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.
Ensure tribal representation on task forces and commissions
Tribal representatives must have the opportunity to serve on federal task forces and commissions seeking to address the opioid epidemic. The Department of Health and Human Services (HHS) Pain Management Best Practices Inter-Agency Task Force and the National Committee on Heroin, Opioid, and Pain Efforts (HOPE) must include tribal representation.[1]
According to the CDC, American Indians and Alaska Natives have the second-highest rate of opioid overdose in the country compared to other racial and ethnic groups.[2] For these challenges to be considered, representation of tribal leaders is needed. Yet representation is lacking on federal opioid and pain management task forces and commissions.[3]
The Comprehensive Addiction and Recovery Act (CARA) of 2016[4] led to the creation of the Pain Management Best Practices Inter-Agency Task Force. The Task Force convenes to propose updates to best practices and issue recommendations on managing chronic and acute pain with the goal of addressing the opioid epidemic.[5] The Task Force does not include tribal representation; only public comments from the Indian Health Service (IHS) were included in their latest report.[6]
Similarly, the IHS National Committee on Heroin Opioids and Pain Efforts (HOPE Committee) established five workgroups that aim to foster tribal relationships to address the increasing crisis facing their communities. Although the workgroups include IHS experts, they also fail to mandate tribal leader representation.[3]
Topics
Fully implement the 988 suicide and crisis lifeline
The Substance Abuse and Mental Health Services Administration (SAMHSA) should continue to fully implement the 988 number, with response driven by healthcare systems, not public safety systems.[1] Enhanced training should be provided to counselors answering 988 calls, and coordination between 988, 911, and all services within the continuum should be strengthened.[2] Clinically staffed crisis response should be integrated within 911, and training provided to 911 operators in identifying mental health needs and linking callers to mental health crisis response services.[1] Congress should provide the funding necessary to scale up 988 to meet the high – and increasing need. Funding should be at least $946 million a year – and should grow over time. Of this amount, $100 million is needed for state Mental Health Crisis Response Grants, $836 for the 988 Suicide & Crisis Lifeline program, and $10 million for the Behavioral Health Crisis & 988 Coordinating Office at the Substance Abuse and Mental Health Services Administration.[3]
The 988 Suicide and Crisis Lifeline, formerly known as the National Suicide Prevention Lifeline, was created to help address the increasing rates of suicide and overdose in the United States.[4] 988 offers 24/7 access to trained counselors via call, text, and chat, who provide support and resources, if needed. Efforts to improve cultural competency training for Lifeline counselors are ongoing.[5] In the fall of 2022, the 988 system set up a program to connect high-risk LGBTQI+ youth to counselors that could meet their needs.[4] Yet, access to a robust crisis services system for those who call does not yet exist.
In May 2023, the Department of Health and Human Services (HHS) announced more than $200 million in funding for 988, which provides opportunities to improve multiple aspects of local responses. These include making enhancements to the 988 workforce, improving services for vulnerable populations, ensuring access to culturally competent support centers, and allowing for systemic follow-up and enhanced coordination of crisis stabilization among emergency services.[2][6]
While this is an important step, more action is needed to implement the 988 system and establish effective care interventions to provide help to those in crisis when they need it most.
