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
Want to understand more about the importance of building a National Strategy for Mental Health & Substance Use Disorders?
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.
Provide a formal definition of anhedonia
When supported by strong clinical data, the U.S. Food and Drug Administration (FDA) should provide a formal indication for a specific psychiatric symptom when that symptom has been mapped onto specific neuronal circuits.
Mental health and substance use disorders (MH/SUDs) are complex, and for some conditions there may never be a single medication that effectively treats an entire condition (e.g., major depressive disorder, bipolar disorder, or schizophrenia). However, researchers have successfully mapped many specific symptoms onto specific neuronal circuits.[1] For example, researchers have mapped the neuronal circuitry for anhedonia, the reduced ability to experience pleasure. Anhedonia is an important and overlooked aspect of opioid use disorder.[2] Where good supportive data exists, the FDA should give a formal indication for medications to treat specific symptoms such as anhedonia regardless of MH/SUD diagnosis.
FDA-approved indications for medicines to treat specific psychiatric symptoms would encourage on-label prescribing across diagnoses where an individual experiences that specific symptom. Such indications would also encourage medication development because medications to treat a specific symptom that has been mapped onto a specific neuronal circuit would have broader indications than one or more diagnoses.
Topics
Ensure hospital compliance with EMTALA
The Department of Health and Human Services (HHS) should issue guidance to hospitals on their obligations under the Emergency Medical Treatment & Labor Act (EMTALA) to stabilize and treat individuals with a substance use disorder (SUD), and Congress should provide financial resources to incentivize hospitals to hire appropriate staff for their emergency departments[1]
The Emergency Medical Treatment & Labor Act (EMTALA) ensures that hospitals provide emergency services, including stabilizing treatment for emergency medical conditions, regardless of an individual’s ability to pay.[2] Conditions related to substance use disorders (SUDs) are responsible for about one out of eleven emergency department visits, making hospitals an important location to initiate treatment.[3] Unfortunately, many emergency departments fail to comply with EMTALA by not conducting SUD screening and diagnosis assessments, by not providing medication for opioid use disorder (OUD), and by not providing post-discharge treatment options and medication.[4] Currently, many emergency departments do not provide adequate SUD screening and treatment due inadequate provider training and bias against SUDs.[5] Social workers and case managers can support hospitals by providing support services for individuals with SUD.[3] To improve SUD screening and treatment in hospitals, updated EMTALA guidance is needed to increase compliance. Congress should also pass legislation to incentivize the initiation of SUD care in emergency departments similar to the Improving Mental Health Access from the Emergency Department Act.[1]
Topics
Promote the director of ONDCP to presidential cabinet
The President should elevate the Director of the Office of National Drug Control Policy (ONDCP), which sits within the White House and oversees U.S. drug and substance use policy across 19 federal departments and agencies, to a cabinet-level position. Congress should also amend ONDCP’s authorizing statute to integrate mental health into the structure of the Office.
For years, the ONDCP Director was a Cabinet-level position, but unfortunately was downgraded in 2009. In early 2023, a bipartisan group of 55 members of Congress wrote to President Biden asking him to elevate the Director. They noted that, in 2001, then-Senator Biden supported the ONDCP Director as a cabinet-level position.[1] Without the status as a cabinet member, the ONDCP Director is left without access to the same resources and mechanisms as other higher-ranking leaders, and the drug crisis in our country is left without an advocate at cabinet-level meetings.[3]
For its part, Congress should amend 21 U.S.C. § 1702 to integrate mental health into the authorizing statute that creates ONDCP. Such integration is vital given the interconnectedness between mental health and substance use disorders, which are frequently co-occurring conditions.[2] Indeed, substance use disorders are a type of mental disorder within the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders. Mental health and addiction policy should not continue to be structurally segregated.
Topics
Establish a single global payment for mobile crisis response
Congress should require the Centers for Medicare and Medicaid Services (CMS) to establish a single global payment under the Physician Fee Schedule for mobile crisis response team services for Medicare beneficiaries experiencing a mental health or substance use disorder (MH/SUD) crisis. A bipartisan group of Senate Finance Committee members has supported this important step.[1]
Mobile crisis teams are a critical part of the MH/SUD crisis care continuum. The components of these teams can vary but generally involve response coordinators and social workers who can respond to MH/SUD crises. Research examining the impact of mobile crisis programs has shown they are effective in diverting individuals from emergency departments, reducing the need for hospitalization, and lowering law enforcement involvement for individuals experiencing an MH/SUDcrisis.[2]
Approximately 20 percent of older adults will experience an MH/SUD and access to services may be limited by mobility and transportation.[3] Additionally, many individuals with disabilities under the age of 65 are also eligible for Medicare. Mobile crisis teams are an indispensable part of the 988 Suicide Prevention and Crisis Lifeline, and access to mobile crisis teams is critical for Medicare beneficiaries experiencing an MH/SUD crisis.
