Reducing the severity of mental health and substance use disorders through community prevention, early identification and intervention is a critical component in changing the trajectory of mental illness and substance use. Because 50% of mental illness begins by age 14 and 75% by the time the brain finishes developing in the mid-20s, early identification and intervention efforts must be focused on children, families, and schools, with special emphasis on the community-based risk factors that negatively impact parents and children. In addition, addressing the underlying vital conditions of a community–social and community factors like affordable housing, reliable transportation, and employment go a long way in setting a positive path for mental health and well-being.

POLICY GOAL

Federal legislation: Require and fund the development and promotion of national comprehensive, evidence-based mental health curriculum guidelines for K-12

State legislation: Require local school districts to adopt comprehensive national K-12 mental health curriculum guidelines

CONTEXT

Comprehensive mental health education in K-12 that is informed by science enables students to be empowered with knowledge on how to take care of the mental health of themselves and others, and know when and how to ask for help.

ALLIES AND OPPORTUNITIES

Health care professional organizations, mental health advocacy organizations, psychologists/mental health professionals, teachers/educators, faith groups

KEY BARRIERS 

Arguments about implementation, educators, parents’ rights groups, schools/academia

CAPACITY NEEDS 

• Branding and messaging
• Education system strategist
• Expert lobbyists
• Financing
• Youth and celebrity/influencer activism
• Equity experts

POLICY GOAL

Federal legislation: Legislation and budget provisions to implement a program that trains youth to provide non-clinical mental health support in their chosen communities and to increase peer-to-peer support for 16-25 year old’s (suggested naming legislation the Youth Peer Support Empowerment Act)

CONTEXT

Youth peer support services can provide valuable non-clinical, recovery-oriented support for youth experiencing mental health challenges, yet are not typically available in the current mental health system.

ALLIES AND OPPORTUNITIES

AmeriCorps, businesses, educators, economic opportunities, peer support in BIPOC, LGBTQ+, and low-income youth communities, open source data to measure impacts, reducing workforce shortages and healthcare costs, workforce guilds, youth

KEY BARRIERS 

Liability and concerns about being sued (concern re youth capacity to handle serious issues), scope of work tensions between clinical and non-clinical staff, support structures for this program that are flexible, but not “squishy”

CAPACITY NEEDS 

• Assistance with projecting costs of project and assessment of feasibility
• Identifying funding sources
• Legal support for liability issues
• Representation of youth at the table to develop this program and shape legislation
• Research and data for comparable models to support arguments for creation of this program (Empower Lab)

Crises–from relapses to severe symptoms of paranoia or delusions to suicidal thinking to overdose–contribute to tragic outcomes. Crisis response and suicide/overdose prevention are indispensable elements in helping people stabilize and get on a path of recovery. There is an explicit focus on removing people from prisons who don’t belong and focusing on primary health (rather than public safety) to respond to crisis.

POLICY GOAL

State legislation: Establish and finance regional task forces charged with creating a plan of how to integrate local/state/federal systems into an integrated crisis continuum of care

CONTEXT

Existing emergency and mental health systems and financing are not well-integrated and local/regional collaboration is needed in order to develop effective, responsive, and sustainably funded crisis systems.

ALLIES AND OPPORTUNITIES

First responders, new funding streams, peer/lived experience voices, people who are able to speak to resources and accessibility of care within their localities, repository of best practices, mobile response to specifically support young people (ages 16-25)

KEY BARRIERS 

Changing the system that exists now, coming up with a one-size-fits all approach for all municipalities, getting people with lived experience to work on this, overcoming inherent distrust of the system, overcoming the stigma of talking about or addressing mental health, those who need the services may not yet be ready to enter the system

CAPACITY NEEDS 

• Build a broad coalition intentionally and meaningfully
• Expanding the mental health workforce in rural areas
• Issue organizing
• Technical assistance
• Training for first responders (knowing what their role is and where the handoff to mental health professionals happens)

POLICY GOAL

Federal legislation: Legislation, with appropriations, to promote mental health crisis response in schools and model school crisis policies

Federal regulation: Create guidelines/recommendations for schools to create healthier virtual learning environments for students

NOTE

The two policy goals noted above were not fully fleshed out due to time constraints. We urge interested activists to build on these concepts to advance crisis response, model school crisis policies, and to create healthier virtual learning environments.

People with mental health and substance use conditions also experience poor rates of access to care and typically poor health and life outcomes. For people of color and other marginalized communities, access to care and outcomes are generally worse. Lack of representation of people of color in the workforce and access to culturally and linguistically competent care further contribute to disparities. Eliminating disparities, particularly through addressing social determinants of health and modifying law enforcement and justice-driven responses to MH/SUD needs, is a cornerstone of a transformed system.

