A Special Issue of The Milbank Quarterly—Mental Health and Substance Use Challenges Facing the United States: What Can State Policymakers Do?

See all articles in the special issue, Mental Health and Substance Use Challenges Facing the United States: What Can State Policymakers Do?

After publishing a special issue in 2023 celebrating the Quarterly’s Centennial Anniversary that was devoted to the broad theme of the future of population health, our editorial team decided to focus the next special issue on a theme of great importance to state health policymakers. So, with the help of members of the Milbank State Leadership Network, we sought to identify issues that are most “top of mind” for state policymakers. It was clear from the feedback we received that the dual problems of mental health and substance use were among the most troubling concerns facing states. This impression was reinforced by available evidence on several fronts, including the high rates of mental illness in adults and adolescents, the disturbing trends in opioid overdose deaths and suicides, the serious difficulties many individuals encounter in accessing mental health and substance use services, and the urgent need to bolster the behavioral health workforce.

Planning for the special issue began 18 months ago when the Quarterly’s editorial team invited Dr. Magdalena Cerdá of New York University and Dr. Beth McGinty of Weill Cornell Medical College to serve as coeditors. With their assistance, we recruited as advisors Dr. Katherine Keyes of Columbia University, Dr. Brandon Marshall of Brown University, and Dr. Richard Rawson of UCLA to assist in selecting specific topics of greatest concern and in identifying potential authors. We then invited a diverse group of leading scholars and policymakers coming from the social sciences as well as from the fields of public health, medicine, epidemiology, government, and law to reflect on the gains and pitfalls of past policy efforts and to contribute their insights into improving future policymaking. The end product is a collection of 20 articles that comprise a mix of original research and thoughtful Perspective pieces offering lessons and potential solutions—policies and strategies—for overcoming the most critical challenges facing states today.

We are indebted to the authors for their outstanding contributions and to Tara Strome, our Managing Editor, and Mary Louise Gilburg, our Publications and Communications Associate at the Milbank Memorial Fund, who oversaw and coordinated manuscript management throughout the editorial process.

The special issue is organized according to four broad thematic areas:

• The Challenges of Mental Health Services Access, Financing, and Workforce Supply

Topics include: the role of economic and social support policies; emergent financing models for mental health crisis systems; strategies to promote the recruitment and retention of the behavioral health workforce; and trauma recovery for underserved victims of violent crime.

• The Challenges of Opioid Use, Overdose Deaths, and Suicide

Topics include: maximizing the public health benefits of opioid settlements; leveraging data science and artificial intelligence to stem the tide of the overdose crisis; racial and ethnic differences in the effects of prescription monitoring program laws on overdose deaths; a collaborative multi-agency initiative for opioid use disorder in a statewide carceral system; laws governing substance use during pregnancy; and integrating mental health and substance use treatment with emergency and primary care.

• How the Medicaid Program Addresses Mental Health and Substance Use Challenges 

Topics include: Medicaid’s role in mental health and substance use disorder care; substance use policy innovation in Medicaid; strategies by Medicaid managed care organizations to improve access to behavioral health services; and Section 1115 waiver strategies for increasing methadone and buprenorphine treatment.

• The Challenges Posed by the Regulation of Consumer Products

Topics include: state policies regarding social media; alcohol problems and policies; legal barriers to safer smoking supplies; the association between flavored e-cigarette use and tobacco and substance use among youth; medical cannabis laws and their impact on cannabis and opioid use disorder treatment; and Maine’s unique risk-based firearm removal approach.

We invite you to dive into the issue, but first, we provide an overview of the most salient lessons that emerge from the various articles.

