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 paid sick and parental leave
Congress should pass the Healthy Families Act,[1] which would ensure paid sick leave, and the Family and Medical Insurance Leave (FAMILY) Act,[2] which would ensure twelve weeks of family or medical leave for workers.[3]
The United States remains one of only two major countries that does not provide paid time off for short-term illnesses nor paid leave for family and medical needs.[3] A quarter of the private sector workforce and 9 percent of the public sector workforce lack paid sick leave.[4] The lack of paid sick leave is associated with workers reporting higher levels of psychological distress.[5] A universal paid sick leave policy, which could be used by individuals with mental health and substance use disorders, would reduce preventable emergency department visits and result in cost savings of $1.1 billion annually, including $500 million for public health insurance programs like Medicare and Medicaid.[3]
Disparities exist by race and ethnicity for access to and use of paid leave. Black and Hispanic workers have lower rates of paid family and medical leave access and use than their White, non-Hispanic counterparts.[6] Research has shown that paid parental leave policies greatly improve maternal mental health; these policies give mothers time to recover from childbirth and to care for their child and enhances families’ economic security.[7] One study found increasing the length of maternity leave from under eight weeks to eight to twelve weeks showed a large improvement in mental health– increasing the length of leave by one week could reduce depressive symptoms by 6 to 7 percent.[8] A longer paid leave policy allows parents to take time off without the risk of economic ruin to bond with their children. Despite these benefits, data from the Bureau of Labor Statistics found that less than one in four workers had access to paid family leave in 2021.[9]
Congress should pass the Healthy Families and the FAMILY Acts to mitigate these disparities and provide paid leave for workers.
Topics
Expand collection of SOGI information
Expand the collection of Sexual Orientation and Gender Identify (SOGI) information in death records and government surveys on youth to create more accurate data on the number of lesbian, gay, bisexual, transgender, or queer (LGBTQ+) youth who die by suicide and who attempt suicide.[1]
An estimated 1.8 million LGBTQ+ youth seriously consider suicide each year, and they are more than four times more likely to attempt suicide than their peers.[1] In 2021, nearly 70 percent of LGBTQ high school youth reported feeling persistently sad and hopeless, compared to only 35 percent of their heterosexual peers.[2]
Accurate data is necessary to address the growing LGBTQ+ youth suicide crisis. Sexual Orientation and Gender Identify (SOGI) data enables those working with LGBTQ+ youth to better understand the health and safety risks among these youth, informs policy change [3] and helps policymakers and leaders understand the full extent of the discrimination the LGBTQ+ community faces.[4] Data informs decisions in public health by tracking better, faster, and more actionable insights.[5] SOGI data will also increase awareness around the LGBTQ+ health crisis, reducing stigma and lowering suicide rates.
The Administration, Congressional leaders, and federal agencies recognize the importance of this data. In June 2022, the White House released Recommendations on the Best Practices for the Collection of SOGI Data on Federal Statistical Surveys, emphasizing the vital role of federal surveys in supporting evidence-based policymaking.[6][7] In June 2023, the LGBTQ+ Data Inclusion Act was reintroduced in both the U.S. House and Senate. The bill would require voluntary questions on sexual orientation, gender identity, and related characteristics in government surveys to help lawmakers and federal agencies address LGBTQ+ issues.[4][8][9][10] In 2022, the bill passed the U.S. House.
Topics
Require foster care mental health screenings
The Department of Health and Human Services (HHS) should require mental health screenings when a child enters foster care and comprehensive assessments when a mental health challenge is identified; improve and invest in the availability and provision of mental health and substance use disorder (MH/SUD) services for youth in foster care; and provide technical assistance for states to cover certain specialized services for foster youth enrolled in Medicaid who have intensive MH/SUD needs with guidance from the Centers for Medicare and Medicaid Services (CMS).[1][2][3]
More than 391,000 children are in foster care, and more than 600,000 children are served by the foster care system annually.[4] Mental health and substance use needs are the largest unmet health need for these children.[5] Nearly 80 percent of children in foster care have significant challenges [6] and are much more likely to have worse mental health than their peers.[7] The long-term effects are substantial - compared to the general adult population, adults previously involved in the foster care system are five times more likely to experience post-traumatic stress disorder and seven times more likely to have a SUD.[6][8]
Annual screenings are critical components of prevention and early intervention of MH/SUDs.[9] Early identification and treatment lead to better outcomes in overall health and may lessen long-term disability.[10] HHS and CMS should guide states in meeting the critical need for children to receive MH/SUD screenings and necessary treatment immediately when entering the foster care system - before, during and after placements - and when emancipating from foster care.[1][3][11] There is also a lack of data about MH/SUD interventions specific to youth in foster care.[12] HHS and CMS should provide technical assistance to states in collecting and reporting data about the children in foster care screened and treated for MH/SUDs.[1][2]
Topics
Require coverage of early interventions for serious mental illness
Congress should pass legislation requiring all public and private health insurance to cover evidence-based early interventions for serious mental illness and should direct the Department of Health and Human Services to create a national strategy to ensure delivery of these interventions.[1]
Serious mental illness (SMI) is a mental, behavioral, or emotional disorder resulting in serious functional impairment, which substantially interferes with or limits one or more major life activities.[2] Approximately 14.1 million adults in the United States (5.5 percent of all U.S. adults) have an SMI.[2] Young adults aged 18 to 25 years have the highest prevalence of SMI. However, a lower percentage of these individuals receive mental health treatment than older adults,[2] emphasizing the importance of early interventions for SMI.
