Improving Behavioral Health | The regulatory review

One in five US adults suffers from a clinically significant mental or substance abuse disorder. In recent years, the prevalence and intensity of these conditions have increased among children and adolescents, a trend exacerbated by the COVID-19 pandemic.

Housed within the US Department of Health and Human Services (HHS), the Substance Abuse and Mental Health Services Administration (SAMHSA) aims to improve the quality and availability of treatment and rehabilitation services for behavioral health challenges. Although SAMHSA oversees the implementation of behavioral health provisions in a series of federal laws and regulations, it delegates authority for many of its programs and services to states, tribes, territories, and local and community organizations. Despite this widespread decentralization, gaps in behavioral health care persist.

With more than 46 million undiagnosed behavioral health cases and many millions more without access to quality and affordable care, the United States faces serious and complex challenges to the adequate delivery of behavioral health services. Individuals reported limited insurance coverage, insufficient mental health workforce, lack of accessible treatment, lack of connection between primary care and behavioral health systems, and insufficient resources to cover treatment as barriers to accessing care. Other barriers to care include social stigma, prejudice, and discrimination against people with behavioral health disorders.

As a result of these systemic barriers, racial and ethnic minorities, as well as under-resourced and vulnerable populations, experience higher rates of poor mental health outcomes. To address these disparities, lawmakers, practitioners, and community advocates are pushing for behavioral health integration—which would allow primary care providers to provide behavioral health care—Medicaid expansion and growth in the behavioral workforce, along with other means. The provision of mental health and substance use treatment through telehealth services has also increased since the onset of the COVID-19 pandemic, highlighting the scarcity and inequity of behavioral health resources.

In this week’s Saturday Seminar, we feature the work of experts who discuss regulatory solutions to the behavioral health crisis.

• The United States is facing a shortage of licensed behavioral health care providers as rates of mental illness and substance abuse rise in the country, Michelle Gilbert and several co-authors explain in a report for the Bipartisan Policy Center. They note that the limited availability of providers who participate in insurance networks limits access to treatment, especially for marginalized communities who cannot afford treatment out of pocket. To close this access gap, policymakers and lawmakers should embrace behavioral health professionals under Medicare and Medicaid and implement a planned program to increase their licensure, Gilbert and coauthors say. They also recommend that the Centers for Medicare and Medicaid Services leverage underutilized community resources by creating a community-initiated care funding demonstration program.
• In a recent article published in Psychiatric services, Amy G. Bonilla of the Veterans Health Administration, and several coauthors examined the relationship between the presence of mental health personnel in primary care settings and rates of mental health treatment. Bonilla and her coauthors found that low-income and uninsured patients who sought medical care at health centers with at least one full-time staff member were more likely to receive mental health treatment than patients in unstaffed health centers. In light of their findings, they argue that hiring mental health staff at health centers can help low-income and uninsured patients access treatment. They suggest that SAMHSA’s Center for Integrated Solutions and the Health Resources and Services Administration provide “financial incentives” and “technical assistance” to encourage health centers to hire mental health staff.
• In an article published in Mental health administration and policy and mental health services research, Elizabeth M. Stone of the John Hopkins Bloomberg School of Public Health and several co-authors examine barriers to the implementation of behavioral health homes in Maryland. Behavioral health homes, Stone and her coauthors explain, are health care programs focused on integrating mental health and primary care services for patients with serious mental illness. In these programs, specialty mental health services coordinate with primary care providers to provide physical care to their patients, they describe. They found that barriers to implementing these programs included staff shortages and coordination with outside providers. To overcome these challenges, Stone and her co-authors argue in favor of implementing financial incentives to encourage primary care providers to coordinate with behavioral health homes. They also advise regulators to develop policies aimed at holding behavioral health homes “accountable for participant outcomes” to promote quality care for high-needs.
• In an article published in Review of Temple Law, Taleed El-Sabawi of Elon University School of Law, and Jennifer J. Carroll of Elon University are proposing the Behavioral Health Response Team Model Act to help policymakers create new institutions to address housing, mental health, and substance abuse crises. The central goal of the act’s model, according to El-Sabawi and Carroll, is to develop crisis call centers and behavioral health crisis response teams to replace state and local reliance on law enforcement and police agencies. El-Sabawi and Carroll emphasize that this model act should specifically authorize local governments to establish these programs without law enforcement personnel, in part because these teams are not intended to facilitate institutionalization or incarceration. The act’s model would therefore avoid replicating historically racist institutions by preventing law enforcement from “co-opting” public health policy, El-Sabawi and Carroll argue.
• In a report issued by the Behavioral Health Workforce Advisory Committee, experts explain that HHS is seeking to expand the number of occupations eligible for credentialing through an alternative substance use disorder (SUD) training pathway. The committee describes how HHS created this training pathway for credentialed new mental health practitioners, including social workers, psychologists, and physicians, after determining that there were not enough providers dually certified in mental health and SUDs to meet the needs of the population with many diseases. Despite the successful use of the SUD alternative education pathway, the committee argued that the SUD credentialing regulations created significant barriers, such as high fees, that necessitated the exploration of other credentialing models.
• In a report for The Century Foundation, Jamila Taylor of the National Association for Women, Infants and Children (WIC) explains the dangers of reducing Medicaid coverage for millions of low-income women—especially black women—during pregnancy and the postpartum period. In 2020, Medicaid coverage ended sixty days after birth, depriving mothers of critical health services, including mental health and behavioral care for postpartum depression, Taylor argued. She argues that by losing health insurance so soon, mothers who care for newborns while struggling to get medical care for their own behavioral health challenges become especially vulnerable to negative health outcomes, such as chronic disease and mortality. Taylor recommends extending Medicaid coverage in every state to one year postpartum to promote maternal behavioral health outcomes.