Lessons Regarding Mental Health Challenges

The articles in this special issue consider how policy can address major mental health challenges in the United States, including high rates of anxiety and depression among youth and adults, mental health crises, and suicide. Rates of depression and anxiety increased during the COVID-19 pandemic and have not yet returned to pre-pandemic levels, and major depressive disorder is the leading cause of disability for people ages 15-44. These are statistics with important implications not only for individual and public mental health but also for labor force participation and the economy. A key takeaway from the papers in this special issue is that a broad set of cross-sectoral policies at the national, state, health system, and organization levels interact to impact public mental health. Three cross-cutting themes stand out. First, the importance of a “mental health in all policies” approach acknowledges that policies with great impact on mental health may not directly target mental health—or even health in general—at all. Second, to improve mental health treatment, policies must address structural issues related to financing and workforce. Third, a comprehensive, cross-sector policy approach to mental health crisis management is needed.

The mental health policy agenda must include policies that ameliorate structural and social determinants of mental health. Donnelly and Farina delineate how state-level social and economic policies such as Medicaid expansions, minimum wage increases, and paid sick leave can protect against mental distress. Critically, as the paper points out, mental distress is not equally geographically distributed in the United States, with large differences across states likely driven in part by varying social and economic policy landscapes. Too often, “mental health policy” connotes policy narrowly focused on mental health treatment or, at best, mental health focused prevention or recovery initiatives. This paper highlights the important reality that many of the policies with significant population mental health impact influence mental health indirectly, through pathways such as financial hardship.

Mental health care financing and workforce policies are foundational to mental health treatment delivery. McEvoy and Maniates detail the major role that the joint federal-state Medicaid program—the largest single payer of mental health services in the United States—plays in mental health (and substance use disorder) care. In addition to playing a central role in ensuring insurance coverage, mental health care access, and care quality, Medicaid is a prime source of innovation in mental health policy. Dovetailing with the paper by Donnelly and Farina on state social and economic policies, McEvoy and Maniates highlight Medicaid innovations addressing social drivers of mental health, including Medicaid coverage to support care upon community re-entry from incarceration, supportive housing, and cross-system initiatives that connect Medicaid with other social service systems to provide whole-person care.

Nevertheless, behavioral health access gaps in Medicaid are well-documented, where managed care organizations (MCOs) now cover most enrollees. Zhu and colleagues examined the strategies employed by Medicaid MCOs to enhance behavioral health access, most notably by contracting with core groups of Medicaid-focused behavioral health providers, and by boosting the existing workforce through outreach, training, and workforce support programs. The authors assert that understanding MCO approaches and common challenges may help policymakers better align resources, incentives, and regulations centered on improving existing gaps in accessing behavioral health care. Workforce, like financing, underpins the ability of mental health systems to provide accessible, high-quality services. Last and Zhu present strategies to bolster the mental health workforce, including increasing insurance reimbursement rates, particularly in Medicaid, which typically pays mental health providers less than Medicare and commercial insurance. Given that Medicaid is the predominant payer of mental health services in the United States, low payment rates contribute to comparatively low salaries for mental health clinicians relative to other specialties. Together, these two papers emphasize the critical role of Medicaid in mental health service delivery and the intertwined nature of Medicaid coverage and reimbursement policies and mental health workforce challenges.

Recent years have seen much-needed growth in policies to support a continuum of services to help people navigate and recover from mental health crises. Integration of mental health services into other settings, including primary and emergency care, is one important component of developing such a continuum. Krawczyk and Samples detail progress toward integration of suicide prevention practices, including screening, risk assessment, and brief intervention into routine care, and highlight the need for increased integration of evidence-based practices aligned with the ZeroSuicide initiative, which positions suicide prevention as a core responsibility of health systems. Dekker and colleagues report on the implementation of the Trauma Recovery Center model in Los Angeles County to provide mental health treatment and case management to underserved victims of violent crime. The authors found that the model brought comprehensive care to the victims, with improvements in post-traumatic stress disorder and quality of life, but that the model’s sustainability is threatened by limitations in funding. In most jurisdictions within the United States, mental health crisis “systems” are loosely connected services delivered by a range of organizations across various sectors, including but not limited to health care and law enforcement. Purtle and colleagues accentuate the challenges, and possible solutions, for bringing these services together in a more comprehensive manner—with an emphasis on financing. The mental health crisis care continuum ranges from crisis call centers to inpatient care. Crisis service financing historically has involved a variety of largely uncoordinated funding streams, including mental health block grants, Medicaid, telecommunication fees, and others. To create and sustain a comprehensive system, a coordinated financing approach is needed.

