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.
Improve mental health screenings for the incarcerated
Evidence-based screening, assessment, and treatment, including psychosocial and pharmacological treatments, should be adopted in jails and prisons. Correctional officers should be trained on de-escalation and safety measures in situations involving an inmate in a mental health crisis. To improve the care within jails and prisons, the Department of Justice (DOJ) should issue guidance and model policies and practices for state and local governments, as well as implement such policies and practices within federal facilities.[1]
The number of incarcerated individuals with mental health and substance use disorders (MH/SUD) continues to increase, and conditions in correctional facilities are known to only exacerbate MH/SUD.[2] Screening and assessment, treatment, and case planning is critical to identifying and meeting individuals’ MH/SUD needs and help with reentry upon release.[3] Correctional officers need training on MH/SUD and how to assist individuals experiencing a mental health crisis.[4] Policies and practices should be developed and implemented to improve the ability of correctional facilities and staff to screen, assess, and treat individuals experiencing an MH/SUD crisis.[1]
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Ensure consumer protections in all health plans
Congress should oppose expansions of any type of health plan that does not have to provide the consumer protections offered by the Affordable Care Act (ACA) or the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA).
In 2023, two bills were introduced in the U.S. House that would expand telehealth-only plans and association health plans (AHPs). As introduced, these bills did not include critical protections for individuals with mental health and substance use disorders (MH/SUD).[1][2][3]
Telehealth-only health plans would limit – or fail to cover altogether – in-person MH/SUD services. While telehealth is a critical delivery mechanism for MH/SUD services that should be covered at parity with in-person services, restricting in-person services through telehealth-only plans will limit access to critical in-person care. Key levels of care (e.g., inpatient) are fundamentally in-person services, while other services may be most effectively delivered in-person (due to the nature of the service or the needs/preferences of the individual). These “excepted benefits” plans should not be expanded.[4]
AHPs are offered by organizations like trade associations or professional groups and are exempted from ACA standards, such as requiring coverage of MH/SUD services and preventing discrimination against individuals because they have (or previously had) an MH/SUD.[5] AHPs also threaten to raise premiums and undermine the stability of higher-quality health plans that serve the majority of Americans by peeling off younger and healthier enrollees who are less expensive. Similarly, short-term limited duration plans, which do not have to follow ACA rules or MHPAEA, should be defined as plans lasting three months or less. These plans offer inadequate coverage and should not be allowed to undermine full-year plans.
Congress should reject any health plans that do not offer strong MH/SUD coverage, are allowed to discriminate against individuals with MH/SUDs, or are not subject to MHPAEA.
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Develop telehealth data best practices
Congress should fund research through the National Institutes of Health on the efficacy of mental health and substance use disorder (MH/SUD) services provided via telehealth, with outcomes studied by service type (e.g., crisis response) and demographic groups, including underserved communities.
Nearly one-third of all MH/SUD visits occurred via telehealth in the second quarter of 2022 – a 45-fold increase from the start of the COVID-19 pandemic.[1] Even after the worst of the pandemic passed, many providers maintained some type of virtual care with the option for hybrid services. However, data and best practices for telehealth are lacking.[2] To effectively measure the effects and outcomes of services delivered via telehealth, Congress should fund data collection and research on best practices in telehealth for MH/SUD services. Based on this information, the Department of Health and Human Services should issue guidance on best practices in providing MH/SUD telehealth services and work to establish standards for digital platforms and data collection. Best practices should be broken down by age and include criteria for determining, with patient input, the best method of service delivery (e.g., audio, video, in-person).
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Ensure network adequacy in employer-based plans
Congress should enact quantitative timely access and geographic distance standards for all employer-based plans nationwide to ensure that plan members have access to mental health and substance use disorder (MH/SUD) care.
Individuals needing MH/SUD services often face difficulties finding and accessing in-network providers. This can result in long wait times, high out-of-pocket costs, and inadequate care. While some states have established their own network adequacy standards for MH/SUD providers, such as timely access and geographic distance standards or provider-to-enrollee ratios, these standards vary widely. And even in many states that have standards, they are qualitative, rather than quantitative in nature, significantly impairing enrollees’ rights and making the standards difficult to measure or enforce.[1] Additionally, large employers often self-fund their plans, which are subject only to federal law and are not required to meet timely access or geographic distance standards.
While federal policymakers are working to require stronger network adequacy standards for Medicaid, Medicare, and individual marketplace plans, individuals in large employer-based plans should not be without protections. Congress should establish uniform, quantitative timely access and distance standards for MH/SUD services for all employer-based plans nationwide. If a plan’s network is unable to provide needed MH/SUD services for an enrollee within these standards, the plan should be required to arrange out-of-network services with the enrollee’s cost-sharing limited to what they would have paid had in-network services been available. Numerous states have implemented such standards, including California, which requires that health plans have medically necessary MH/SUD services available within 10 days.[2] More than a dozen other states have mandated quantitative time and distance standards.[1]
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Require GAO report on MH/SUD reimbursement rates
Congress should require the Government Accountability Office (GAO) to report to Congress on current reimbursement rates paid for mental health and substance use disorder (MH/SUD) services by Medicare, Medicaid, individual and group health plans, and other types of health coverage, both in and out of network. Rates should be assessed for their sufficiency to increase in the supply of participating providers and pipeline for clinicians entering MH/SUD fields, as well as compared to physical health reimbursement.[1]
Millions of individuals with MH/SUDs are unable to access the services they need. A significant part of the problem is that reimbursement rates for MH/SUD services are often lower than those for physical health services, which can discourage providers from participating in certain insurance networks or accepting insured patients.[2] Conversely, higher reimbursement rates can incentivize providers to join insurer networks and encourage more people to become MH/SUD clinicians, increasing access to care.[3] Reimbursement rates also vary widely across payers and markets.[4] This variation can create challenges for providers to navigate complex billing and payment systems and for patients to afford and access quality care. The GAO can play an important role in increasing transparency of reimbursement rates paid and disparities that exist that inhibit access to care.
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End forced arbitration in ERISA
Congress should amend the Employee Retirement Income Security Act (ERISA) to prohibit ERISA plans from inserting forced arbitration provisions into plan policies that prevent consumers from using the courts to challenge wrongful coverage denials.
Forced arbitration provisions are a long-standing and widespread practice to prevent consumers from accessing the judiciary system to gain relief, forcing individuals to agree to a closed-door tribunal not subject to important legal safeguards.[1] While current ERISA regulations prohibit such provisions, plans may nonetheless seek to use them and argue that the Federal Arbitration Act overrides the regulations.[2] If these provisions become widespread and are deemed enforceable, they would have devastating consequences for Americans’ health coverage rights, including under the Mental Health Parity and Addiction Equity Act. This is because arbitration results are not public and cannot be used to change health plans’ widespread practices, which can affect large numbers of people – not only the claimant. Forced arbitration in ERISA plans threatens the civil rights of the nearly 150 million Americans covered by ERISA plans.[3] The Mental Health Matters Act, which includes a subsection to ban such provisions, passed the U.S. House in 2022.[4]