Evidence-based early interventions for SMI, including programs that deliver coordinated clinical and supportive services early in the course of SMI onset, are effective[1] and could help delay or prevent loss of function and allow those with SMI to manage problems before they become disabling.[3] However, many programs and emerging early interventions for SMI are not appropriately covered.[1] The Centers for Medicare and Medicaid Services, which oversees Medicaid, the single largest payer of mental health and substance use disorder services in the country,[3] can play a particularly important role in financing, disseminating, and scaling life-changing interventions.
Topics
Pass the Behavioral Health Crisis Care Centers Act
Congress should pass the Behavioral Health Crisis Care Centers Act, which would provide grant funding for states, cities and counties, and tribal governments to establish, operate, and expand one-stop crisis facilities and wrap-around services.[1][2][3] Additionally, Congress should require the Centers for Medicare and Medicaid Services (CMS) to establish a bundled payment under the Outpatient Prospective Payment System (OPPS) for crisis stabilization services for Medicare beneficiaries in crisis to cover up to 23 hours of crisis stabilization services.[4] CMS should also publish a report examining options for providing Medicare coverage of crisis stabilization services furnished by non-hospital providers that cannot bill Medicare under the OPPS.[4]
Crisis facilities are critical for providing stabilization services, short-term care services, and helping transition individuals with MH/SUD to any needed long-term treatment.[3] Unfortunately, MH/SUD crisis care is inconsistent and inadequate, and crisis centers are underfunded, leaving gaps in stabilization services.[3][5] The Behavioral Health Crisis Care Centers Act would increase funding for the establishment, operation, and expansion of crisis facilities and close gaps in services for individuals in MH/SUD crisis.[1][2][3]
About one in four Medicare beneficiaries has a MH/SUD. While OPPS covers some in-patient and out-patient MH/SUD services, and some medications, there are limits in coverage and reimbursement.[6][7] CMS has proposed OPPS updates for 2024 that would cover intensive outpatient MH/SUD services, which is similar to partial hospitalization services. However, crisis stabilization services are still not covered, including screenings and assessments for a MH/SUD crisis.[8] To address this gap, CMS should develop a bundled payment under OPPS that would cover the full range of stabilization services and report on options for covering crisis care provided by non-hospital providers. In late 2022, a bipartisan group of Senate Finance Committee members supported requiring such a bundled payment and report.[4]
Topics
Ensure access to non-emergency medical transportation
Congress should ensure access to Non-Emergency Medical Transportation (NEMT) benefits so they are available to all individuals enrolled in state Medicaid programs while also expanding the types of transit that may be qualified for coverage.[1][2]
Approximately 3.6 million Americans do not obtain medical care because they lack transportation.[3][4] Inequitable access to transportation perpetuates disparities in access to health care and highlights the importance of transportation as a critical social determinant of health.[1][5] For adults without access to transportation, one in five forgo necessary health care services, including for mental health and substance use disorders (MH/SUD), which can interfere with consistent health care, create cumulative deficits in patient treatment, and negatively affect long-term health outcomes.[1][6][7][8] Individuals who are Black or Latino, have low family incomes, have public health insurance, or have a disability are more likely to skip care because of transportation barriers.[1]
Public transportation expansion improves access to health care, especially for people who live in urban areas; are Black, Hispanic/Latinx, or elderly; or have disabilities or low incomes.[1][2][5] NEMT is a Medicaid benefit that delivers people who lack transportation to necessary but non-emergent medical appointments, which commonly include MH/SUD treatment.[2][9][10] Improved access to NEMT for Medicaid beneficiaries results in cost savings for preventative services and treatment for chronic conditions.[2] While state Medicaid programs are required to provide NEMT benefits, administration and reimbursement varies considerably across states and some states have previously carved out the benefit through waivers.[1][2] Congress should require uniform access to NEMT for all eligible individuals covered by Medicaid.