Importantly, all of these papers highlight the vital role of states as laboratories for evidence-based policymaking—and the challenges of this model. Policy must be enacted and implemented in order to be rigorously studied, and resulting evidence often suggests the need to shift approaches, either by amending a policy or de-implementing it in favor of a different option. Such shifts are easier said than done within the complex policymaking process.

Lessons Regarding Substance Use Disorder Challenges

The articles in this issue that address substance use focus on the two leading contributors to the decline in US life expectancy: drug use and alcohol use. While drug use is the leading cause of death and disability in people aged 15-49, alcohol is the second leading cause of death and disability in this age group. Several important lessons emerge from the papers in this issue. First, supply-side strategies to address the overdose crisis may have limited beneficial impact and may produce unintended consequences. Second, implementation strategies are a key element that defines the impact of state and local laws on substance use. Third, funding strategies will define access to evidence-based strategies to prevent harms from substance use. Fourth, equity needs to be a central element in policy evaluation.

The impact that supply-side policies have on opioid use disorder and overdose is illustrated in two papers. Joshi and colleagues evaluated the impact of prescription drug monitoring programs with must-query mandates (PDMP-MQ) on overdose deaths. PDMP-MQs are considered one of the leading strategies to regulate opioid prescribing, including reducing inappropriate prescribing and dispensing, and identifying people at risk for opioid use disorder. Yet, concerns exist about potential unintended consequences of policies that restrict the prescription opioid supply, especially after a cohort of people became dependent on prescription opioids following the rise in use of opioids to treat chronic non-cancer pain. Indeed, the authors found that, while PDMP-MQs led to modest decline in overdoses involving prescription opioids, they were associated with an overall increase in overdose deaths. Interestingly, cannabis has been proposed as a substitute for opioids in the context of an increasingly restricted prescription opioid supply, and this has led to growing interest in the potential for cannabis legalization to serve as a tool to address the opioid crisis. McGinty and colleagues examined the effect of medical cannabis legalization on health care use related to cannabis use disorder, opioid use disorder treatment or overdose among Medicare beneficiaries under age 65 with chronic, non-cancer pain. They found no effect of medical cannabis legalization on health care use, suggesting that cannabis substitution may not happen with enough frequency or intensity to shift population-level trends in treatment or overdose. Together, these two papers suggest that a policy aimed at restricting the prescription opioid supply has had minimal impact on prescription opioid overdose deaths and may have contributed to a rise in overdoses involving illegal opioids. Increasing access to and availability of cannabis likely will not offer a feasible alternative for reducing population-level rates of opioid use disorder and overdose.

Policy implementation is another key theme that arises in this special issue. For example, Jordan and colleagues describe the New York State multi-agency implementation of programs to provide medication for opioid use disorder in New York State carceral facilities. While passing a law requiring opioid use disorder treatment in carceral settings was an essential element driving this investment, this paper makes clear that it was not sufficient, and points to the important role that multiagency collaboration at the state and local levels played in ensuring health care access to incarcerated populations. The authors provide a framework of key elements that led to the delivery of treatment across all county jails and state prisons, including funding (in this case, opioid settlement funds), leadership support, shared goals, training, and accountability through data collection systems. Lessons learned from this experience could help inform policy implementation in other areas of substance use policy.

Beginning in 2015, states could apply for 1115 Substance Use Disorder (SUD) waivers to strengthen their continuum of care for treatment of opioid use disorder. Lindner and colleagues examine waiver implementation in eight states between 2016 and 2021, finding that methadone use increased in Virginia, West Virginia, and New Jersey, while buprenorphine prescribing increased in Pennsylvania, Washington, and New Hampshire. Methadone and buprenorphine use both increased in Louisiana and Indiana. States employed a variety of strategies, including adding coverage, increasing reimbursement rates, and engaging providers and managed care organizations through education and training activities. These waiver strategies could be of interest to other states seeking to increase use of medications for treating SUD.

