Boldly Addressing the Current Mental Health and Wellbeing Crisis for Economically Marginalized People and Communities of Color
The coronavirus, associated job losses, and the country’s reckoning with police brutality and racism have severely exacerbated anxiety and depressive disorder symptoms. Many people in the United States already had an unmet need for mental and behavioral health services. Among those 51.5 million people over 18 years of age with any mental illness (AMI), 26 percent (13.3 million people) showed an unmet need for mental health services in 2019, higher than the percentages for each year from 2008 to 2018.1 This is in addition to new pressures that emerged from the coronavirus’s death toll and destruction, the anxieties of working in jobs increasing virus exposure, as well as mandated stayat-home orders and social distancing.
The U.S. Census Bureau Household Pulse Survey’s Phase 2, Week 15 data states that at least 27 percent of individuals living in every state have reported symptoms of anxiety and depression, ranging from 27.7 percent in North Dakota, 38.3 percent in New Jersey, to 47.6 percent in Oregon.2 CDC data from surveys conducted in June 2020 noted that 40.9 percent of individuals reported at least one adverse mental or behavioral health condition, and the percentages of people who seriously considered suicide were much higher among 18 to 24-year-olds, Black and Hispanic respondents, non-paid caregivers, and essential workers.3
The immediate action steps that we recommend underscore that people of color and people struggling to make ends meet have particularly unique experiences with the mental health system. Policy solutions must have an explicit focus on how a person’s race and ethnicity affect how they interact with the health system, and those policies must reflect a direct understanding of how mental health and wellbeing are seen by those who live in poverty.
Historic and modern-day policies rooted in discrimination and oppression have created and widened harmful inequities impacting many communities of color. Therefore, effectively and equitably addressing mental health requires intervening at systemic and policy levels to dismantle the structures that produce negative outcomes like generational poverty, intergenerational and cultural trauma, racism, sexism, and ableism. Changing social, economic, and physical environments alongside key mental and behavioral health supports through immediate relief and longer-term fixes will have an impact on individual and community mental health and wellbeing.
As part of the immediate COVID-19 response, the Biden-Harris Administration and incoming lawmakers have the opportunity to make immediate interventions to fix a broken mental and behavioral health system that has barred millions from accessing quality and effective care. Our immediate proposals are grounded in a list of principles that CLASP believes are essential to follow to significantly reform and reimagine mental health and other systems that support the wellbeing of people with low incomes. The principles are listed in detail in Appendix A.
When everyone has equitable access to trusted mental and behavioral health care, our families and communities are healthier, stronger, and more economically secure.
We recommend three action steps to respond to the immediate mental and behavioral health crises while focusing on racial and economic injustice, laying the foundation for transformational change:
I. Include targeted, culturally responsive mental health asks in the immediate COVID-19 response package
II. Issue an executive order immediately to take actions that coordinate (and align) with the legislative agenda
III. Ensure continued momentum to build on these actions as all health reforms move forward including for mental and behavioral health.
I. Crucial Mental and Behavioral Health Priorities for the Covid-19 Response Package
The following asks are crucial to respond to the mental and behavioral health crisis created by the pandemic, the country’s recognition of racial inequity, and the recession. We make the following recommendations because they respond to urgent needs and build the foundation for longer-term change. They respond to the economic emergency both by creating jobs, addressing state budget shortfalls, and responding to the urgency of a racial justice lens that has been necessary for a long time.
- Funding for a robust behavioral health workforce to meet the needs of the mental health crisis, including providers across disciplines (peer-support providers, recovery specialists, doulas, and social workers, as well as psychologists and psychiatrists), and in different locations (schools, afterschool care, child care facilities, Federally Qualified Health Centers, clinics, workforce agencies, community-based organizations, etc.), including building future pipelines through loan repayment scholarships and strategies.
- To enable this funding to be used effectively, Congress must include language directing HHS to revise the Medically Underserved Area (MUA) and Health Professional Shortage Area (HPSA) criteria with input from communities to ensure that current racial/ethnic/ primary language demographics are being represented and current needs are being met for primary care and mental health.'
