Alignment for Progress: 
A National Strategy for Mental Health and Substance Use Disorders

The impact of environmental pollution and degradation, including the worsening effects of climate change, has a profound impact on communities’ mental and physical health. For example, numerous studies have shown that air pollution leads to higher levels of stress, depression, and even death for individuals with serious mental illness.[2] Recent research has shown that air pollution affects brain development and the mental health of children, with one large study finding that air pollution “is significantly associated with increased risk of psychiatric disorders.”[3] The authors of this study suggest that neuroinflammatory mechanisms may be to blame. A recent meta-analysis of more than 100 studies found that nearly three-quarters showed that mental health symptoms worsened after exposure to high levels of air pollution.[4] The study’s lead author remarked, “People who breathe polluted air experience changes within the brain regions that control emotions, and as a result, they may be more likely to develop anxiety and depression than those who breathe cleaner air.”[5] Yet another study found that exposure to air pollution was associated with an increase in psychiatric visits to emergency departments among children.[6]

Given the long history of higher levels of environmental pollution in and around Black and other communities of color,[7] including the siting of pollution sources such as highways and industry, it is essential that Congress take affirmative steps to eliminate the sources of pollution and the inequitable effects. The A. Donald McEachin Environmental Justice for All Act would be a major step in the right direction of addressing these injustices by providing resources, engaging with affected communities, fixing inequitable practices, and ensuring meaningful remedies.

More than half of all U.S. counties do not have a mental health or substance use disorder (MH/SUD) provider. While many MH/SUD services can be provided via telehealth, much more needs to be done to expand the MH/SUD workforce, including peer support specialists. These critical providers are formally trained and offer peer support, using their lived experience with a MH/SUD to promote recovery in other individuals. Peer support specialists are cost-effective and provide critical support that helps individuals build stronger support systems, engage with treatment, and manage both MH//SUD and physical health conditions. Increasing utilization of peer support specialists (including through telehealth) is a critical way to alleviate shortages of MH/SUD professionals, particularly in rural and other underserved areas. By helping individuals get the support and care they need, peer support specialists help prevent costly negative outcomes, including disability, hospitalization, incarceration, and even homelessness.[1] Indeed, research has shown that peer support services were associated with 2.9 fewer hospital admissions each year, and Medicaid programs saved an average of over $2,000 per month.[2]

Unfortunately, barriers remain in expanding the peer support specialist workforce. One critical barrier is insufficient standardization. For example, credentialing of peer support specialists is not standardized across states. The Substance Abuse and Mental Health Services Administration (SAMHSA) and the Health Resources & Services Administration (HRSA) should take steps to standardize credentialing. Additionally, the U.S. Bureau of Labor Statistics’ Standard Occupational Classification (SOC) system does not have a separate classification for peer support specialists.[3] Instead, peer support specialists are lumped in with “Social and Human Services Assistants.” The SOC system is how federal agencies classify workers in order to collect, calculate, and disseminate data. Congress should direct SAMHSA and HRSA to take steps to standardize credentialing of peer support specialists and the Office of Management and Budget to revise the SOC Manual to include a definition of peer support specialists.

Another barrier is that HRSA does not publish data on peer support specialists.[4] Such data is collected and published for psychiatrists, psychologists, and social workers – and includes information on the number of professionals and their location. Having data on peer support specialists would help identify gaps across the country, including where peer support specialists could fill gaps in available clinicians. HRSA collects much of this data through the Behavioral Health Workforce Education and Training (BWHET) program, but this data is not published. Congress should direct HRSA to add peer support specialists to its Workforce Bureau dashboard.

Finally, in 2022, the Senate Finance Committee’s Task Force on Workforce released draft legislation, which included a Medicaid workforce demonstration project modeled after a previous demonstration project.[5] Unfortunately, peer support specialists were not named within the draft. It is critical that any new workforce demonstration projects explicitly authorize peer support services so that these projects cover the range of provider types.

American moms are dying at the highest rate in the developed world, and the United States is the only country in the developed world with rising maternal mortality rates.[1] For every death, 70 more moms experience “near misses.”[2] Black moms are dying at three to four times the rate of their White counterparts,[3] while Native American moms are more than twice as likely to die from pregnancy-related causes.[4] Though maternal deaths have increased by 89 percent since 2018, [1] 80 percent of maternal deaths are preventable with appropriate care and treatment.[5]

The Black Maternal Health Momnibus Act includes 13 bills that would help decrease maternal deaths and reduce disparities.[6] Key provisions include:

• Funding community-based organizations to address social determinants of health that influence maternal health outcomes, like housing, transportation, and nutrition, and extending Women, Infants, and Children (WIC) eligibility in the postpartum period from 6 months to 24 months and in the breastfeeding period from 12 months to 24 months.
• Investing in digital tools to improve maternal health outcomes in underserved areas.
• Promoting payment models that incentivize maternity care and non-clinical support during and after pregnancy.
• Establishing and funding programs within hospitals to provide pregnant and postpartum patients the ability to report instances of racial, ethnic, or other types of bias.
• Funding local initiatives supporting people with mental health conditions or substance use disorders during or after pregnancy and funding programs to grow and diversify the maternal mental clinical and non-clinical healthcare workforce.
• Ending the practice of shackling pregnant people and targeting funds to federal, state, and local prisons and jails to establish programs for pregnant and postpartum women to access perinatal and postpartum healthcare.
• Requiring the Centers for Medicare and Medicaid Services (CMS) to consider models that improve the integration of telehealth services in maternal health care and establishing a new CMS Innovation Center demonstration project to promote equity and quality in maternal health outcomes for moms covered by Medicaid.
• Funding community-based programs, research, and health professional schooling that identify and address climate change-related maternal and infant health risks.

