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

Peer support specialists are formally trained providers who offer peer support, using their lived experience with a mental health or substance use disorder (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. More than half of U.S. counties lack any MH/SUD professionals. 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]

While the Veterans Administration and a majority of state Medicaid programs have recognized the value of peer support specialists and cover these services, Medicare lags behind.[3] This is particularly problematic given that older adults are the least likely to receive needed mental health services; only 80 percent of older adults needing care receive it.[1] Congress took initial steps in 2022 when it passed legislation allowing Medicare billing of peer support services as part of mobile crisis interventions and integrated care.[4] However, many settings are still not allowed to bill peer support services, including important settings such as Community Mental Health Centers, Rural Health Centers, Federally Qualified Health Centers, and Community-Based Organizations. Congress should pass legislation ensuring full coverage of peer support services in Medicare.

MA provides healthcare coverage through private managed care plans for hospital and physician services as an alternative to traditional Medicare FFS. Enrollment in MA has continued to grow over the years and now accounts for more than 50 percent of Medicare enrollees. As enrollment continues to increase in the MA program, it’s critical for policymakers and regulators to fully understand any key differences in the ability to access care between MA and traditional Medicare FFS, including the ability to access care for MH/SUDs and the quality of the care that is delivered to MH/SUD patients.

CMS’ Star ratings are measures to help Medicare beneficiaries assess the performance of Medicare Advantage plans. The highest-performing plans can receive five stars. The rankings are based on a set of weighted measures, including services covered, administrative efficacy and service, and quality of care provided.[2] Not included in these measures is access to MH/SUD services, the quality of care received, or the degree to which MH/SUD care is integrated with physical health care.[1] Roughly a quarter of MA beneficiaries are enrolled in plans with access barriers, such as referral requirements, indicating a need for better plan reporting on MH/SUD treatment access and quality.[3] With about 20 percent of adults over 65 reporting symptoms of anxiety or depression, tools are needed to help beneficiaries pick a MA plan that best fits their care needs.[3] CMS should update its Star Ratings system to include measures that evaluate and track plans’ MH/SUD service accessibility and integration with physical healthcare.[1]

Voting is a fundamental right. Yet, a disproportionate number of incarcerated individuals within state prison systems experience mental health and substance use disorders (MH/SUD). According to the U.S. Department of Justice’s Bureau of Justice Statistics, an estimated 43 percent of state prisoners had a history of mental health conditions (with many more undiagnosed).[1] And the National Institute on Drug Abuse has noted that approximately 65 percent of prisoners in the U.S. have a SUD.[2]

Therefore, state restrictions that prevent voting in federal elections after release disproportionately affect individuals with mental health and substance use disorders (MH/SUD).[1][2] Twenty-six states deny individuals with past criminal convictions the right to vote in federal elections. The Democracy Restoration Act would grant formerly incarcerated individuals the right to vote in federal elections and notify individuals with past criminal convictions about their right to do so. Notifications to these individuals occur during sentencing and upon release from a correctional facility.[3][4] States that continue to deny individuals with past criminal convictions thereby discriminate against individuals with MH/SUD.

Congress should pass the Democracy Restoration Act to dismantle barriers against formerly incarcerated individuals  who disproportionately experience MH/SUD. These millions of Americans with MH/SUDs should not be disenfranchised in federal elections due to discriminatory state laws.[5]

Medicaid beneficiaries are disproportionately more likely to experience a MH/SUD than those with private insurance.[2] However, Medicaid beneficiaries access MH/SUD services at lower rates than those with other insurance types.[3] One reason for the disparate access to care may be inadequate reimbursement within state Medicaid programs that disincentivizes providers to accept Medicaid patients.[4] Research shows Medicaid reimbursement rates for MH/SUD remain extraordinarily low, with some providers not having seen increases in rates in 30 years, causing experienced providers to be less likely to accept it and compounding an existing shortage of providers.[4][5] To sufficiently understand this problem and how to address it, Congress should direct the GAO to conduct a study examining Medicaid payment rates for both MH/SUD and physical health services across a sample of states to determine whether MH/SUD services are being reimbursed adequately. In late 2022, a bipartisan group of Senate Finance Committee members supported requiring such a report.[1]

Clubhouses are operated by members and staff and provide a range of services and supports, including primary and psychiatric services, care management, home and community-based services, and employment and education supports. This cost-effective approach helps members reclaim their agency and dignity, while improving outcomes and reducing hospitalizations and costs.[1][2] The clubhouse model has existed for more than 65 years, and a meta-analysis of the clubhouse model found evidence that clubhouses are an important component of rehabilitative services for individuals with serious mental illness.[3] Clubhouse International, an international network of clubhouses, has quality standards and offers accreditation, which 80 percent of clubhouses have achieved.[4] Clubhouses have been shown to reduce hospitalization, incarceration, and costs.[5]

Digital tools such as software-driven applications, wearable devices, as well as detective or biomarker-based interventions can be leveraged to identify needs, assess care, and deploy substance use disorder (SUD) treatments.[1][2][3] An example of such a technology are “devices that transmit findings from smartphones directly into the medical record.”[1]

No independent regulatory agency, such as the Food and Drug Administration (FDA), is charged with consistently examining all mental health and substance use technology or applications. While the FDA may review certain apps (e.g., those that may require a prescription or function as a medical device), the agency uses its enforcement discretion with respect to many other mental health and substance use applications. The Federal Trade Commission (FTC) can also investigate potential false claims that an app developer may make.

While Congress should designate a regulatory body to oversee these emerging technologies, patients and providers would benefit from foundational research on how best to evaluate behavior modification apps to ensure they are effective. This information would support the development of a new regulatory framework for this technology, including how the FDA currently may review mobile health applications for the treatment of mental health and substance use disorders.

Once a technology or product is deemed safe and effective, it is critical for payers, including Medicare and Medicaid, to ensure the timely creation of reimbursement codes so that consumers can access emerging technology that helps meet their needs.[2]