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

School “zero-tolerance” policies, many of which were imposed in the 1990s, for discipline encourage a strict approach, increasing the number of expulsions and suspensions for actions ranging from possessing weapons or drugs to fighting and swearing.[2][3] However, research has shown that zero-tolerance punishment is ineffective in changing student behavior and that proactively engaging students has more productive and cost-effective outcomes than punitive actions.[1][2][3][4][5]

SEL and executive function programs have proven to be an effective means for positively influencing student behaviors.[3][5] SEL programs, like the Responsive Classroom approach to teaching, engage students in developing academic, social, and emotional skills in a safe and responsive learning environment.[6] Executive function training programs like ACTIVATE improve cognitive function for children with attention deficit hyperactivity disorder (ADHD), autism, or other learning disorders.[7] Using Federal Title I education funds, schools should replace zero-tolerance policies with SEL and executive function training programs.[1]

Peer support programming for youth and young people can effectively provide mental health support outside of traditional healthcare systems and can support culture change within healthcare systems. It is a trauma-informed practice recognized by SAMHSA that can help youth and young people manage their physical and mental health, build support networks, and engage in services.[1] Peer support is a priority outlined in President Biden’s 2022 Presidential Unity Agenda, and SAMHSA has issued National Model Standards for Peer Support Certification for local, state, federal, and tribal partners. [2][3]

Peer support is a Medicaid-covered service in over 45 states and reimbursable by the Veterans Administration. In 2013, CMS and SAMHSA issued an Informational Bulletin providing guidance to states on how to establish peer support services as a Medicaid benefit for children, youth, and young adults with “significant behavioral health conditions.” [4] Still, Medicaid funding for youth peer support is commonly funded under state Medicaid waivers, limiting available funding to a small percentage of high-need youth.[5] School-based health centers that are designated federally qualified health centers can also receive increased federal matching funds for providing Medicaid-approved mental health services like youth peer support but often express confusion about how to seek those funds. Similarly, school districts are often not familiar with how to properly bill Medicaid for peer support services – either provided by the school or by a peer hired by the school, community mental health center or provider, or other school-linked community organizations.[5] The Bipartisan Safer Communities Act invests in school-based services through Elementary and Secondary Education Act grants. However, it is unclear that youth peer support may be implemented with this funding.[6]

CMS and the DOE should ensure schools and states are aware that youth peer support programs may be implemented and expanded and should provide guidance to states on billing for peer services. CMS should update its administrative claiming guide with information about claiming and billing for youth peer support, with additional guidance on the topics of parental consent and alignment with provider requirements. CMS should also issue clarifying guidance that people under 18 years old can be provided peer support by another person under the age of 18. Guidance should discuss both Medicaid reimbursement pathways through managed care organizations and Medicaid fee-for-service reimbursement. CMS and SAMHSA should additionally offer learning collaboratives and technical assistance to states on peer support implementation and billing best practices and offer learning communities.[5]

Schools play a vital role in preventing, identifying early, and addressing students’ mental health and substance use challenges, especially in the wake of the COVID-19 pandemic. However, many schools lack adequate resources and staff to provide effective and accessible MH/SUD services and supports.[1]

The ASSIST Act would establish a new grant program at the Department of Health and Human Services to help schools and school-based health centers hire and retain qualified MH/SUD providers, such as counselors, social workers, psychologists, and psychiatrists. The ASSIST Act would also permanently increase the federal government’s share of Medicaid reimbursement of school-based services, including MH/SUD care, to 90 percent.[2] This would help states sustainably increase the rate of pay for school-based providers, which would help reduce provider shortages and turnover. A higher Medicaid reimbursement rate would also reduce the administrative burden on schools and states to claim Medicaid reimbursement for school-based services.

By passing the ASSIST Act, Congress can make a significant investment in the mental health and well-being of our nation’s students. School-based MH/SUD care can improve access to care, allow for early identification and treatment of MH/SUD challenges, reduce stigma and discrimination, and promote academic achievement and positive youth development.[3] The ASSIST Act would help ensure that every student has access to the behavioral health services they need to thrive.

More than one in five U.S. adults is estimated to live with a mental health condition (57.8 million in 2021), and almost half of adolescents will experience a mental health condition in their lifetime.[3] Crisis services are a critical part of a community’s response to MH/SUDs, because these services can help divert people away from emergency rooms, psychiatric hospitalization, and interventions by law enforcement.[4] For instance, crisis stabilization services can provide short-term observation by MH/SUDprofessionals in a non-hospital environment.[4]

The Behavioral Health Crisis Services Expansion Act would establish national requirements for MH/SUD crisis services and expand health insurance coverage for these services, including within Medicare, Medicaid, ACA health plans, employer-sponsored coverage, the Veterans Administration,  TRICARE, and the Federal Employee Health Benefits Program.[2][3] The bill would also provide funding and technical assistance for communities to deliver behavioral health crisis services and establish an expert panel that will make recommendations to improve coordination and integration between 911 dispatchers and 988 Crisis and Suicide Prevention Hotline call centers in cases involving MH/SUD crises.[2][3]

LGBTQ+ youth often experience discrimination and a lack of acceptance that can negatively affect their mental health, increasing their risk for MH/SUDs. Many are unable to receive needed services, and data relating to the most effective treatments and supports for individuals who belong to multiple, frequently marginalized groups is too often limited.[1][2][3]. Black and Native communities are experiencing increased suicide rates, and communities of color are broadly experiencing an increase in drug overdoses.[4] People of color are estimated to be underdiagnosed with MH/SUDs and face additional barriers to accessing care.[4] To advance health equity, our country must provide culturally competent – and congruent – high-quality and affordable healthcare services for underserved communities. Additionally, we must fund foundational and applied research that includes members of diverse communities to ensure that clinical interventions are effective across communities.[5][1]

States have a multitude of complicated Medicaid eligibility requirements, with many states having a $2,000 asset test (for a single person) to qualify and maintain eligibility in Medicaid, an amount established in 1989. For SSI, which assists low-income older adults and individuals with disabilities, the $2,000 asset test is the strictest limit of any federal program. This very low asset test penalizes savings, makes it extraordinarily difficult to weather emergencies, and also constrains family members from helping their loved ones with disabilities achieve economic security.[1] The asset tests also lead to churn in and out of these programs if individuals temporarily exceed the limit. Because the tests have not been indexed to inflation, each year they apply to more individuals, including those with mental health conditions, including autism and substance use disorders. If the current $2,000 SSI asset limit were adjusted to account for inflation, it would be $10,000 today. The Center on Budget and Policy Priorities, in its analysis of proposals to increase the SSI asset limit to $10,000 (as has been proposed on a bipartisan basis in the Savings Penalty Elimination Act)[2], to $100,000 (which would be consistent with limits of recently created tax-advantaged saving accounts for individuals with disabilities), and to eliminate the SSI asset test altogether, estimates that all would meaningfully increase SSI participation while not ballooning programs costs.[3][4] There is a growing movement to raise or eliminate such asset tests, with California ending its Medicaid asset test in 2024.[5]