The Community Schoolyards project is an initiative that aims to transform asphalt schoolyards into green spaces that can serve as public parks and outdoor recreation areas for urban communities. The project is based on the idea that schoolyards are a valuable but underutilized resource that can benefit students, families, and neighbors, such as improving health, education, equity, and climate resilience.[1]

According to Trust for Public Land, parks are essential for healthy, equitable communities, but across America, 100 million people - including 28 million children, do not have a park close to home. This means they miss out on the physical, mental, and social benefits of spending time in nature. In our biggest cities, communities of color have access to 44 percent less park space than majority white communities.[2] This creates environmental injustices and health disparities that affect people’s quality of life and well-being. Nationwide, 36 percent of public school students attend school in heat islands, which negatively impacts cognitive development and can cause heat stress in children.[2] A growing body of research also connects extreme heat – which is even worse in urban heat islands – to increases in attempted and completed suicides, depression, substance use, and hospitalizations for mental health conditions.[3]

Gaps in park access and the effects of urban heat islands can be addressed by turning existing public schoolyards into vibrant, shared outdoor spaces that benefit the entire community. American public schools own a combined two million acres of land with much of it remaining closed to the public outside of school hours. If every public schoolyard in the U.S. functioned as a shared outdoor space, 20 million more people, including over 5 million children, would have access to a park within a 10-minute walk of home.[2] This would significantly improve the quality of life and well-being of millions of Americans, especially those who live in underserved communities.Green schoolyards can provide multiple benefits for students and communities, such as improving physical and mental health, enhancing academic performance and attendance, increasing prosocial behavior, reducing crime and violence, and mitigating urban heat islands and stormwater runoff.[2][4] Access to green spaces in childhood has also been shown to protect against the development of many mental health disorders in adolescence and adulthood. One of the most significant benefits is psychological restoration, which can help prevent stress-related issues, depression, and mood disorders.[5]The ORLP grant program is a nationally competitive program funded through the Land and Water Conservation Fund (LWCF). The program targets grant assistance to urban areas with little or no access to publicly available outdoor recreation spaces.[6] The program is administered by the NPS and is an ideal mechanism for codifying the Community Schoolyards initiative at the federal level. The program aligns with the goals and objectives of the initiative by prioritizing projects that create new or reinvigorate parks in economically disadvantaged areas.

Children’s mental health is a critical issue that affects millions of families in the United States. According to the American Academy of Pediatrics, more than 14 million children and adolescents in the United States have a diagnosable mental health condition.[1] Using data from the 2016 National Survey on Children’s Health, researchers at the University of Michigan also found that only half of children with mental health conditions were receiving treatment.[2] Moreover, the COVID-19 pandemic has exacerbated the mental health crisis among children, with increased rates of anxiety, depression, and substance use disorders.[3] Many communities lack enough options for children’s mental health treatment, and often children do not receive the care they need, which can lead to more severe mental health problems. Consequently, children’s hospitals are seeing more children in crisis who are “boarding,” or waiting in hospitals (often emergency departments) for suitable care placements to open up.[4]

The Strengthen Kids’ Mental Health Now Act would improve access and quality of mental health care for children and adolescents by increasing community-based provider rates for pediatric mental health services. The bill would also improve state implementation of Early and Periodic Screening, Diagnostic, and Treatment (EPSDT), a Medicaid coverage requirement that provides comprehensive and preventive health care services for children under age 21, to improve accessibility to pediatric mental health and substance use services that EPSDT guarantees, but often fails to deliver.[5]

The legislation also identifies the regulatory and legal hurdles that prevent providers from increasing their ability to provide pediatric mental health services and encourages existing flexibilities states can use to broaden mental health services, while creating a new Health Resources and Services Administration (HRSA) grant program to improve community-based pediatric mental health services and help communities implement or develop new programs and policies that suit the mental health needs of children and adolescents. Additionally, the bill aims to establish a new HRSA workforce grant program that focuses on strengthening the pediatric mental health workforce, through more training for the current workforce and focused investment in the recruitment, retention, and diversity of future pediatric mental health professionals. Finally, the bill proposes to create a HRSA program that aims to enhance vital pediatric mental health infrastructure and expand our national ability to deliver suitable care for children with more intensive treatment needs.[5]

Domestic and sexual violence have damaging long-term mental health effects on both mothers and their children. About 20 percent of people who survive IPV experience new mental health disorders as a result of the abuse, including major depressive disorder, post-traumatic stress disorder, generalized anxiety disorder, and a wide range of substance use disorders (SUDs).[1] Tragically, more than 50 percent of female homicide victims are killed due to some type of IPV.

Congress should pass the Protect Moms from Domestic Violence Act, which would address IPV during pregnancy by requiring the Department of Health and Human Services to study maternal mortality and morbidity due to IPV, with recommendations on best practices for reducing maternal mortality due to IPV. The bill would also require the National Academy of Medicine to study whether various forms of violence increase the risk of suicide, SUDs, and drug overdose among pregnant and postpartum people. Finally, the bill would provide grants to nonprofit and community-based organizations to improve maternal and child outcomes of IPV victims.[2]