription or function as a medical device), the agency uses its enforcement discretion with respect to many other mental health and substance use applications. The Federal Trade Commission (FTC) can also investigate potential false claims that an app developer may make.
While Congress should designate a regulatory body to oversee these emerging technologies, patients and providers would benefit from foundational research on how best to evaluate behavior modification apps to ensure they are effective. This information would support the development of a new regulatory framework for this technology, including how the FDA currently may review mobile health applications for the treatment of mental health and substance use disorders.
Once a technology or product is deemed safe and effective, it is critical for payers, including Medicare and Medicaid, to ensure the timely creation of reimbursement codes so that consumers can access emerging technology that helps meet their needs.[2]
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Forbid same-day billing restrictions in Medicaid
Congress should prohibit same-day billing restrictions in state Medicaid programs as a condition of receiving federal funding, as recommended by a bipartisan group of Senate Finance Committee members.[1][2]
Despite the demonstrated efficacy of increased integration between physical and mental health and substance use disorder (MH/SUD) care, several states currently restrict billing for MH/SUD and physical health services on the same day to avoid duplicative billing.[3][4] This has restricted the ability to receive MH/SUD and physical health services on the same day, limiting the ability to meaningfully integrate care for individuals needing MH/SUD and physical health services.[5] Additionally, these restrictions present an undue burden on low-income individuals enrolled in Medicaid who are less likely to have sufficient access to time off and transportation for multiple office visits to accommodate their physical and MH/SUD needs separately.[5] The current reality for both patients and practitioners in states with same-day billing restrictions is antithetical to expanding integrated care.[1][2]
Topics
Expand value-based payments to encourage care integration
Congress should require the Centers for Medicare and Medicaid Services (CMS) to conduct an analysis of integration models in Medicaid and publish guidance describing state options for adopting or expanding value-based payment arrangements that integrate mental health or substance use disorder (MH/SUD) care within the primary care setting and best practices.[1][2][3]
Value-based payment systems are designed to improve patient care with financial incentives to providers, and such programs have been successfully implemented by the Centers for Medicare and Medicaid Services (CMS) for several programs aimed at reducing hospital-acquired illnesses and readmissions.[4] By incorporating mental health and substance use disorder (MH/SUD) care within primary care settings and expanding value-based payment models that tie quality metrics to payment, it can align incentives to improve the quality of care and outcomes.[3] In its 2022 Mental Health Care Integration Discussion Draft, the Senate Finance Committee proposed requiring CMS to analyze Medicaid integration models and deliver guidelines for states to incorporate value-based payment arrangements integrating MH/SUD and primary care.[1][2][3]