- Grants to states to implement mobile crisis programs alongside the National Suicide Hotline Designation Act by promoting models that send mental health professionals first (rather than a co-responder model) and ensuring mental health professionals beyond psychiatrists and psychologists (e.g. peer support specialists) are first responders.
- Grants to states to expand scope-of-practice laws to ensure non-clinical providers (e.g. peersupport providers, recovery specialists, social workers, etc.) can provide essential mental and behavioral health services.
- Grants directly to community providers, as well as funding to support an initiative focused on Reimagining Mental Health for economically marginalized communities, based on the principles above. This will include establishing a network of community organizations to serve primarily communities of color, as well as people with lived experience living in economically marginalized neighborhoods, and set goals and provide suggestions for necessary fixes, coordinated by the Reimagining Mental Health Initiative.
- Ensure grants and other funding mechanisms for federal and state funding include “nontraditional” settings outside of clinical spaces (e.g. afterschool centers, job centers, workforce agencies) to provide needed mental health and wellbeing services.
II. Executive Order to Take Immediate Actions
An Executive Order must be coordinated with the major legislative asks outlined above, including key actions to respond to the pandemic-related mental health emergency and lay the groundwork for the future. This should be done in combination with repealing the Executive Order on Combating Race and Sex Stereotyping, which will continue to hinder the progress needed to address systemic racism and local, state, and federal policies rooted in racism and discrimination.
The Executive Order should:
- Direct the Department of Health and Human Services to:
- Ensure that any measures focused on strengthening the Affordable Care Act include covering mental and behavioral health on par with physical health, according to the principles outlined above by working with the Internal Revenue Service (IRS), the Centers for Medicare and Medicaid Services (CMS), and the Department of Labor (DOL).4
- Within the Office of Civil Rights (OCR):
- Rescind the proposed rules to the Affordable Care Act’s Section 1557 (85 FR 37160). These proposed rules amend the original protections in non-discrimination, focusing on removing protections that discriminate against LGBTQIA+ individuals and women, as well as take away trusted communications resources for Limited English Proficient populations.
- Conduct a review of private, short-term, and traditional and alternative state benefit Medicaid plans, as well as eligibility within states by income and race/ethnicity, to determine whether particular plans disproportionately create barriers for communities of color.
- Review state plans for medical necessity and qualified provider definitions in mental and behavioral health to ensure communities of color and LGBTQIA+ populations have equal access.
- Ensure OCR divisions across agencies are communicating and collaborating over intersectional issues considering race/ethnicity, gender identity, disability, language access, and access to services.
- Dismantle the Conscience and Religious Freedom Division.
- Direct the Centers for Medicare and Medicaid Services to:
- Extend and expand telehealth services both during and after the COVID-19 crisis, as well as eliminate copayments or out-of-pocket expenses, working with HHS and CDC to implement and enforce rules (See Appendix B for a broad outline of what to include).
- Maintain broad applicability for telehealth services in Medicare created due to the COVID-19 pandemic and ensure that they apply in Medicaid.
- Ensure that the definition of “qualified provider” is expanded (building on guidance on August 15, 2007, SMDL #07-011 and the clarification made on May 1, 2013) to include peer-support providers, doulas, recovery specialists, and other paraprofessionals, and work with states to expand their definitions.
- Work with states to enforce federal mental health parity regulations and promote good state parity laws,5,6 ensuring reimbursement creates parity with in-person care.
- Remove any state mental health parity exemptions for self-funded, non-governmental health and employer plans.
- Prioritize a Core Set Measure focused entirely on behavioral health, and include behavioral health measures focused on prevention in the Primary Care Core Set, working with a public-private partnership if needed.
- Follow the lead of employers and private insurers who incorporate app-based mental health into their services, keeping culturally responsive models in mind, so that individuals enrolled in Medicaid are not left behind.
