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

Existing law allows employers to pay individuals with disabilities, including mental health and substance use disorders (MH/SUDs), below minimum wage.[3] This practice is commonly referred to as “subminimum wage”. The majority of subminimum wage workers have intellectual, developmental, mental health, or other disabilities and are paid less than $3.50 an hour.[3] Supported employment programs, which address MH/SUD and employment needs concurrently, help individuals with MH/SUDs find competitive employment, work more hours, and earn higher wages.[4] Research shows that 70 percent of adults with MH/SUDs would like to work and the majority would be successful with supported employment programs. However, only 2 percent receive any form of supported employment.[4]

The TCIEA would limit the ability to offer subminimum wages to individuals with disabilities.[1] The legislation would also direct the Department of Labor to award grants to assist states in transforming business and program models that support individuals with disabilities and provide technical assistance to employers in offering competitive employment and wages for disabled individuals.[1]

Individuals with MH/SUDs deserve opportunities for competitive wages and sustained employment through supported employment programs. Congress should help meet these needs by prohibiting subminimum wage for individuals with MH/SUDs and funding evidence-based supported employment programs.[2]

Suicide rates for Black youth are increasing faster than any other racial/ethnic group.[1][3][5][6][7][8] Additionally, Black adolescents are significantly less likely to receive care for depression—a major risk factor for suicide—because pervasive structural inequities around the social determinants of health and stigma and mistrust of healthcare providers create barriers to treatment.[1][5][9][10][11][12]

Little research exists around recommendations for universal screening for suicide risk in adolescents,[1][3][4] and much less specific to Black youth.[1][2][3][4][6][8][11] Yet, limited funding is dedicated to investigate evidence-based interventions relating to mental health and suicide risk or study risk factors, protective factors, mental health utilization and engagement, as they pertain to Black youth.[1] Demonstration projects would provide opportunities to test, assess, and advance best or promising practices in youth suicide interventions, guided by expert researchers and clinicians,[1] and can occur in schools, through government/public-private partnerships, and in collaboration with faith-based organizations.[3][6][10][12] Congress should fund research, including demonstration projects, to address suicide risk and intervention for Black youth and other under-researched populations.[1][6][9]

The power sector is the largest stationary source of greenhouse gases (GHGs), emitting 25 percent of U.S. emissions that are mostly from fossil fuel combustion.[1] Standardizing GHGs emissions and limiting the use of fossil fuels in power plants is a step in protecting public health and reducing harmful pollutants.[1] The EPA estimates that its proposals would avoid approximately 1,300 premature deaths; 800 hospital and emergency room visits; 2,000 cases of asthma onset; 300,000 cases of asthma symptoms; 38,000 school absence days; and 66,000 lost work days.[1] The EPA’s proposed standards would provide an estimated $85 billion in climate and public health benefits over the next two decades,[1] an annual net benefit of approximately $6 billion.[2]

For more than a decade, the EPA has acknowledged that GHG emissions negatively impact public health and welfare.[3] Evidence shows that climate stressors, like GHG emissions, affect mental health, resulting in what is referred to as “climate anxiety.”[4] Factors like geography, pre-existing conditions, socioeconomic and demographic inequalities may increase the likelihood of climate change impacting mental health.[5] Extreme weather, including increases in wildfires and wildfire smoke, heat waves, hurricanes, flooding, and other climate-related disasters, negatively affects mental health. Nearly 70 percent of U.S. adults have reported anxiety about climate change, and increased temperatures have been shown to increase mental health emergency departments visits and even suicide attempts. Air pollution has also been directly tied to increased risk of mental health disorders.[6] By addressing the fossil fuel-fired power plants’ impact on the environment, the EPA’s proposed standards will directly benefit those more likely to experience mental health conditions.

