Hillary Clinton’s Comprehensive Agenda on Mental Health

Wow, a very, super duper, comprehensive plan for mental health treatment and programs. Thank you Hillary, soon to be Madam President!

https://www.hillaryclinton.com/briefing/factsheets/2016/08/29/hillary-clintons-comprehensive-agenda-on-mental-health/Today, Hillary Clinton announced her comprehensive plan to support Americans living with mental health problems and illnesses—by integrating our healthcare systems and finally putting the treatment of mental health on par with that of physical health. Nearly a fifth of all adults in the United States, more than 40 million people, are coping with a mental health problem.[1] Close to 14 million people live with a serious mental illness such as schizophrenia or bipolar disorder.[2] Moreover, many of these individuals have additional complicating life circumstances, such as drug or alcohol addiction, homelessness, or involvement with the criminal justice system.[3] Veterans are in acute need of mental health care, with close to 20% of those returning from the Iraq and Afghanistan wars experiencing post-traumatic stress or depression.[4] And the problem is not limited to adults: an estimated 17 million children in the United States experience mental health problems,[5] as do one in four college students.[6]

Americans with mental health conditions and their families need our support. The economic impact of mental illness is enormous –at nearly $200 billion per year nationwide in lost earnings[7] —and the human cost is worse. Too many Americans are being left to face mental health problems on their own, and too many individuals are dying prematurely from associated health conditions. We must do better. To date in this campaign, Hillary set out policies that will direct support to individuals with mental health problems and their families—including a detailed agenda to support military service members and veterans, an initiative to end America’s epidemic of drug and alcohol addiction, and a robust caregivers’ agenda. Today, she is building on those proposals with a comprehensive agenda on mental health. Hillary’s plan will:
Promote early diagnosis and intervention, including launching a national initiative for suicide prevention.
Integrate our nation’s mental and physical health care systems so that health care delivery focuses on the “whole person,” and significantly enhance community-based treatment

Improve criminal justice outcomes by training law enforcement officers in crisis intervention, and prioritizing treatment over jail for non-violent, low-level offenders.

Enforce mental health parity to the full extent of the law.

Improve access to housing and job opportunities.

Invest in brain and behavioral research and developing safe and effective treatments.

As a down-payment on this agenda, Hillary will convene a White House Conference on Mental Health during her first year as President. Her goal is that within her time in office, Americans will no longer separate mental health from physical health when it comes to access to care or quality of treatment. The next generation must grow up knowing that mental health is a key component of overall health and there is no shame, stigma, or barriers to seeking out care.

Early Diagnosis and Intervention
Most mental health conditions have their origins in childhood and adolescence. But today, two-thirds of children with mental health problems receive no treatment at all,[8] and children in high-risk groups – such as those in juvenile justice settings, in the child-welfare system, or whose mothers experienced depression during or after pregnancy – are particularly underserved. The consequences of delayed and inadequate treatment for children and young adults with mental health problems play out over decades. For instance, adolescents with serious mental illness are about three times more likely to drop out of school and twice as likely to face a premature death as are their cohorts who do not face such problems. Hillary is committed to expanding early diagnosis and treatment of mental health conditions, and preventing them when possible. As president, she will:
Increase public awareness and take action to address maternal depression, infant mental health, and trauma and stress in the lives of young children. Hillary will ensure that the public health and early education communities receive needed information and action steps to address maternal depression, infant mental health, and trauma and stress. New studies show that as many as 1 in 5 women develop symptoms of depression, anxiety, or mental health disorders in the year after giving birth.[9] The U.S. Preventive Services Task Force now recommends that women be screened for depression during pregnancy and after giving birth. We also know that infant mental health depends on children forming close and secure relationships with the adults in their lives, and that too many children are growing in environments that cause them to experience trauma or develop stress. Hillary will build on innovative state Medicaid practices to increase screenings for maternal depression, infant mental health, and toxic stress, with the goal of these screenings becoming standard practice in Medicaid
Scale up efforts to help pediatric practices and schools support children facing behavioral problems. Hillary believes we must redouble our efforts around early screening and intervention – and that means training pediatricians, teachers, school counselors, and other service providers throughout the public health system, to identify mental health problems at an early age and recommend appropriate support. There are many promising state and local programs aimed at early detection and intervention of mental health problems, such as Positive Parenting Program, Nurse Family Partnership, Typical or Troubled Program, Mental Health First Aid, Incredible Years, and Massachusetts’ Child Psychiatry Access Project (MCPAP).[10]Hillary will fund promising programs like these by increasing the set-aside in the Mental Health Block Grant for early intervention from 5% to 10% of the annual budget, and she will move this from set-aside funding to a stand-alone program.