POLICY GOAL

Federal regulation: HHS adopts equity metrics, goals, and standards for government-funded health plans and mental health delivery systems (SMART measures?)

CONTEXT

Currently, there are no standard measures for equity. Developing standardized metrics for equity and uniformly assessing health plans and care delivery systems will help identify both areas of progress, areas needing intervention, and create a culture of accountability for addressing inequities

ALLIES AND OPPORTUNITIES

The Aakoma Project, Active Minds, AFSP, Biden Administration (friendly regulatory environment), Black and brown community partners (including faith leaders), cross-cutting policy partnerships, Historically Black Colleges and Universities (HBCUs), Inseparable, legislators with lived experience, MTV, NAMI, Active Minds, etc.), states (like CA) that can serve as models, youth voices

KEY BARRIERS 

Accounting for intangibles (racism, historical trauma, etc.), continued growth of national healthcare expenditures, enforcement on state and local level, hospital association lobbyists, integrated and up to date data systems, lack of designated data on equity metrics, responsible agency/team to enforce equity, state compliance with federal standards

CAPACITY NEEDS 

• c4 funding
• Consistent definitions
• Culturally competent providers
• Data accumulation
• Money
• More education and advocacy done by privileged communities in order to remove some of the burden on marginalized communities who typically shoulder
• Political capital
• Responsible entity for enforcement
• Smaller hospitals need technical assistance

POLICY GOAL

Local legislation: Local budgets and incentives are aligned to support equitable mental health needs

CONTEXT

Historically marginalized communities often have different mental health needs that are not prioritized by existing funding structures. Resources need to be allocated to address the root causes of those needs and to support recovery and resiliency

ALLIES AND OPPORTUNITIES

Black and brown community partners (including faith leaders), certified community behavioral health clinics (CCBHCs), cross-cutting policy partnerships, HBCU’s, housing and social service agencies, integration into community needs assessments, legislators with lived experience, local mental health service agencies, advocacy organizations/allies such as The Aakoma Project, Active Minds, AFSP, Inseparable, MTV, NAMI, mobilize storytelling, research institutions, youth voices

KEY BARRIERS 

Accounting for intangibles (racism, historical trauma, etc.), continued growth of national healthcare expenditures, cultural competency training for professionals implementing the system, disagreement on specific metrics, enforcement on state and local level, hospital association lobbyists, integrated and up to date data systems, lack of designated data on equity metrics, lack of implementation, lack of intersectional packages for mental health, members of Congress, police, qualifying community input and involvement, responsible agency/team for enforcement, state compliance with federal standards

CAPACITY NEEDS 

• c4 funding
• Consistent definitions
• Culturally competent providers
• Data accumulation
• Money
• More education and advocacy done by privileged communities in order to remove some of the burden on marginalized communities who typically shoulder
• Political capital
• Responsible entity for enforcement
• Smaller hospitals need technical assistance

Integrating mental health and substance use care with other health services is fundamental to shifting from siloed, marginalized services to holistic care for the whole person. Care integration not only facilitates better and earlier care, it reduces stigma and decreases barriers to accessing care early, effectively, and efficiently. In addition, integrating care with research across healthy systems and universities enables continuous improvement of outcomes.

POLICY GOAL

Federal legislation: Boost federal reimbursement for evidence-based or evidence-informed integrated behavioral health care that allows for innovative approaches

CONTEXT

Traditional financing of health care does not fully support or incentivize integration of effective mental health and substance use care into primary care and other care delivery settings. Changing financing would allow for more people to receive care in settings that are more appropriate, familiar, and accessible to them.

ALLIES AND OPPORTUNITIES

AARP, AMA, Medicare-focused groups, medical societies, NCLA, National Council for Mental Wellbeing, outside groups like NMA, patient advocacy groups, payors and federal insurance plans, provider lobbyists, state Medicaid agencies

KEY BARRIERS 

Budgetary constraints, Congressional Budget Office (CBO) score, public perception, need to incentivize providers/practices to adopt, defining quality and process measures required for enhanced rates

CAPACITY NEEDS 

• Try to replicate and do our own budget score to include key factors associated with score and the voice of the community is heard
• Technical assistance to train practices
• Work with the administration to ensure implementation is as simple and streamlined as possible
• Connect disparate parts of the movement, including outside groups that would be interested in increased rates
• Inside and outside strategy that includes translation of topic for general audience and messaging that allows youth and others to get behind

POLICY GOAL

Federal legislation: (Workforce training and technical assistance) Legislation to significantly expand and refocus SAMHSA’s center for integrated mental healthcare to provide centralized federal funding and standardized technical assistance across health care settings within three years