Topics
Expand states’ capacity to provide MH/SUD services under Medicaid
Congress should incentivize states to expand their capacity to provide mental health and substance use disorder (MH/SUD) services under Medicaid, which will improve equity. For example, Congress should authorize a planning grant or demonstration program to provide participating state Medicaid programs with additional federal funding to expand or improve the capacity of MH/SUD participating providers.[1]
Medicaid is the single largest payer of MH/SUD services in the United States, with 40 percent of the nearly 14 million beneficiaries requiring some form of MH/SUD treatment in 2020.[2] However, Medicaid beneficiaries are disproportionately more likely to encounter MH/SUD services through visits to emergency departments during a crisis, indicating barriers to access.[3] This is, in part, due to a shortage of MH/SUD providers who accept Medicaid.[4] Planning grants provided by the Centers for Medicare and Medicaid Services (CMS) have been used to assist states in building out MH/SUD crisis services, including mobile crisis response.[5][6] Congress should incentivize increased state Medicaid program innovation and their capacity to provide MH/SUD services with additional federal funding attached to these or new planning grants.[1]
Topics
Expand mental health training for law enforcement
Law enforcement receiving federal funding should be required to train officers and non-sworn personnel[1] in recognizing signs and symptoms of Mental Health/Substance Use Disorder, as well as use de-escalation using models (e.g., the Police Assisted Addiction and Recovery Initiative)[2] and specialized training (e.g. Crisis Intervention Team [CIT], Law Enforcement Assisted Diversion [LEAD]).[3] Training should help officers identify and respond to potential mental health crises. Policymakers should expand the National Training Center to meet the existing demand for training/support Office of Justice Programs (OJP) expansion to train and provide technical assistance through state grant-making agencies to service providers.[1]
Americans in mental health crisis are more likely to encounter law enforcement and become incarcerated than receive the medical care and treatment they need.[4][5] All levels of the criminal legal system – from the Department of Justice to local law enforcement agencies - should take steps to establish policies and support programs that divert individuals living with mental health and substance use disorders (MH/SUD) away from the criminal legal system and into treatment.[5][6] Evidence-based model programs that provide training and support to law enforcement officers and non-sworn personnel to help them more appropriately identify, triage, and respond to individuals experiencing MH/SUD crises are critical to helping to decriminalize MH/SUDs in America. [1][2][3]
Topics
Fund drug court programs and mental health courts
Congress should increase appropriations for drug court programs (34 U.S.C. § 10611) and mental health courts (34 U.S.C. §10471). Additionally, the federal cap on grant funding for mental health courts should be removed.[1]
Every year, almost 2 million people living with a mental health condition enter into jails or prisons. Once in jail, they are two times more likely to remain confined than others facing the same conviction.[2]
To reduce the number of people with mental health and substance use disorders in the criminal legal system, Congress should provide funding and support to drug court programs that offer substance use treatment and services, including relapse prevention, health care, education, vocational training, job placement, housing placement, and child care.[3][4] Congress should also provide appropriations for mental health courts that train law enforcement and others in the criminal legal system to assess the needs of individuals with mental illness, and connect them with treatment plans and social services, including skills training.[5][6] To ensure proper funding and support for these mental health courts, Congress should eliminate the current restrictions on Department of Justice grant funding, which is currently capped at 100 programs.[5]
Topics
Increase access to Naloxone
Federal agencies and Congress should dramatically expand the distribution of Naloxone, the lifesaving opioid overdose reversal medication, utilizing the widespread distribution of Automated External Defibrillators (AEDs) for heart attacks as a possible model.[1][2] Policymakers should ensure that no-cost naloxone is available to respond to opioid overdoses.
In 2021, nearly 80 percent of overdose deaths were caused by opioids, many of which could have been prevented if Naloxone was readily available and used to reverse the overdose.[3][4] In early 2023, the Food and Drug Administration (FDA) approved the over-the-counter Naloxone nose spray, Narcan.[5] The Biden Administration has launched a campaign to raise awareness of the benefits of this life-saving drug.[3] However, cost can be a barrier to access, as it can vary based on the facility or geographical location where an individual obtains Naloxone.[4] The Administration and Congress should work together to ensure the widespread availability of low-cost (or even free) naloxone. One model that has been scaled successfully are AEDs, devices that can deliver life-saving interventions for individuals experiencing cardiac arrest and are now widely distributed across a range of public and private settings. Federal agencies, including the Department of Health and Human Services, Department of Education, Department of Housing and Urban Development, the Federal Emergency Management Agency (FEMA), and the Bureau of Indian Affairs, should take action to ensure that a variety of funding streams can be used to distribute naloxone and promote such use of funds.[1][2][6]