People with mental health and substance use disorders (MH/SUDs) are disproportionately represented in the criminal legal system—an estimated 44 percent of those in jail and 37 percent of those in prison have a mental health condition (compared to 20 percent of the general population). Furthermore, 63 percent of individuals in jail and 58 percent in prison have an SUD.[2]

Food insecurity, just one barrier formerly incarcerated individuals face upon reentry, is significantly and positively associated with psychological distress.[3] Research has found that formerly incarcerated individuals, and the children of currently incarcerated individuals, are twice as likely to experience food insecurity.[4] Federal law[5] imposed a lifetime ban on Supplemental Nutrition Assistance Program (SNAP) and Temporary Assistance for Needy Families (TANF) benefits for individuals with a previous drug felony conviction, though states have the flexibility to remove or modify the ban.[6] While most states have done so for at least one of the programs, some states still restrict or completely ban food assistance under SNAP, cash assistance through TANF, or both for individuals with a drug-related felony conviction.[6][7] Research suggests that SNAP participation reduces psychological distress, including decreasing the association between food insecurity and depression.[3]

Passing legislation that prohibits states from enforcing restrictions or bans on federal food assistance programs to formerly incarcerated individuals would decrease food insecurity for those individuals and their families, reducing one barrier to reentry, and decreasing an important risk factor for mental health and substance use.

Across multiple generations, communities of color and low-income communities have been negatively impacted by discriminatory transportation public policy decisions.[2][3] For example, decisions made over decades about the placement of highways  contributed “to the residential concentration of race and poverty and created physical, economic, and psychological barriers” as the construction displaced primarily Black households, churches, schools, and businesses.[4] The Bipartisan Reconnecting Communities Act intends to reconnect and revitalize neighborhoods divided by the construction of the Interstate Highway System, empowering communities to reverse the legacy of the construction’s harm.[5] The Biden Administration’s American Jobs Plan included $20 billion for a similar program to “reconnect neighborhoods cut off by historic investments and ensure new projects increase opportunity, advance racial equity and environmental justice, and promote affordable access.”[6]

Centuries of racism, including the construction of the Interstate Highway System, negatively impact all aspects of the Social Determinants of Health[7] (e.g., safe housing and transportation, economic stability, access to quality education, healthcare, and food, and clean air and water)[8]), all of which influence community mental health. Numerous studies have tied air pollution (including small particulate matter, nitrogen oxide and nitrogen dioxide – which are associated with vehicle exhaust) to higher levels of stress and increased risk of depression, schizophrenia, bipolar disorder, personality disorder, and even suicide.[9]

Passing the Reconnecting Communities Act and supporting similar efforts is the first of many steps necessary to reconnect and revitalize communities through infrastructure investments.

The United States is facing a severe housing crisis, especially in high-cost, high-demand areas where the supply of housing has not kept up with population and job growth. According to a report by the National Low Income Housing Coalition, there is a shortage of 7.3 million affordable and available rental homes for extremely low-income renters nationwide.[1] The lack of affordable housing negatively impacts the economy, the environment, and the well-being of millions of Americans. One way to address this crisis is to increase the production of housing near transit, which can provide multiple benefits, such as reducing traffic congestion, greenhouse gas emissions, and transportation costs, as well as improving access to jobs, services, and opportunities.[2]

However, many local governments have imposed restrictive zoning and land-use regulations that limit the availability of housing and drive up housing costs, wasting critical resources.[3][4] These local barriers increase homelessness and the number of unsheltered individuals living on the streets, including a disproportionate number of individuals with mental health and substance use disorders (MH/SUDs), leading to worsening health outcomes and criminal legal system involvement. A recent landmark study by the Benioff Homelessness and Housing Initiative at the University of California San Francisco showed that high housing costs and low incomes were the primary factors driving homelessness. Having one or more MH/SUD prior to homelessness was a key contributing risk factor, and individuals’ mental health and substance use worsened after they became homeless, yet they had little access to treatment.[5]

Congress, DOT, and HUD should tie federal transportation and housing funding to housing production to incentivize local governments to reform exclusionary zoning and land-use policies that drive up housing costs, increase homelessness, and disproportionately impact individuals with MH/SUDs who are at significantly higher risk for homelessness, which can cause further deterioration of the conditions.