CONTEXT

Currently, federal technical assistance and funding for integrating behavioral health and primary care spans multiple federal agencies. Centralizing grant funds and expanding and standardizing TA would help health care providers more easily access funding and create more consistency in care integration

ALLIES AND OPPORTUNITIES

AAMC, American Psychiatric Association, American Psychological Association, evaluators, employers, HRSA, National Association of Social Workers, National Association of Peer Supporters, American Psychiatric Nurse Association, providers trying to implement integrated care, patient advocate groups, payors/insurers, professional guilds, SAMHSA, unions, university medical centers, workforce associations

KEY BARRIERS 

Challenges of cross-agency work, getting information out to practices, limitations of scaling with grant funding

CAPACITY NEEDS 

• Policy translation/making it accessible
• Education and translation on how this impacts general public
• Storytelling and narrative to provide human selling point

Coverage and funding drives health system behavior, so it is crucial to break down the treatment limitations, barriers and inequities that continue to marginalize mental health and substance use services. Striking down these systemic impediments is essential to realizing the intent of the Mental Health Parity and Addiction Equity Act (MHPAEA) and state mental health parity laws.

POLICY GOAL

Federal regulation: Implement quantitative network adequacy standards for mental health and addiction care nationwide

State regulation: Implement quantitative network adequacy standards for mental health and addiction care

CONTEXT

Currently, there are significant barriers to accessing behavioral health care due to inadequate provider networks. Stronger requirements for health care plans and service delivery systems are needed to ensure equitable access to behavioral health care compared to other medical care.

ALLIES AND OPPORTUNITIES

Consumer advocates/people with lived experience, employees, food service industry/restaurant workers, healthcare providers, human rights organizations, labor unions, mental health providers and organizations, schools, state and local mental health leaders, community leaders

KEY BARRIERS 

Ideological barriers, insurance companies and plans, lack of available workforce, lack of acceptance of non-clinical providers, cultural responsiveness and language access, lack of general public knowledge, large employers

CAPACITY NEEDS 

• Ability to hold state insurance commissioners/agency accountable
• Communications hub/strategy
• Data and research
• Dedicated staffing for campaign/coalition building
• Grassroots support/mobilization
• Public education
• Dedicated staffing for regulators and their education
• Federal advocacy working group to help develop/refine language on network adequacy and meet with the administration
•  

POLICY GOAL

Federal regulation/legislation:

• Legislation to enable penalties/damages for non-compliance

• Executive branch rules, regulations, and enforcement actions that robustly support parity implementation, including good faith estimates

State regulation: Work within NAIC to promote robust state parity enforcement

CONTEXT

Despite federal and state parity laws, many plans still do not comply with parity requirements. Financial penalties or damages, along with stronger rules and regulations, are needed to ensure the intent of parity is realized.

ALLIES AND OPPORTUNITIES

Civil rights organizations, consumer advocates, Democratic governors, disability rights organizations, faith based groups, healthcare advocates, labor organizations, provider organizations, federal regulators

KEY BARRIERS 

Chamber of Commerce, insurance companies, large employers, other priorities within administration, small businesses with carve outs

CAPACITY NEEDS 

• Technical assistance for regulatory language
• Coalition building
• Data for departmental analysis
• Federal rulemaking regulatory experts
• Lobbyists
• Significant stakeholder response to regulations
• Stakeholder buy-in and resources to pressure the administration

To improve health outcomes and quality of life for people with mental health and substance use conditions, it is necessary to establish and hold systems accountable to implementing standards of quality care and to adopting payment models that support the cost of providing effective, integrated care. 

POLICY GOAL

Federal regulation/legislation:

• Create public-private partnership to review evidence, develop standards, and create a consumer dashboard for non-FDA eligible mental health apps

• Strengthen FDA oversight of digital therapeutics

CONTEXT

As app-based and virtual services for behavioral health conditions have grown exponentially in recent years, there is rising concern about the lack of easily-understood and accessible information about the effectiveness or potential risks of an app or digital therapeutic.