Medicare currently covers psychiatric evaluation and depression screenings, which can be delivered in-office or through primary care integration, but does not explicitly cover mobile crisis teams.[4] Given that Medicare Part B has always covered emergency department and ambulance transportation services for physical health emergencies, Medicare should cover mobile crisis teams to ensure these important services are reimbursed and can be scaled to meet rising needs. Advancing parity for MH/SUD crisis services will reduce unnecessary emergency department visits, hospitalization, and law enforcement involvement. Congress should direct CMS to establish a global payment under the Physician Fee Schedule for mobile response team services for Medicare beneficiaries.[1]
Topics
Ensure informed consent for opioid prescriptions
The Department of Health and Human Services (HHS), Department of Labor (DOL), Department of Veterans Affairs (VA), Department of Defense (DOD), the Food and Drug Administration (FDA), and the Office of National Drug Control Policy (ONDCP) should work with stakeholders to develop model statutes, regulations, and policies to ensure informed patient consent before an opioid is prescribed for chronic pain.[1]
Individuals seeking pain-related medical attention, including in the aftermath of surgery, should be fully informed of the risks, benefits and alternatives to taking opioids. While there has been much work completed to inform prescribers and patients about the risks associated with opioid use, a standard informed consent does not yet exist.[2] The Department of Veterans Affairs has developed a patient guide for the “safe and responsible use of opioids for chronic pain” to help Veterans make informed decisions about their care.[3] Additionally, in 2022 the Centers for Disease Control and Prevention (CDC) released a “Clinical Practice Guideline for Prescribing Opioids for Pain” to improve communication between providers and their patients to reduce risks of suffering from an opioid use disorder, overdose, and death.[4] However, a report by the National Academy of Medicine found that while all states have requirements for counseling patients on opioid use before writing a prescription, there are insufficient policies to address standardized prescription practices.[5]
Topics
Expand eligibility for loan repayment programs
Congress should expand funding the eligibility criteria for national and state loan repayment programs to include bachelor-level social workers, health and human services providers, and certified drug and alcohol counselors, while also expanding service delivery location sites to include more home, school, and community-based settings.[1]
Certified drug and alcohol counselors, social workers, and other health professionals work in different capacities to provide mental health and substance use disorder (MH/SUD) care.[1][2] Serious workforce shortages exist among MH/SUD clinicians nationwide.[2]
HRSA’s student loan repayment programs have been leveraged to encourage providers to practice in communities facing behavioral health staff shortages.[3] For instance, the National Health Service Corps (NHSC) Loan Repayment Program (LRP) offers student loan forgiveness for primary behavioral health care clinicians who agree to provide two years of service in areas where communities face limited access to care.[5] Additionally, the State Loan Repayment Program provides grants to states who administer loan forgiveness programs for health professionals who work in shortage areas for two years, including MH/SUD clinicians.[6] Congress should increase funding for both the NHSC and the State Loan Repayment Program.
Unfortunately, the current eligibility criteria for national and state repayment programs typically exclude some bachelor-level health professionals who may play an essential role in expanding access to treatment and recovery services, such as social workers and certified drug and alcohol counselors.[1][4][5][6][7] Furthermore, NHSC does not provide assistance to peer support specialists, which are an integral part of the continuum of care and often better mirrors the communities they serve. Loan repayment programs should be expanded to include a greater range of professionals and peer support specialists degrees to quickly expand the capacity of our nation’s MH/SUD workforce.
Finally, loan repayment programs should also expand the types of sites in which health professionals may work in order to be eligible to receive loan forgiveness.[1] For instance, HRSA’s Substance Use Disorder Workforce Loan Repayment Program allows loan recipients to work at community mental health centers, private practices, and school-based clinics.[7] However, there are no approved home-based settings or sites.[7] Additionally, NHSC programs do not currently specify that crisis programs be eligible sites. HRSA should align eligibility with Substance Abuse and Mental Health Services Administration (SAMHSA) guidelines for crisis services, which include a range of facilities such as call centers, mobile crisis response teams, and crisis receiving and stabilization facilities.[8]