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

There are numerous federal, state, and local agencies working to improve MH/SUD outcomes in the country. However, these agencies often work in their own lanes, siloed in goals, data, and metrics. Federal agencies overseeing state and local government programs often do not have the ability to access key data and metrics relevant to agency efforts or share across agencies, and state and local programs often do not have the data systems capacity to manage information on their programs. This leads to programs and initiatives that operate in silos, independently of each other, and a wide inability of the government to collect data on mental health and addiction programming outcomes, conduct research, share information, or tailor programs that build on the lessons learned from previous programs and grants. Today’s information and cloud-based technology opens up new opportunities to allow valuable data to be protected and shared across federal agencies. An integrated data systems approach can address these challenges, and improve cross-agency coordination, data collection and research, and program outcomes.

In 2016, the 21st Century Cures Act (Cures Act) effectively made sharing electronic health information an expected norm in health care. The Cures Act took nearly seven years to implement a common general health data format, but there has not been a similar effort to define MH/SUD common data needs.[1] In August 2022, CMS proposed rules to improve Medicaid and Children’s Health Insurance Program (CHIP) quality reporting across states. The proposed rule would make it mandatory for states to annually report on three different MH/SUD measure sets, including core sets for children’s health in Medicaid and CHIP, mental health and addiction measures in adult health in Medicaid, and health home quality measures in Medicaid.[2] CMS should finalize its proposed rule to make it mandatory for states to annually report MH/SUD measures for adults, children, and health homes.

Additionally, all agencies providing MH/SUD funding – including the Substance Abuse and Mental Health Services Administration (SAMHSA), the Health Resources and Services Administration (HRSA), and CMS –should work to create and use a core MH/SUD data model, leveraging previous data modeling efforts undertaken by SAMHSA and CMS as part of the 21st Century Cures Act. These agencies should use one common data collection portal and require all community block grants to include common core data reporting elements in tracking and reporting. To support this effort, HHS should reestablish its HHS Data Council, chaired by the Office of the National Center for Health Information Technology, and extend its responsibility to include data management.

The Centers for Disease Control and Prevention should also update the NVSS in its existing NVSS modernization efforts by adding new MH/SUD statistics records, including national statistics at the city and county level, and provide timely data updated monthly. These standards have not been updated since 2003. Future phases could include progress reporting and dashboard creation. Each NVSS report could be linked to the community-block grants, as well as link services to payers, HRSA, SAMHSA, and state and local health agencies, so that the value of the investment can be tracked.

The MTSS framework is an evidence-based prevention system consisting of three tiers of intensity for instruction, intervention, and support for students needing academic, social, and emotional support. Tier 1 supports are preventive supports and programming for all students and may include screening for additional areas of need. Tier 2 supports are small group, targeted standardized academic interventions or mental health supports using validated intervention programs for students identified as at-risk. Tier 3 supports are intensified and individualized interventions for students not responding to Tier 2 through instruction and supports that are intensified and individualized based on student needs.[1]

States and districts across the country have adopted MTSS as a governing framework for school-based mental health, but there is little consistency in how this framework is defined and implemented across states and districts. This results in programming that is implemented with varying fidelity to best practices. States and districts should be following a consistent set of MTSS-aligned best practices for mental healthcare delivery, but it is difficult to do so without federal guidelines that outline standard definitions and best practices for each tier of the MTSS framework.[2]

The DOE should create clear, standardized definitions of best practices for each tier of the MTSS framework, a certification program that recognizes districts that have implemented these best practices, and collect and publish federal dashboards to report on key mental health performance metrics and MTSS adherence, and build a federal resource library of professional and adult learning content on youth mental health.[2]

To mitigate common confusion over whether Tier 1 supports, which are inherently preventative, fit under “prevention” under Medicaid’s EPSDT coverage mandate for youth (note: the “P” stands for “Prevention”), CMS should clarify that Tier 1’s preventative supports and programming are indeed within the scope of “prevention” under EPSDT.

Additionally, the DOE should establish a permanent position for school-based Medicaid services at the DOE that can support state education agencies in implementation. Absent this action, Congress should require DOE to do so.

Congress should double OAA funding of supportive services (Title III B), as well as increase funding for Native American Aging Programs (Title VI) and the research, demonstration, and evaluation center for the Aging Network (Title II). According to the U.S. Census, by 2035, older adults will outnumber children in the United States.[1] This increase in the older adult population will also increase the need for funding and services for aging. The current federal funding for older adults will not keep up with the growing older population.[2] OAA funding of supportive services is particularly important to prevent and address mental health and substance use challenges among older adults. Social isolation among older adults increases hospital and nursing facility spending, leading to an estimated $6.7 billion in additional annual costs to Medicare.[3] Adults over the age of 75 have among the highest suicide rates of any group.[4]

President Biden’s 2024 budget proposed a historic $3 billion for the Administration for Community Living.[5] This increase will be vital to the most urgent priorities: services, prevention, and workforce.

