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

The Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents provides primary care practices with key background information and theory-based, evidence-driven recommendations for themes critical to healthy child development to be used at all preventative care screenings and health supervision visits.[1][3] The Guidelines recommend behavioral, social, and emotional screenings begin at birth[4] to assess infant and early childhood mental health (I-ECMH). I-ECMH encompasses a child’s capacity in three areas – emotions, interpersonal relationships, and familial and cultural environments.[2] Children with adverse childhood experiences, including physical abuse, mental illness, substance use, or other trauma, are at greater risk of developing I-ECMH disorders.[2] Approximately one in six U.S. children aged 2-8 years have a diagnosed mental, behavioral, or developmental disorder.[5][6] For those living below 100 percent of the federal poverty level, more than 20 percent have a mental, behavioral, or developmental disorder.[6] These children are part of the 27 million children under age 18 in the United States covered by Medicaid.[7]

However, neither guidance for I-ECMH screening nor available I-ECMH-trained practitioners is consistently supported within the Medicaid program.[8] Mandating that Medicaid follow the Bright Futures guidelines to screen for and, if indicated, further evaluate a child for I-ECMH disorders would support prevention and treatment for children and their families[2] and ensure that treatment incorporates the unique developmental needs of young children.[9]

U.S. Surgeon General Vivek Murthy’s landmark 2023 report on loneliness and isolation found that older adults’ social isolation increases Medicare spending by an estimated $6.7 billion annually due to increased nursing home and hospital costs.[1] Additionally, social isolation was the greatest risk factor for hypertension among older adults, higher even than diabetes. Social isolation is also related to accelerated cognitive decline and a higher risk of dementia, self-harm, and suicide.[2]

The Elder Justice Reauthorization and Modernization Act of 2023 would appropriate $250 million to address social isolation and loneliness for older adults. Additionally, the act could support community-based interventions and connect at-risk older adults with social and clinical support.[3] By taking steps to address the epidemic of isolation and loneliness among older adults, this legislation would improve older adults’ mental and physical health and overall well-being.

In 2016, the Department of Housing and Urban Development (HUD) issued guidance on the use of criminal records by providers of housing under the federal Fair Housing Act.[1] In 2022, HUD issued an additional memorandum on how criminal background screening policies and practices can violate the Fair Housing Act’s requirements. The memorandum noted that while the U.S. population is about 13 percent Black, Black people account for about 27 percent of all arrests and that Black males have an incarceration rate nearly six times higher than White non-Hispanic males. The incarceration rate of Hispanic/Latino people in state prisons is 1.3 times the rate of White non-Hispanic people. The memorandum expressed concern that background check reports were “often inaccurate, incomplete, or have no relationship to whether someone will be a good tenant.” It also noted that the use of algorithms to screen and reject applicants may contain racial or other prohibited biases.[2] While HUD has explained the requirements of the Fair Housing Act, additional action is needed.

In February 2023, the FTC and CFPB requested stakeholder comments on how the use of criminal and eviction records and algorithms in rental housing impacts individuals, families, and underserved communities.[3] Given that an estimated 44 percent of individuals in jail and 37 percent in prison have a mental health condition and 63 percent and 58 percent, respectively, have a substance use disorder,[4] the widespread and largely unregulated use of criminal and arrest background checks as part of the rental screening process makes it much harder for individuals with these conditions to find housing after they are released. The FTC and CFPB should move forward expeditiously with rulemaking to tackle this long-standing problem.

Approximately 600,000 people are released from prison each year. Within five years, three-quarters will have been rearrested.[1] Housing is essential to reducing recidivism and helping individuals with mental health and substance use disorders (MH/SUDs) sustain their recovery. Securing stable post-release housing is particularly critical for the estimated 44 percent of individuals in jail and 37 percent in prison with a mental health condition and 63 percent and 58 percent, respectively, with an SUD.[2] By passing legislation such as the Returning Home Act, which would provide $100 million for community organizations to establish housing demonstration projects for individuals returning from incarceration and authorize funds for rental assistance and other housing stabilization services, Congress could make progress towards decriminalizing mental illness in America.[3]

Evidence-based home visiting programs provide new parents with health, social, and child-development services that have proven effective in the detection and intervention of prenatal complications, postpartum depression, Adverse Childhood Events (ACEs), and developmental concerns for pregnant parents and young children under five.[1][2] In partnership with the Administration for Children and Families (ACF), the Health Resources and Services Administration’s (HRSA) Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program provides funding to state programs to deliver these services through local agencies; however not all state Medicaid programs cover these visits, and-out-of-pocket costs can range from one to five thousand dollars annually.[3][4] Home visiting programs can improve health equity and provide a head start for all families.[5] However, to do so, they must be offered as a covered benefit for all health plans.[1]

School shootings instill a deep sense of fear in communities, and education systems are under intense pressure to implement policies to address and mitigate the risk of school shootings. Over 95 percent of K–12 schools in the United States participate in active shooter drills. [1]

Active shooter drills range in content but typically require students and school staff to lock down and practice safety measures. They can often include more involved tactics like fighting back and evacuating and can be planned or unaccounted simulations. At least 40 states require active shooter drills.[2] School active shooter drills are associated with increased anxiety, stress, and depression (39-42%).[3] In a report on active shooter incidents, the Everytown for Gun Safety Support Fund, the American Federation of Teachers, and the National Education Association concluded there is almost no research affirming the value of active shooter drills for preventing school shootings or protecting the school community when shootings do occur. [2]

Congress should pass legislation such as the PREP for All Students Act to establish the Council on Emergency Response Protocols to provide evidence-based guidelines for use by states, early child and education settings, local educational agencies, and institutions of higher education in developing and implementing emergency response protocols including gun violence response, natural disaster protocols, and fire drills, that provide for students’ safety, do not do further harm, and are inclusive and accessible. [4]