Help providers share information and best practices. People experience mental illness in a variety of ways, with symptoms often differing even with the same illness. The Early Psychosis Intervention Network (EPINET) is a platform at the National Institute of Mental Health, which serves as a centralized source of information, data, and best practices to providers and clinicians who treat psychosis. Hillary will support EPINET and other efforts like it that enable mental health practitioners to share information, and she will build on what works.

Ensure that college students have access to mental health services. Mental health and well-being are integral to campus success. Hillary will encourage every college to put in place preventive services, comprehensive treatment and coverage of services, and an interdisciplinary team (including but not limited to school leadership, faculty, students, and personnel from counseling, health services, student affairs, and the office supporting students with disabilities) to oversee the campus’s mental health policies and programming. Hillary will also strengthen support for under-resourced schools that serve a disproportionate number of low- and middle-income students and communities of color, and she will help those schools improve coordination of care with local clinical providers.

Federal Support for Suicide Prevention

Suicides, which are usually fueled by mental illness, are rising among numerous population groups, from adolescents and college students[11] to veterans[12] and older adults.[13] The overall rate of suicide increased by 24 percent between 1999 and 2014, and is now at its highest level in 30 years.[14] Over 40,000 Americans die of suicide every year, making it the tenth-leading cause of death nationally.[15] As the former director of NIMH, Dr. Tom Insel, often notes, suicides have 11 victims: the person who dies, and at least 10 people close to them who will never be the same. Hillary believes that suicide is a critical issue that she will prioritize as president. She will:
Create a national initiative around suicide prevention across the lifespan that is headed by the Surgeon General: As president, Hillary will move toward the goal of “Zero Suicide” that has been promoted by the Department of Health and Human Services. She will direct all relevant federal agencies, including HHS, the VA, and the Department of Education, to research and develop plans for suicide prevention in their respective settings, and create a cross-government initiative headed by the Surgeon General to coordinate these efforts. She will also launch a citizen input and feedback mechanism, to enable outside groups to comment on agency recommendations, and explore how we can harness technology to reach out to people who need support.
Encourage evidence-based suicide prevention and mental health programs in high schools. In 2013, a survey of high school students revealed that 17 percent considered attempting suicide in the last year, with 8 percent actually attempting it. The suicide rate among American Indian/Alaska Native adolescents is even higher, at 1.5 times the national average. There are effective ways to respond. It is critical that school districts emphasize evidence-based mental health education, so that students, teachers, and school nurses are aware of the warning signs and risk factors of mental illness and how to address them. The Model School District Policy on Suicide Prevention, released by four leading mental health organizations, includes concrete recommendations that school districts can follow. Hillary will direct the Department of Education to emphasize mental health literacy in middle and high schools and will work with regional and national PTA, school counselor associations, and associations of secondary school principals to encourage school districts to adopt this model policy.

Provide federal support for suicide prevention on college campuses. Hillary believes that every college campus should have a comprehensive strategy to prevent suicide, including counseling, training for personnel, and policies that enable students to take leave for mental health. Such multi-layered approaches have a proven track record of decreasing suicides. For instance, the Air Force launched an initiative in 1996 that brought together multiple intervention programs and reduced the suicide rate among Air Force personnel by nearly a third in under a decade. Groups such as the Jed Foundation, American Foundation for Suicide Prevention, the Suicide Prevention Resource Center, and Active Minds have created frameworks around suicide prevention tailored for colleges and universities. Hillary will dramatically increase funding for campus suicide prevention, investing up to $50 million per year to provide a pathway for the country’s nearly 5,000 colleges – whether private or public, two-year or four-year – to implement these frameworks on behalf of students.

