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

The onset of a mental health or substance use disorder (MH/SUD) occurs before age 14 for one-third of individuals and before age 18 for nearly half.[2] One in five students experience a significant mental health issue during their school years, highlighting the importance of educators understanding mental health conditions.[3] A number of pieces of legislation have been introduced to address the integration of evidence-based, trauma-informed, and culturally competent social, emotional, and cognitive skills programs in elementary and secondary schools and to train and educator training in best practices in responding to the mental health and behavioral needs of students.[4][5][6] Congress should fund educator training and professional development on mental health conditions in students by amending the Elementary and Secondary Education Act.[1]

The DREAM Act, first introduced in 2021, would provide legal protections to undocumented immigrants who came to the United States as children, commonly referred to as “Dreamers”.[3] These individuals are at an increased risk for mental health issues as they face many stressors related to working status, societal exclusion, and fear of deportation.[4] In 2012, former President Obama issued an executive order authorizing the Deferred Action for Childhood Arrivals (DACA) program, which provides temporary protection from deportation and allows individuals to get a time-limited work permit.[5] Unfortunately, DACA recipients and the broader population of Dreamers continue to experience mental health needs, though the needs of the community are not fully known. And when individuals do seek mental health treatment, they end up not finding culturally competent providers who understand their situation.[6] The DREAM Act of 2023 would alleviate some of the stressors of Dreamers and DACA recipients, thereby also improving their mental health.[1][2]

Unfortunately, high turnover and low wages have led to long-term staffing shortages among the direct care workforce, which includes home health and personal care aids, as well as certified nursing assistants who assist older adults and individuals with disabilities and other chronic conditions, including mental health and substance use disorders (MH/SUDs).[1] The direct care workforce is essential to help individuals and their families provide needed care and supports. To strengthen the direct care workforce, investments are needed in pay and benefits, education and training, and career advancement opportunities. Legislation such as the Supporting Our Direct Care Workforce and Families Caregivers Act would be a significant step in the right direction to addressing these challenges.[2]

Congress should also work to cover family caregiver supports in Medicare to allow family members or friends to receive modest assistance to allow them to care for individuals, particularly those who might otherwise be at risk of entering restrictive and expensive institutional settings. The Medicare Payment Advisory Commission (MedPAC), a nonpartisan, independent agency that advises Congress, previously reported that individuals who received more frequent care from informal caregivers, including family and friends, had fewer high-cost incidents that Medicare needed to cover.[3] While Medicaid allows states to reimburse for family caregiving through a range of different mechanisms, various agencies within the Department of Health and Human Services (HHS) could help improve family caregiver supports across states. Specifically, a recent report from the National Academy for State Health Policy recommended that HHS agencies identify and disseminate information about states’ family caregiver strategies; collect data relating to family caregivers who assist Medicaid beneficiaries; promote innovative state strategies; and provide technical assistance to states.[4]

Suicide is a leading cause of death in the United States, accounting for more than 48,000 deaths in 2021.[3] Suicide affects all ages, particularly youth ages 10-14 and young adults ages 20-34. Some groups, including veterans, people living in rural areas, and young people who identify as lesbian, gay, bisexual, or transgender (LGBTQ+), have higher rates of suicide.[4]

The Centers for Disease Control and Prevention’s (CDC) Comprehensive Suicide Prevention Program (CSP) funds programs to implement and evaluate a public health approach to suicide prevention. This includes convening and connecting multi-sector partners; using data to understand contributors to and track trends in suicide and suicidal behavior; identifying gaps in existing strategies; and sharing data and outcomes with other partners.[5] However, the CSP currently funds programs in only seventeen states.[1] Expanding the CSP to all fifty states, the District of Columbia and eighteen tribal and territorial jurisdictions will support the CDC’s goal of reducing suicide by 20 percent by 2025.[1]

Every Veteran of the U.S. military, especially those with visible and invisible wounds of war, should have access to high-quality services and supports, including for MH/SUDs. Congress should work to close gaps in services, including for Veterans who live in U.S. Territories (Puerto Rico, the U.S. Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa) and U.S.-affiliated Pacific Islands that are freely-associated states (the Marshall Islands, Micronesia, and Palau). Individuals from U.S. territories are U.S. citizens, while individuals from freely-associated states are eligible to come to the U.S. as nonimmigrants to work and live indefinitely.[1] The U.S. is currently investing billions of dollars in military installations on these Pacific Islands as part of the U.S. geostrategic pivot to Asia.[2]

Nearly 3 percent of all U.S. Veterans live in U.S. territories, and Veterans make up nearly 8 percent of Guam’s population and more than 5 percent in American Samoa, the Northern Mariana Islands, and the U.S. Virgin Islands. Puerto Rico has more than 80,000 Veterans.[3] Given the high proportion of Veterans, Congress must do more to ensure the availability of services across U.S. territories. Currently, the nearest Veterans Affairs Medical Center to Guam is 4,000 miles away in Hawaii.[2]

While Veterans in freely-associated states are entitled to care, Congress should pass the Care for Compact of Free Association (COFA) Veterans Act to allow the Department of Veterans Affairs (VA) to provide services in the Marshall Islands, Micronesia, and Palau and to compensate Veterans for the cost of travel to receive needed health care services.[4] In June 2023, the U.S. Secretary of State Anthony J. Blinken and Interior Secretary Deb Haaland requested that Congress make these essential changes to help these U.S. Veterans access services.[5]

More broadly, Congress should work with the VA to streamline the process of applying for VA benefits, which is notoriously complex and frequently requires help to navigate.[6] One issue is that the Veterans Health Administration (VHA) has a wide variety of different, complicated authorities that limit which Veterans are eligible to receive different benefits. Congress should work with the VHA to streamline these authorities and simplify eligibility requirements to help reduce the bureaucracy, thereby improving the efficiency of service delivery and increasing Veterans’ access to MH/SUD services and supports.

Neonatal abstinence syndrome (NAS) is a group of conditions that can occur when newborns withdraw from certain substances, including opioids, that they were exposed to before birth.[2][3] Approximately 7 percent of women self-report using prescription opioid pain relievers while pregnant; of those, one in five report misuse of prescription opioids.[4][5] Six newborns are diagnosed with NAS for every 1,000 newborn hospital stays, equivalent to one baby diagnosed with NAS every 24 minutes or more than 59 newborns diagnosed every day.[4][6][7] The number of babies born with NAS increased by 117 percent nationally from 2009 to 2020.[6]

Recent studies found that newborns diagnosed with NAS who stay with their mothers after delivery, (i.e., “room-in,”) have better outcomes than those who go to the neonatal intensive care unit (NICU).[8][9][10] Babies with NAS who room-in with their mothers are far less likely to need pharmacological interventions and leave the hospital days sooner than those who remain in the NICU.[8][9][10] Rooming-in and other non-pharmacologic interventions, such as creating a low-stimulation environment, swaddling, and feeding on demand, should be the evidence-based standard of care for newborns with NAS.[1][8][9][10][11][12]

Hospitals may not have the infrastructure to keep mothers and babies in the same room.[13] Therefore, incentives are needed – including tax credits and grant programs – to fund new and existing efforts within the NICU so mothers and infants with NAS remain together immediately following birth.[1]