ALLIES AND OPPORTUNITIES

Consumers, digital leaders for good, federal agencies, mental health care providers, payors, researchers, technical experts, youth

KEY BARRIERS 

Disparities with digital divide (audio only vs. audio-visual), limited resources within federal agencies, resistance from telehealth companies, speed of technology development too fast for regulations/standards to keep up, unintended consequences, accessibility of apps for disabled populations

CAPACITY NEEDS 

• Clear identification of what will be standardized and how
• Dedicated resources and organizing
• Developing a clear business case
• Inside and outside game

POLICY GOAL

Note: A similar policy goal was also developed by the Early Identification and Prevention work group

Federal regulation/legislation: Create peer-informed, developmentally-appropriate, culturally responsive K-12 mental health education curriculum

State legislation: Establish and finance K-12 standardized, developmentally-appropriate, culturally responsive mental health education with peer-designed training and supports

CONTEXT

Without standards for K-12 mental health education, curricula are not necessarily age-appropriate, responsive to the needs of children and youth, or culturally responsive. Standards would help ensure more consistent and appropriate K-12 mental health education, and should include peer-designed training and supports

ALLIES AND OPPORTUNITIES

Boards of education, curriculum developers, governors, medical professionals, mental health/child advocates, PTA, students, teachers/school staff, community health workers

KEY BARRIERS 

Funding, social-emotional learning (SEL) politics, teacher’s associations

CAPACITY NEEDS 

• Accountability/ROI on funds spent
• Capacity to test/measure outcomes, and shifting the traditional definition of a standard
• Oversight for quality
• Youth input on curriculum development

To meet growing demand, the mental health delivery system of the future must expand the professional workforce as well as leverage community skills and resources. New service delivery models can ensure that those with greatest need have access to skilled clinicians while creating support in the community for those with less intensive needs.

POLICY GOAL

Federal regulation/legislation:

• Expand Medicare reimbursement and reimbursement models to include the full range of behavioral health providers, including peer support specialists and non-clinical providers

State legislation:

• Require Medicaid to allow billing of services based on ACEs score in lieu of a diagnosis (CA legislation has done so; this increases the ability to bill Medicaid as it does not require a formal mental health diagnosis)

• Increase provider reimbursement rates, including living wages for peers and community health workers (to increase the financial viability of serving in these vital roles)

• Streamline Medicaid and commercial credentialing processes for behavioral health providers (to reduce the barriers to providers being able to join provider networks and bill plans for services)

• Explore incentives to increase capacity of providers, such as pediatricians, to provide mental health care (in order to provide integrated care, providers need funding/incentives that allow them to add staff or collaborate with other providers)

• Ensure state Medicaid plan includes the full range of behavioral health providers, including peer support specialists (unless behavioral health providers are included in a state Medicaid plan, they cannot bill Medicaid for services)

CONTEXT

With a severe nationwide shortage of behavioral health providers, despite rising demand for services, there is a need for multiple approaches to increase the availability of providers. This includes removing barriers that prevent current providers from billing (and providing) services and creating reimbursement rates and incentives that result in more people entering and staying in behavioral health professions and for integrating behavioral health care into existing practices

ALLIES AND OPPORTUNITIES

Community organizations (YMCA, Big Brother, etc.), consumers, educators (NEA/schools), families, first responders, hospitals, insurance commissioners, insurance companies, first responders, mental health advocates, politicians, professional organizations (APA, AOTA, social workers, etc.), politicians, state legislative mental health caucus, health advocacy groups, including Families USA

KEY BARRIERS 

Administrative challenges, insurance companies beyond Medicare and Medicaid, money, possibly some professional guilds and unions, state credentialing, time/capacity

CAPACITY NEEDS 

• Coalition building
• Data collection, including baseline
• Focus on a particular issue
• Political muscle

POLICY GOAL

Federal legislation:

• Legislation to expand loan repayment/forgiveness programs for a full range of behavioral health professionals, with preference to students from historically marginalized communities

• Legislation to create a new nationwide behavioral health service corps, similar to AmeriCorps, to train 50,000 members over 5 years

• Provide training opportunities and incentives to work in mental health deserts

• Provide diversity and equity training curricula that are anti-racist, inclusion centering, culturally responsive, trauma-informed, healing-centered and inclusion centering

State legislation:

• Legislation to finance and establish a behavioral health workforce development program that includes high schools and community colleges (CA legislation as model)

• Legislation to provide paid internships and practicums for a full range of behavioral health providers, including peer support specialists

• Legislation to finance and establish a loan repayment/forgiveness program for behavioral health professionals, with preference to students from historically marginalized communities

• Legislation to waive certain credentialing requirements for personnel already working in the system

CONTEXT

One core aspect of addressing the shortage of behavioral health providers is the need for a pipeline of diverse professionals and paraprofessionals who are well-trained and supported to join the behavioral health workforce. Increasing training opportunities, reducing financial and other barriers, and creating incentives are needed to help more people enter careers in this field

ALLIES AND OPPORTUNITIES

Academic programs, community colleges, hospitals, federally qualified health clinics (FQHCs), local education agencies (LEAs), professional training schools/guilds, skilled nursing facilities (SNFs), teacher and health care professional unions, peer support specialists and supervisors/program managers, community health workers

KEY BARRIERS 

Messaging, scope of practice, unions and guilds, vested interests of other licensed professionals