Partner with colleges and researchers to ensure that students of color and LGBT students are receiving adequate mental health coverage. Evidence suggests that the psychological needs of students of color are disproportionately unmet, impeding their ability to adapt to college life. LGBT students face added burdens as well, with gay youth being four times more likely than their straight peers to attempt suicide. Hillary will direct the Departments of Education and Health and Human Services to work with universities, researchers and community programs to determine how best to meet and respond to the challenges these students face and to provide specialized counseling.

Integrate our Healthcare Systems and Expand Community-Based Treatment

Demand for mental health services far outpaces supply, and our health care system lacks the treatment infrastructure and behavioral health workforce necessary to provide adequate care. Of adults experiencing any mental illness today, nearly 60% are untreated. Of those with a serious condition, 40% are untreated.[16] We need to close the treatment gap, and ensure that there is no wrong door to access care. Hillary’s plan will:
Foster integration between the medical and behavioral health care systems (including mental health and addiction services), so that high-quality treatment for behavioral health is widely available in general health care settings. The responsibility for mental health care and substance use disorders is increasingly falling on general care providers. One study finds that today, over a third of patients with mental disorders who use the health care system are treated by primary care providers.[17] While some primary care providers offer excellent care, many do not receive dedicated training in treating mental illnesses. In addition, the medical and behavioral health care systems are highly segmented—to the point that when a patient has both conditions, providers have trouble collaborating and jointly managing the patient’s treatment plan. Hillary believes we should break down the barriers between medical and behavioral health care, and move the system so that it focuses on the whole person. System integration could yield $26-$48 billion in savings annually to the health care system, with $7-$10 billion coming from Medicaid alone.[18] That is why Hillary will:
Expand reimbursement systems for collaborative care models in Medicare and Medicaid. Collaborative care is a model of integrated care that treats mental health and substance use conditions in primary care settings. A team of health care professionals work together to coordinate the patient’s services, including a primary care doctor, a care manager, and a behavioral health specialist. These integrative approaches not only produce better medical outcomes and patient satisfaction, they also result in significant savings to the health care system. Hillary will expand reimbursement structures in Medicare and Medicaid for collaborative care by tasking the Center for Medicare and Medicaid Innovation to create and implement new such payment models. She will also issue recommendations on best practices for private plans.

Promote the use of health information technology to foster coordination of care. Hillary will adjust payment systems in Medicare, Medicaid, and under the Public Health Service Act, to allow for reimbursement of tele-psychiatry and other telehealth services delivered through primary care and hospital settings.

Promote the use of peer support specialists. Peer support specialists have been shown to provide needed, cost-effective services for individuals with mental health conditions and addiction. Hillary will support initiatives to include peers in clinical care teams in primary care settings, mental health specialty care settings, hospitals, and Accountable Care Organizations. She will encourage all 50 states to reimburse peer services in state Medicaid programs, which 30 states do currently, and continue providing the Consumer and Consumer Supporter Technical Assistance Center grants.

Encourage states to allow same-day billing. Many state Medicaid programs prohibit payments for mental health services and primary care services furnished to the same individual on the same day. This results in unnecessary obstacles to care and segmentation of health care practices. Hillary will issue best practices guidance to states, encouraging them to lift this restriction.

Support the creation of high-quality, comprehensive community health centers in every state. A 2014 law established a demonstration program in eight states, under which new benefits would be available to health centers certified by the federal government as Certified Community Behavioral Health Clinics (CCBHCs). To be a CCBHC, a clinic must provide a range of physical and mental health services, including emergency psychiatric care, treatment for mental health and substance use disorders, and peer support. In return, the clinic can receive reimbursement at rates similar to those received by federally-qualified health centers. Hillary will invest $5 billion over the next ten years to scale up this demonstration project and help bring it to every state in America. This will vastly expand community-based treatment, by enabling thousands of health centers across the country (i.e., FQHCs, CMHCs, etc.) to upgrade to an integrated center.