The Family Educational Rights and Privacy Act (FERPA) (20 U.S.C. § 1232g; 34 CFR Part 99) protects the privacy of student education records and applies to all schools that receive funding from the DOE.[1]

The updated May 2023 CMS guide for delivering Medicaid school-based services introduces an extremely challenging FERPA requirement that threatens to negatively impact schools’ ability to bill Medicaid.[2] As a part of the cost settlement model, local education agencies (LEAs) are reimbursed, in part, based on the percentage of Medicaid-enrolled students at the LEA, also referred to as the Medicaid Eligibility Ratio (MER). The CMS guidance states: “The MER is a ratio of Medicaid-enrolled students (per FERPA who have parental consent to release information to Medicaid) at each LEA (or other claiming entity) divided by the total number of enrolled students.” The addition of FERPA as a requirement will significantly reduce the MER for most districts, resulting in a major decrease in school funding.[2]

However, the FERPA statute itself does not require consent to be included in the MER. Current FERPA regulations allow states a pathway where FERPA consent is not required for the MER. The current guide, as written, would not allow states to follow this pathway.[2][3]

CMS should clarify in writing - through the TA center or other means -  that the requirement to have the free care numerator include only those students who are both Medicaid enrolled and have FERPA consent is not meant to supersede the allowable FERPA exceptions. The DOE should also provide State Education Agencies guidance that audits of the school Medicaid program conducted by the Office of the Inspector General (OIG) fall under the audit exception to FERPA. The DOE should clarify that for the purposes of audits, school Medicaid is considered an education program and LEAs are free to release information to auditors.[3]

Absent this action, Congress should ​update the FERPA statute to allow for school Medicaid exceptions that clearly allow: (1) LEAs to disclose all necessary information to the state Medicaid agency for the purposes of determining Medicaid enrollment; (2) LEAs to provide all necessary information to OIG in the event of an audit – including individual education plans (IEPs); and (3) LEAs to submit necessary billing/claiming information to the Medicaid agency without FERPA consent. The free and reduced lunch exceptions to FERPA set a precedent for this approach. [3]

Firearms are a leading cause of injury and death among children in the United States. According to the Centers for Disease Control and Prevention (CDC), 2,281 children under the age of 18 died from firearms in 2020, with 721 of these deaths classified as suicide and 121 classified as unintentional. About 43 percent of child suicides involve the use of a firearm.[1]

One of the main risk factors for firearm-related injury and death among children is the accessibility of firearms in their homes. The 2021 National Firearms Survey found that guns are stored unlocked in almost half of households with both firearms and children, and that these unlocked guns are stored loaded in about 15 percent of these households.[2]

A majority of states, including states from across the political spectrum, have enacted child-access or secure storage laws.[3] To prevent children from firearm injury and death, Congress should pass legislation to establish federal statutory requirements to regulate the storage of firearms on residential premises such as the Safe Guns, Safe Kids Act, which would require firearms on residential premises to be safely and securely stored if a minor would reasonably have access, and would hold the owner of the firearm liable if a minor were to obtain and use the firearm in an unlawful way.[4]

Lack of employment opportunities for youth in low-income and other marginalized communities contributes to negative outcomes such as lower adult earnings and increased risk of criminal legal system involvement and early mortality. Among teenagers 16 to 19 years old, the unemployment rates were highest for Black youth, Hispanic/Latino youth, and Asian youth.[1] Similarly, American Indian/Alaska Native youth were less likely to be employed than other youth.[2]

Youth employment programs provide employment for youth who work at selected employers during the summer, and often include job readiness training and other supports. These programs have been shown to reduce youth violence by providing opportunities to learn interpersonal skills from positive role models and mentors and to improve confidence and self-control through work experience. Researchers found that summer employment offered to youth through the One Summer Plus (OSP) in Chicago resulted in 43 percent fewer youth violent crime arrests.[3] Another study of a youth employment program in New York City found increased earnings for youth and decreased incarceration and mortality.[4]

While youth employment programs drive positive outcomes, they unfortunately often lack the resources to address the oftentimes significant mental health needs of the youth they serve. A recent survey of youth programs found that 90 percent or more reported observing anxiety or depression among youth, and 60 percent of programs believed more than half of their youth needed mental health services. Yet 64 percent did not have a process for screening or monitoring youth’s mental health needs, and 89 percent were unable to provide quality mental health training to staff.[5] Youth employment programs face challenges related to limited and unstable funding, insufficient capacity and quality (including related to helping address youth’s mental health needs), and lack of coordination and evaluation.

Congress has contributed to these challenges by allowing WIOA, the primary federal funding source for youth employment, to expire in fiscal year 2020. As a result, WIOA programs have relied on short-term extensions through annual appropriations bills. Congress should reauthorize WIOA and increase investment levels, particularly given the unprecedented mental health challenges youth are facing in the aftermath of the COVID-19 pandemic.[6] Furthermore, Congress should dedicate funding to increase the availability of mental health services and supports among youth employment programs.[5]