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

Research shows that income insecurity among children and adults can significantly contribute to mental health disorders.[3] The Earned Income Tax Credit (EITC) provides qualified low to moderate-income workers and families with a tax break that varies with specific criteria, like income, marital status, number of children or dependents, and disability.[4] Pre-COVID-19 pandemic data demonstrate that the EITC lifts people above the poverty line—more than 5.5 million people, including nearly 3 million children.[5] In the 2021 tax year, 31 million workers and families received about $64 billion in EITC thanks to expanded eligibility criteria passed by Congress as part of the American Rescue Plan Act.[6]

The Worker Relief and Credit Reform Act (WRCR Act) would build upon the ARPA expansions and change the EITC criteria to better reflect the current economic conditions of students, workers, caregivers, and the elderly.[1] Proposed reforms include recognizing caregiving and higher education as work, expanding the eligibility age range, and providing taxpayers with assistance, safeguards, and educational and outreach programs.[1] Congress should pass the WRCR Act to lift more people out of poverty, improving the mental health individuals and families.

Previously incarcerated individuals receive inadequate assistance and resources as they re-enter their communities, which puts them at increased risk for being rearrested.[1] Many states ban incarcerated individuals from eligibility for public assistance programs that provide access to food or affordable housing.[1][3] Without access to these programs, recidivism and substance use is higher.[1] Congress should prohibit states from restricting access to previously incarcerated individuals.

Substance use is a leading cause of death in pregnant women and contributes to birth-related complications, including preterm labor. Pregnant people with SUDs often lack access to prenatal and postpartum health care. Additionally, many substance use treatment programs do not accept pregnant clients and/or Medicaid beneficiaries, while maternity care providers often do not have experience with SUDs. These gaps lead to a lack of  evidence-based SUD care for pregnant and postpartum individuals.

The MOM model addresses gaps in care for pregnant and postpartum Medicaid beneficiaries with opioid use disorder. The MOM model provides coordinated and integrated physical health care, behavioral healthcare, and wrap-around services. State Medicaid agencies implement the model with community providers, including hospitals and Medicaid managed care organizations. The MOM model includes services such as well-woman care, medications for opioid use disorder, prenatal and postpartum care, labor and delivery, and neonatal/ infant care.

CMS should expand the coordinated, wraparound care provided in the MOM model to pregnant Medicaid beneficiaries who have other SUDs, such as alcohol use disorder and stimulant use disorder, for which coordinated care is beneficial.[1]

Recovery support services (RSS) are non-clinical services utilized by individuals recovering from a mental health or substance use disorder (MH/SUD).[1][2] These services provide system-level support to reduce barriers to education, employment, and housing and connect individuals and their families with additional support in the community.[2] There are several challenges in providing RSS to individuals with MH/SUD, including cost and lack of collaboration between support programs.[3] The Recovery-Oriented Systems of Care (ROSC) framework highlights the importance of RSS and describes how these services should be implemented before, during, and after MH/SUD treatment.[4] The Department of Health and Human Services (HHS) should implement guidelines for RSS using this framework as a model.[1]

Additionally, Congress should act to improve reimbursement of RSS.[1]  For example, the Maximizing Opioid Recovery Emergency (MORE) Savings Act, as introduced in the 118th Congress, would require the Center for Medicare and Medicaid Innovation (CMMI) to test a model providing RSS under Medicare without cost-sharing, allow Medicaid to cover RSS as part of medication-assisted treatment (MAT), and require private health insurance coverage of MAT-associated RSS at no cost.[5][6]

SBIRT delivers early intervention and treatment services through universal screenings that are comprehensive and integrated into primary care for persons at risk for or with substance use disorders.[2] While initially used in clinical settings, SBIRT services are increasingly offered in high schools and universities.[1] For example, trained middle school and high school staff in Massachusetts reinforce prevention, screen for substance use, provide counseling, and make referrals to students beginning in seventh grade, with the intent to motivate students to seek treatment if they are engaged in substance use.[1] Successful college programming focuses on student substance use assessment, prevention, treatment, and recovery, including SBIRT and Collegiate Recovery Programs.[3] Informed by these models, the DOE should collaborate with states to implement screening, prevention, and treatment programs for middle school, high school, and college students.[1]

The CTC expansion resulted in an unprecedented decline in child poverty, which reached a record low of 5.2 percent in 2021. More than 2 million children were lifted above the poverty line due to the increase in the credit and disparities in child poverty rates decreased for children of all races and ethnicities.[2] Several ARPA changes were particularly important, including increasing the amount of the credit (to $3,600 per child under age 6 and to $3,000 per child aged 6-17, with 17 years olds being included for the first time), making the credit fully refundable so that low-income families could fully benefit, and allowing the Treasury Department to issue 50 percent of the criteria to families as advance monthly payments. Making the credit fully refundable was particularly critical for Black and Latino children, as well as children in rural areas, because previously large percentages of these families had not earned enough to take full advantage of the credit. With the changes, 27 million additional children from the poorest families received the full CTC.[3]

With a significant body of research demonstrating the link between financial stability and mental health[4][5], not surprisingly the CTC expansion improved mental health. One study found that the expanded CTC was associated with reduced anxiety symptoms for parents receiving the CTC, with Black and Latino families particularly benefitting. The study concluded that “[t]he expanded CTC has the potential to improve the environments in which vulnerable low-income children grow up.”  Congress significantly harmed youth mental health by allowing the expanded CTC to expire. It should restore it without delay.