Launch a nationwide strategy to address the shortage of mental health providers. The United States is already experiencing shortages in its mental health workforce, and those shortages are projected to worsen in the coming years. For example, there are only 8,300 practicing child and adolescent psychiatrists today, which is one provider per 38,000 children.[19] Moreover, there is an increasing need for mental health professionals to be trained in cultural competency, so that they can deliver effective care to different populations. Hillary will launch a national strategy to bolster our mental health workforce, pulling together the Substance Abuse and Mental Health Services Administration, Health Resources and Services Administration, Center for Medicare and Medicaid Services, Indian Health Service, Department of Education, and public and private partners. This cross-governmental initiative will aim to: recruit more persons into the mental health fields; expand resources for mental health training, from loan forgiveness programs, to scholarships, to grants for training programs and additional GME funding; disseminate telehealth systems so that providers can reach underserved populations remotely; and expand culturally competent care.[20]

Improve Outcomes in the Criminal Justice System

Today, our criminal justice system is increasingly becoming the “front line” of engagement with individuals with mental health problems. Law enforcement officers routinely have to intervene or respond to unfolding situations that involve individuals with mental illness. As many as 1 in every 10 police encounters may be with individuals with some type of mental health problem.[21] And our county jails today house more individuals with mental illness than our state and local psychiatric hospitals.[22] Hillary believes that while greater investments in prevention and community-based treatment for behavioral healthcare will minimize these encounters with the criminal justice system, there are also specific steps we should take to improve outcomes for those individuals who do end up interfacing with law enforcement. She will:
Dedicate new resources to help train law enforcement officers in responding to encounters involving persons with mental illness, and increase support for law enforcement partnerships with mental health professionals.Even though an increasing number of police encounters or use-of-force incidents involve people with mental health problems, law enforcement officers receive minimal training in how to handle such situations. According to one study, the average police officer receives only 8 hours of training for crisis intervention, which is far below the recommended amount.[23] Hillary will ensure adequate evidence-based training for law enforcement on crisis intervention and referral to treatment, so that officers can properly and safely respond to individuals with mental illness during their efforts to enforce the law.
Prioritize treatment over punishment for low-level, non-violent offenders with mental illnesses. Over half of prison and jail inmates today have a mental health problem, and up to 65% of the correctional population meets the medical criteria for addiction. Many of these individuals are first-time or nonviolent offenders, whose prospects for recovery and reentry would be far enhanced were they to participate in diversionary programs rather than serve time in jail. Hillary will increase investments in local programs such as specialized courts, drug courts, and veterans’ treatment courts, which send people to treatment and rehab instead of the criminal justice system. She will also direct the Attorney General to issue guidance to federal prosecutors, instructing them to prioritize treatment over incarceration for low-level, non-violent offenders. Finally, she will work to strengthen mental health services for incarcerated individuals and ensure continuity of care so that they get the treatment they need.

Enforcing Mental Health Parity

The Mental Health Parity and Addiction Equity Act of 2008, which Hillary proudly co-sponsored, requires that mental health benefits under group health plans be equal to benefits for other medical conditions. The Affordable Care Act built on this important law by requiring that insurance plans offered in the individual and small group markets offer mental health coverage as an essential health benefit. But while the right laws are on the books, they are too often ignored or not enforced. Millions of Americans still get turned away when seeking treatment for mental illness, even when the interventions are well-established and evidence-based. A recent report published by the National Alliance on Mental Illness suggested that a patient seeking mental health services is twice as likely to be denied coverage by a private insurer as a patient seeking general medical care.[24] As part of her commitment to fully enforcing the mental health parity law, Hillary will:
Launch randomized audits to detect parity violations, and increase federal enforcement.Hillary will ensure that the Departments of Labor and HHS have the authority they need to conduct randomized audits of insurers, to determine whether they are complying with the parity law. She will direct both agencies to bring appropriate enforcement actions against insurers, and to make their enforcement actions more transparent so that the general public is more aware when insurers violate the law.
Enforce disclosure requirements so that insurers cannot conceal their practices for denying mental health care.The parity legislation provided the Departments of Labor and HHS the power to demand key information from insurers on the medical management decisions they use to deny care for behavioral health care. This information is essential for the government and patients to be able to identify and prove parity violations. Hillary will direct the DOL and HHS to fully enforce the disclosure requirements—requiring that plans specifically disclose how their non-quantitative treatment limitations comply with the parity law—and she will work to ensure that public insurers are subject to the same transparency.

