County Role in Mental Health

Direct mental health service delivery responsibilities are falling increasingly to America’s counties, who serve as the nation’s safety net for residents in need, first responders, and operator of crisis lines, public hospitals and detention centers. Counties are integral of any local, state or national level effort to strengthen mental health services because of the various touchpoints counties have among residents seeking care.

COMMISSION SCOPE

Through the advancement of county policy priorities, showcasing community strategies and elevating county voices, the Commission will:

1. Stimulate a national sense of urgency through an intergovernmental partnership framework, for addressing our nation’s crisis with mental health and wellbeing of residents, especially our most vulnerable.​
2. Elevate the national awareness of the roles, innovations and pain-points facing county governments in addressing this escalating crisis.​
3. Achieve public policies that support the county role in safeguarding the nation's mental and behavioral wellness, such as the full implementation of Mental Health Parity standards, promoting the equal coverage of mental health care through the modernization of the "institutions for mental disease" (IMD) prohibition, repealing the Medicaid Inmate Exclusion Policy for people detained in jail pre-trial, and building the mental health workforce to ensure that local communities have a sustainable continuum of care. 
4. Align a cohesive national and intergovernmental strategy to improve and enhance the mental health and wellbeing of all Americans, with a special focus on our most vulnerable populations.

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COMMISSION MEMBERS

NACo President Denise Winfrey appointed 14 county leaders from across the United States with the mission to improve the ability of counties to equitably increase access to mental health services and treatment.

AMEND EXCLUSIONARY POLICIES UNDER MEDICAID

Amend the Medicaid Inmate Exclusion Policy (MIEP) for improved care continuity of individuals with mental illness and substance use disorder. The MIEP is a federal policy outlined under Section 1905(a)(A) of the Social Security Act, that revokes federal health benefits for adults and juveniles that are being housed in correctional institutions - making no distinction between individuals who are being detained in jails prior to conviction, versus individuals who have been adjudicated and sentenced to time in a jail or prison. Without revision, this policy creates inequitable and unconstitutional disruptions to primary and behavioral health care services for justice-involved populations, thus exacerbating rates of untreated mental illness and substance use disorder in local communities.  Amending the MIEP to allow individuals who are detained pre-trial to retain access to Medicaid and other federal health benefits will help break the cycle of recidivism exacerbated by untreated physical and mental illnesses and substance use disorders. 

POLICY SOLUTIONS 

• Expand the approval of regulatory measures that would allow Medicaid payment for medical services furnished to an incarcerated during at least the 30-day period preceding the individual’s release. 
• Advance federal policy that would allow Medicaid payment for medical services furnished to an incarcerated during at least the 30-day period preceding the individual’s release. 
• Advance federal policy that would remove limitations under Medicaid, Medicare, CHIP and the Department of Veterans Affairs on benefits for persons in custody pending disposition of charges. 

Modernize the Institutions for Mental Diseases (IMD) exclusion to reduce barriers to the provision of comprehensive behavioral health treatment and increase access to short-term residential treatment when clinically appropriate. The federal Medicaid statute prohibits federal reimbursement for care provided in psychiatric or other residential treatment facilities with more than 16 beds, defined as Institutions for Mental Diseases (IMDs). IMD restrictions have created significant barriers to providing clinically necessary inpatient mental health services and contributed to inequities in access to treatment and care for low-income individuals on Medicaid. Modernizing the Medicaid IMD exclusion would greatly expand the treatment capacity of county-operated hospitals and behavioral health facilities while also promoting equitable access to treatment options for low-income individuals.  

POLICY SOLUTIONS  

• Expand the approval of regulatory measures that waive IMD restrictions for adults with serious mental illness (SMI) children with serious emotional disturbance (SED), and short-term residential stays for the treatment of substance use disorder (SUD).  
• Advance regulatory or legislative policy that waive IMD restrictions for short term crisis stabilization facilities, as a critical component of the crisis care continuum.  

BUILD & SUPPORT THE MENTAL HEALTH WORKFORCE

Obtain direct and flexible resources to support the recruitment, training and retention of a sufficient behavioral health workforce. Counties across the nation are investing in programs and initiatives that both assist with and incentivize the recruitment, training and placement of behavioral health providers that will work within local and under resourced communities. Counties rely on our federal partners to supplement these investments through the enhancement of existing programs that promote workforce recruitment and retention. With over 30 percent of the population across the nation residing in a county that is designated as having a mental health professional shortage, new financial incentives for integrated care may result in an increase of individuals taking jobs in the behavioral health care field and increase access to these critical services.  

POLICY SOLUTIONS  

• Enhanced funding authorizations for existing programs that promote workforce recruitment and retention in local areas. 
• Federal policy that removes barriers and creates clear pathways into a variety of behavioral health professions, particularly in rural and underserved areas.  

BUILD & ENHANCE IN LOCAL CRISIS RESPONSE SYSTEMS  

Enhance the intergovernmental partnership for the development and modernization of local crisis response systems and infrastructure. Our nation’s lack of an effective and widely available mental and behavioral health crisis services system has contributed to tragic outcomes for people in crisis. Counties are working to develop and support new models of servicing individuals in crisis that are tailored to fit the unique needs of their community which include the development of tiered and co-response models, integrative care, wraparound service and referral systems and 24/7 call centers that support the recently implemented 988 National Suicide Prevention Lifeline. Not only does this shortage of a crisis services system have real-life negative impacts on our residents, but also drive up costs for counties that have to bare the financial burden when an individual is hospitalized or incarcerated. The long-term success of these efforts is dependent on a strong intergovernmental partnership, where all levels of government are invested in the construction and modernization of local crisis response systems.  

POLICY SOLUTIONS  

• Federal coordination on resources and technical assistance to local governments on the development of crisis call centers. 
• Increased funding for existing programs that aid in the development, expansion and sustainment of crisis response infrastructures. 
• State and federal support for the expansion of evidence-based crisis response models, including  CIT, CAHOOTS etc. 
• Authorization of Medicaid financing for regional and local crisis call center operations, crisis stabilization facilities and integrated primary, mental health and crisis response care models such as Community Behavioral Health Centers (CCBHC) 

ENFORCE MENTAL HEALTH PARITY  

Enforce policies that ensure equal coverage of treatment for mental illness and addiction. The Mental Health Parity and Addiction Equity Act (P.L. 110-343) is a federal parity law that was enacted in 2008, and required comprehensive standards for equitable coverage of mental health and substance use disorder treatment and coverage of physical treatment. Despite legislative advancements over the last decade, there are still disparities in the coverage of mental health and substance use disorders under both public and private health insurance plans, when compared with coverage for medical and surgical benefits. Furthermore, while Medicaid and Managed Care Plans (MCOs) must follow federal parity laws, Medicaid fee for service plans do not, which inhibits many individuals from accessing potentially lifesaving coverage. Strengthening behavioral health parity protections and enforcing existing protections is a critical component of improving coordination and integration of primary care and behavioral health care in the health care delivery system, and better addressing the behavioral and mental health needs of our community more broadly.   

POLICY SOLUTIONS  

Federal and state-level legislation that incentivizes and enforces existing parity policy and ensures that laws are uniformly implemented across both public and private insurers providers, and in all 50 states and the District of Columbia.