Top 10 County Policy Priorities for Behavioral Health Reform
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Naomi Freel
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County Behavioral Health Landscape
America’s 3,069 counties are integral to America’s behavioral health system. Counties annually invest over $130 billion in community health systems, including behavioral health services. Through 750 behavioral health authorities and community providers, county governments plan and operate community-based services for persons with mental illnesses and substance use conditions. County-based behavioral health systems exist in 23 states that represent 75 percent of the U.S. population.
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NACo Commission on Mental Health and Wellbeing
(2023-2024) Counties increasingly handle direct mental health service. NACo’s Commission on Mental Health and Wellbeing developed reports and united county leaders to address the mental health crisis through key policy priorities.
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CMS Issues Interim Final Rule on Medicaid Community Engagement Requirements
On June 1, 2026, the Centers for Medicare & Medicaid Services (CMS) issued an Interim Final Rule with Comment Period (IFR) establishing binding standards for how states must implement Medicaid community engagement ("work") requirements enacted under the One Big Beautiful Bill Act (P.L. 119-21), also referred to as H.R. 1.