Strengthen federal monitoring of health insurer compliance with network adequacy requirements. The list of providers that health insurers give to beneficiaries should adequately reflect the providers who are in-network and provide care to patients with that insurance. Hillary will ensure that insurers provide up-to-date lists on mental health provider networks, so patients know where to get care.

Create a simple process for patients, families, and providers to report parity violations and improve federal-state coordination on parity enforcement. Hillary will direct the Departments of Labor and HHS to issue clear, easy-to-follow guidance on where to report parity complaints, and to publish data on complaints the agencies received and how they responded. She will also ensure that patients and families are aware of consumer hotlines that they can call to understand their rights under the parity law, and navigate the complaint and appeals processes. Finally, she will direct officials to work with the National Association of Insurance Commissioners as well as state leaders, patient advocates, and other key stakeholders to set milestones and hold one another accountable to improve parity enforcement across-the-board.

Housing and Job Opportunities

Hillary supports a full range of housing and employment support for individuals with mental health problems, to help them lead independent and productive lives. As president, Hillary will:
Expand community-based housing opportunities for individuals with mental illness and other disabilities. Hillary will launch a joint initiative among the Departments of Housing and Urban Development (HUD), Health and Human Services, and Agriculture to create supportive housing opportunities for thousands of people with mental illnesses and disabilities, who currently reside in or are at risk of entering institutional settings. As the Supreme Court held in the Olmstead decision, individuals with mental or physical disabilities should not be segregated in institutional settings when community-based services can be accommodated. Hillary’s new program will provide dedicated Housing Choice Vouchers and other critical assistance to individuals with mental illnesses or disabilities, enabling such persons to live independently while paying no more than 30% of their adjusted monthly income in housing costs. Public housing authorities will administer the new housing subsidies, while HUD will work with HHS and USDA as well as state mental health agencies to identify qualifying individuals. Hillary will dedicate an average of $100 million to this initiative per year over the next ten years. This funding builds on her stated commitment to expand support for community-based housing through the HUD Section 811 program, authorized by the Supportive Housing Investment Act of 2010.
Expand employment opportunities for people with mental illness. Research has shown that supported employment helps people with mental illness avoid hospitalization, while also giving them the opportunity to earn money and contribute to society. The employment rate for people with serious mental illness is below 20 percent, even though many of these adults want to work and more than half could succeed with appropriate job supports.[25] Hillary will work with private employers and state and local mental health authorities to share best practices around hiring and retaining individuals with mental health problems, and in adopting supported employment programs. That includes expanding HHS’s “Transforming Lives Through Supported Employment” program, which already assists states and communities in providing supported jobs to people with mental illness. Another area of focus will be encouraging employment for individuals with mental illness within the mental health sector itself, including as peer support specialists and recovery coaches.

Expand protection and advocacy support for people with mental health conditions. Hillary will support and expand funding for the Protection and Advocacy for Individuals with Mental Illness (PAIMI) Program to ensure advocacy services for individuals with mental health conditions. These services make a critical difference for those who need reasonable accommodations for housing, employment, and other support and services.

Brain and Behavioral Science Research

We are still in the early stages of unraveling the mysteries of human brain development and behavior. Hillary believes we need a pioneering, multi-sector effort to transform our knowledge of this field—from mapping the human brain to generating new insights into what drives our behavior to investing in clinical and services research to understand the interventions that work best and how to deliver them to patients. Combining neurobiological research with behavioral, clinical, and services research will help us develop new therapies to help patients today while laying the foundation for future breakthroughs. Through it all, Hillary believes we must ensure that the resulting data and insights are widely available to researchers. As president, Hillary will:
Significantly increase research into brain and behavioral science research. As part of a broad new investment in medical research, Hillary will provide new funding for the National Institutes of Health; build on cross-collaborative basic research efforts like the BRAIN initiative; scale up critical investments in clinical, behavioral, and services research; and integrate research portfolios with pioneering work on conditions like PTSD and traumatic brain injury already underway at DoD, the VA, and HHS. Together, these efforts will transform the landscape of funding for brain and behavioral research, and improve clinicians’ ability to detect and treat mental illness at the earliest stages.
Develop new links with the private and non-profit sectors. Hillary will work with her biomedical research team to forge new links with the private and nonprofit sectors. In addition to the NIH, pioneering work in these fields is taking place at foundation-funded centers, academic institutions, and private firms. As she scales up investments in brain and behavioral research, Hillary will ensure that federal government efforts are aligned with those of other sectors to ensure that progress occurs as quickly as possible.

