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.
Develop comprehensive diversion plans
Senate and House appropriators should include in the annual Commerce, Justice, Science, and Related Agencies spending bill a requirement that as a condition of receiving certain Department of Justice funding, local criminal legal systems, including law enforcement and juvenile justice programs, should be required to develop comprehensive diversion plans with health systems and mental health and substance use disorder (MH/SUD) providers in their communities.[1] Additionally, efforts to universally screen and assess individuals at arrest, sentencing, and all points across the criminal legal system continuum for MH/SUD should be expanded to inform connections to appropriate treatment and services.[2]
Individuals with MH/SUD are disproportionately involved with the criminal legal system, and jails and prisons have tragically become major providers of MH/SUD services.[3] As a condition of receiving DOJ funding, state and local governments should be required to support efforts focused on expanding interventions that divert people with a MH/SUD away from the criminal legal system and into treatment.[3][4] This includes working with health care systems and community MH/SUD providers to develop diversion plans[1][5], and expanding efforts within the criminal legal system to improve screening of individuals for MH/SUD.[2]
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Pass a 10 percent set aside for crisis services
Congress should pass a 10 percent set-aside for crisis services in the Mental Health Block Grant to address gaps in vital crisis services across the United States. At present, the set-aside stands at 5 percent, which falls short of effectively meeting the growing demand for mental health support, including in moments of mental health and substance use disorder (MH/SUD) emergencies.
Under the Consolidated Appropriations Act of 2021 and the Coronavirus Response and Relief Supplemental Appropriations Act of 2021, the Substance Abuse and Mental Health Services Administration (SAMHSA) was directed by Congress to set aside 5 percent of the Mental Health Block Grant (MHBG) allocation for each state to support crisis systems.[1] The MHBG is a grant program designed to provide comprehensive community health services to individuals MH/SUDs.[2]
The COVID-19 pandemic underscored the urgency of prioritizing MH/SUD services, and many states have struggled to meet the surging demand for crisis services. A permanent 10 percent set-aside ensure states allocate the resources needed to build up critical MH/SUD crisis services. This is equivalent to $165 million, with a funding level of $1.653 billion for the MHBG.[3] A robust crisis response system not only helps individuals navigate immediate challenges but also serves as an avenue for ongoing care and recovery.
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Make mobile crisis services mandatory under Medicaid
Congress should make mobile crisis services mandatory under Medicaid. At a minimum, these services should be made a permanent state option available to states eligible for enhanced federal Medicaid match funding.[1]
Mobile crisis teams are a critical part of the mental health and substance use crisis care continuum. The components of these teams can vary but generally involve response coordinators and social workers who can respond to mental health 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 interventions for individuals experiencing a mental health crisis.[2]
Since the launch of the Crisis Assistance Helping Out On The Streets (CAHOOTS) program in Oregon, more than 35 states have implemented mobile crisis programs using various Medicaid authorities, including waivers and demonstrations.[3] Mobile crisis teams are an indispensable part of the 988 Suicide Prevent and Crisis Lifeline, and states across the country are seeking to build out capacity to ensure the availability of an in-person response for 988 callers who need it. To expand the availability of these programs, Congress created a new state option under Medicaid with an enhanced federal matching rate of 85 percent for mobile crisis services as part of the American Rescue Plan Act (ARPA) of 2021.[2] Congress also provided funding to support state planning grants to ease implementation and support take-up of the new option.[4]
This new option is only temporary and expires in 2027. Given that physical health emergency services are covered by all state Medicaid programs, Congress should make mobile crisis services a mandatory Medicaid benefit. At minimum, Congress should make the the state option with the 85 percent federal matching rate permanent.[1]
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Reimburse for contingency management
Congress should require Medicare and state Medicaid programs to reimburse for Contingency Management.
Contingency Management is a highly effective approach to treat individuals with substance use disorders (SUDs). It provides small tangible reinforcements such as prizes, vouchers, or small amounts of money to motivate and sustain objectively measured positive changes in behavior (e.g., abstinence or decreased drug use). It takes advantage of the brain’s reward response – the same response that fuels substance use. While Contingency Management treats many SUDs, there is a particularly urgent need to increase its use to treat stimulant use disorder, which lacks other proven effective treatments. One meta-analysis[1][2] found that Contingency Management “has an extraordinarily strong evidence base and is a demonstrably cost-effective technique that has been used for decades to promote abstinence from benzodiazepines, cocaine, tobacco, opiates, alcohol, marijuana, and methamphetamine.”
In addition to Congress requiring Medicare and state Medicaid programs to reimburse Contingency Management, the Centers for Medicare & Medicaid Services (CMS) should educate state Medicaid programs that Contingency Management is THE treatment-of-choice for the nation's stimulant use disorder epidemic. CMS should also establish billing codes and rates for full-value, Office of Inspector General-approved, cash-equivalent, evidence-based Contingency Management, which is the only approach proven to be effective for stimulant use disorder.
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Loosen HIPAA overdose notification restrictions
The Secretary of Health and Human Services (HHS) should use the waiver process established by Section 1135 of the Social Security Act to temporarily modify Medicare, Medicaid, and the Children's Health Insurance Program (CHIP) requirements to augment treatment capacity and loosen Health Insurance Portability and Accountability Act (HIPAA) restrictions to allow notification to families of persons who have overdosed and been revived.[1]
On October 26, 2017, the Secretary of Health and Human Services (HSS) declared a nationwide opioid public health emergency (PHE). This declaration was most recently renewed on April 1, 2023.[2] Section 1135 of the Social Security Act gives the Secretary of HHS the ability to waive certain requirements under Medicare, Medicaid, and the Children's Health Insurance Program (CHIP) during a PHE to ensure health care supplies and services are available.[3] While 1135 waivers have been used for PHEs in the past, they have not been used during the opioid PHE.[4] As a result, regulatory flexibilities that could increase support for millions of individuals with opioid use disorder (OUD) have not been put to use.[5]
Additionally, families can play a crucial role in supporting individuals receiving OUD treatment.[6] However, under the Health Insurance Portability and Accountability Act (HIPAA), families are only notified of an overdose and revival if the individual gives permission, is incapacitated in an emergency as deemed by the provider, or to prevent a serious imminent threat to themselves or others.[7] Outside of these exceptions, families are not notified, limiting their ability to provide support during treatment.[6]
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Fund mobile crisis intervention
Congress should make permanent the recent increase to the Medicaid federal matching rate for mobile crisis team response services, originally passed in the American Rescue Plan Act in March 2021.[1]
Mobile crisis teams (MCTs) are trained health professionals who can provide on-site crisis assistance to people experiencing mental health or substance use disorder (MH/SUD) crises. MCTs can help reduce the reliance on law enforcement and emergency departments and provide more appropriate and effective care for people experiencing a crisis.[2] However, not all states have adequate funding or infrastructure to implement MCTs in their communities.[3] The American Rescue Plan Act (ARPA) of 2021 increased investments in MCTs by authorizing federal Medicaid matching funds for community-based mobile crisis response services. Under this option, states that provide qualifying mobile crisis services under their Medicaid programs will receive an enhanced federal matching rate of 85 percent for the first three years of implementation.[4] The existing option provides a significant incentive and opportunity for states to expand their MCTs and improve their behavioral health crisis response systems. By making the enhanced matching rate for MCTs permanent in Medicaid, Congress will help states grow sustainable MCTs into the fabric of their MH/SUD emergency response.