- Work with SAMHSA to convene states about best practices for Alternative Payment Methodologies that consider the social and societal determinants of health and mental/ behavioral health, using CLASP’s policy report on payment reform in maternal mental health as a guide.
- Invest in the up-front costs of appropriate technology infrastructure by developing private-public partnerships to improve telemental health—including expanding broadband access and distribution of technology for economically marginalized communities to access telehealth services and aligning reimbursement policy with technology developments.
- Ensure treatment for substance use disorders is available through telehealth and that individuals have more opportunities to access treatment that involves less supervision (e.g. buprenorphine vs. methadone).
- Direct SAMHSA to release a “State of America’s Mental Health” report:
- Focusing on key data metrics across the states and territories, gathering as much disaggregated race/ethnicity data as possible.
- Ensuring that the data portrait considers, where possible, intersectional issues across sex, gender, immigration status, job status, education, housing, etc.
Key Recommendations for Policy Change
Federal and state agencies and lawmakers need to make significant changes to reform and reimagine systems supporting the wellbeing of populations with low incomes. It means that universal health coverage is necessary. Our recommended mental health policies look beyond the current system to reimagine what is possible to help communities of color, including immigrants, thrive. CLASP recommends key changes to mental health systems and policies, which include:
- Incorporating supports for mental and behavioral health within workforce development, child care programs, and other trusted community-based service providers.
- Recognizing and creating policy to alleviate the stress imposed by living without consistent access to basic needs, such as food and housing, coupled with the oppressive requirements of programs (i.e. work requirements in Medicaid, lengthy paperwork) that are supposed to help struggling families—but that are rooted in racist and paternalistic stereotypes.
- Understanding the breadth of ways mental health and wellbeing can be supported and need to be funded.
- Recognizing that the justice system should not be the first touchpoint for anyone to receive mental health services. A comprehensive set of our policy recommendations will be available in the coming month.
Establish the following in the White House:
- A position under the Health Policy office of the Domestic Policy Council focused on mental and behavioral health policy that is responsible for leading coordination with the stakeholder network listed below, as well as HHS (OMH, NIMH, CDC, SAMHSA, ACF, HRSA), DOI, DOL, DOE, DOJ, DHS, and White House’s OPE and ONDCP. (We would be glad to talk more about the Trump Executive Order from October and whether to repeal or modify it.)
- A federal interagency Task Force on Mental and Behavioral Health, with a specific focus on communities of color, with the following elements:
- Key agencies within the federal government (including, but not exclusive to HHS- CMS, SAMHSA, CDC, NIMH, OMH, ACF, HRSA, as well as DHS, DOL, DOJ, DOI, and DOE) charged with developing, implementing, and enforcing recommendations focused on improving mental health and wellbeing, with guidance from SAMHSA’s Office of Behavioral Health Equity to identify key partners.
- Require that the Task Force be led and coordinated by a staff member at the Domestic Policy Council,
- Hold meetings across the country and ensure that state/local stakeholders providing community-level services are included, as are network members outlined above.
- Create a report outlining key strategies needed to ensure individual and community wellbeing is at the forefront, including proposed investments on the agency and community levels.
- A federal interagency Task Force on Mental and Behavioral Health, with a specific focus on communities of color, with the following elements:
III. Maintaining the necessary momentum for change
Building on these immediate steps, the Administration must make major additional steps over the first year, taking advantage as other opportunities arise, and ensuring that a proper infrastructure is in place. These include:
- Work with Congress to propose legislation based on learnings from the network of community organizations and individuals, the agency Task Force, and public-private partnerships noted above, as well as the overarching principles stated in this memo, as the Reimagining Mental Health Initiative continues.
- Develop private-public partnerships to improve telemental health, including:
- expanding broadband access and distribution of technology for communities that have historically been economically marginalized so they can access telehealth services, and
- aligning reimbursement policy with technology developments.
- Develop private-public partnerships to directly fund services that address the broad definition of wellbeing, helping to close the gaps of unmet need.