Commit to brain and behavioral science research based on open data. Hillary understands that we must not only improve funding of brain and behavioral research but ensure that findings are widely shared. Beyond promoting research partnerships across sectors, Hillary believes that the way we fund research must change to fully embrace open science and data. The open science principles put forth by One Mind offer a useful guide, and the success of the Human Connectome Project serves as an important model. Hillary will work with leaders in the research community to structure grants in a way that promotes timely access to results for all researchers while preserving patient privacy.

Hillary is committed to delivering on the above agenda and to ensuring that mental health is treated like the national priority it already is. As a down-payment on her agenda, Hillary will convene a White House Conference on Mental Health within her first year in office, to highlight the issue, identify successful interventions, and discuss barriers that must be removed to improve today’s system.

Hillary has also laid out policies that offer additional support to individuals with mental health problems and their families, beyond today’s announcement. Earlier this year, she released a robust Caregivers Agenda, to support family members and workers who care for individuals with health conditions, including mental illness. She also set out a $10 billion Initiative to Combat America’s Deadly Epidemic of Drug and Alcohol Addiction, which provides incentives to every state to dramatically expand its prevention and treatment programs for substance use disorders. And she has released a detailed Veterans Agenda that outlines a robust plan for tackling the issues facing veterans, our service members, and their families, including expanding access to mental health care and treatment, ending the epidemic of veteran suicide, and reducing homelessness.
Hillary Clinton’s Record
The comprehensive mental health agenda Hillary released today builds on her record of fighting for better services for Americans with mental illnesses. In the U.S. Senate, she co-sponsored the Campus Care and Counseling Act, which established critical mental health support and early suicide prevention for college students across the country. She supported a $500 million increase in mental health care for veterans, co-sponsored the Joshua Omvig Veterans Suicide Prevention Act, and worked across the aisle to make sure their mental health needs would not be forgotten in policy recommendations to the Department of Veterans Affairs. And she strongly supported the enactment of mental health parity laws, which have helped ensure that millions of Americans with mental illness do not lose access to the services that they need because of financial restrictions or arbitrary treatment limits. This record reflects Hillary’s strong belief that mental illness must be treated no differently from other medical conditions and her commitment to the needs of Americans and their families coping with mental illness.
[1] Behavioral Health Trends in the United States: Results from the 2014 National Survey on Drug Use and Health, September 2015, http://www.samhsa.gov/data/sites/default/files/NSDUH-FRR1-2014/NSDUH-FRR1-2014.pdf).
[2] Center for Behavioral Health Statistics and Quality, Behavioral Health Trends in the United States: Results from the 2014 National Survey on Drug Use and Health (2015). The range of conditions includes depression, which the CDC estimates will soon become the second leading cause of disability in the world, PTSD, which affects nearly 8 million Americans, anxiety, and bipolar disease and schizophrenia.
[3] Nearly half of the people in treatment for drug or alcohol addiction also have a co-occurring mental health problem, as do more than half of incarcerated individuals. See SAMSHA, National Survey of Substance Abuse Treatment Services, at 3 (2013), http://www.samhsa.gov/data/substance-abuse-facilities-data-nssats/reports; NIH, http://www.nimh.nih.gov/health/statistics/prevalence/inmate-mental-health.shtml (using DOJ reports) A quarter of those who are homeless have a mental health problem. HUD, The Annual Homeless Assessment Report to Congress, at 18 (2010), https://www.hudexchange.info/resources/documents/2010HomelessAssessmentReport.pdf.

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