Cooper and colleagues consider policy implementation from the perspective of laws governing substance use during pregnancy. The United States has the highest maternal mortality rate of all high-income countries, and overdoses are a leading cause of these deaths. Punitive laws reduce prenatal care and substance use disorder treatment engagement. The authors discuss the need to study policy implementation to identify who benefits and who is harmed by laws regulating substance use during pregnancy, and to identify strategies for working with actors at multiple levels, including state executive branches, organizations entrusted to implement guidance, and service providers, in order to ensure all groups receive care in an equitable and non-stigmatized manner. The authors propose new directions for research methods to apply in the study of policy implementation; these strategies could help address an important gap in current substance use policy research.

Funding is an important driver of policy change. The special issue addresses two main sources of funding for substance use services: opioid settlement funds and Medicaid. Marshall and colleagues discuss the opportunity that opioid settlement funds offer to drive investment to address the opioid crisis. State and local governments have received more than $50 billion in opioid settlement funds over 18 years to address the harms from the opioid crisis. There is a need to invest in comprehensive approaches that include a combination of prevention, treatment, harm reduction, and recovery services. Marshall and colleagues offer guiding principles to direct investment, including creating formal processes for community engagement and input, strategies to promote transparency about spending and allocation decisions, ways to create sustainable funding streams following this initial investment, and the need for strong leadership in administering the funds. Saloner examines funding strategies from the perspective of Medicaid, one of the main funders of substance use disorder treatment services. The Mental Health Parity and Addiction Equity Act and the Affordable Care Act expanded eligibility and coverage by Medicaid, and increased requirements for the coverage of substance use disorder treatment services by Medicaid. Saloner discusses Medicaid policy innovations and challenges in expanding access to substance use disorder treatment under Medicaid. Innovations include building the delivery system, such as enforcing minimum standards of care, paying for low-threshold services, and promoting flexible opioid use disorder treatment strategies; using value-based payments to reward high-quality care; and promoting integration with housing, supported employment, and care during reentry from incarceration. At the same time, Saloner also discusses threats to Medicaid under the current federal administration, including capping federal expenditures on Medicaid, adding work requirements, and requiring states to pay a larger share of the cost.

Equity in policy implementation and impact is a cross-cutting theme in the special issue. For example, Joshi and colleagues show that the benefits and harms of PDMP-MQ were experienced in an inequitable fashion, so that the decline in prescription opioid overdose deaths following adoption of this policy occurred only among Whites, while the greatest increase in overall overdose deaths occurred among Hispanics and Blacks. Cooper and colleagues discuss how laws on drug use in pregnancy are enforced more harshly against structurally marginalized people, likely contributing to racial/ethnic disparities in maternal mortality. Their recommendations on research regarding policy implementation are provided through an equity lens, to reduce the inequitable impact of punitive laws on substance use during pregnancy, and to promote the adoption of laws that protect the health of pregnancy people who use drugs and their offspring. Marshall and colleagues discuss concerns about equity in the allocation of opioid settlement funds: despite recommended strategies to ensure equitable access to services, less than 4% of funds are being spent on targeted interventions for the communities experiencing the greatest risk of opioid-related harms. Saloner’s article suggests that the threats to Medicaid may only increase disparities in substance use-related harms, as Medicaid is the main funder of services for low-income individuals.

Several papers also make recommendations for new research directions in the area of substance use policy. Cerdá and colleagues provide an overview of methods from data science that can help answer questions regarding resource allocation to prevent substance use-related harms. Advances in artificial intelligence and data science can help us to develop better measures and identify the effects of laws, and to figure out where to target interventions, what types of demographic subgroups benefit the most and least from interventions, and what interventions to invest in for each setting and population. Readers may apply the methods proposed by Cerdá to answer the types of policy questions posed by Marshall and colleagues, Saloner, Jordan and colleagues, and Cooper and colleagues, among others.

Lessons Regarding Consumer Product Challenges

Decades of research suggest that the government has enormous power to regulate consumer products in ways that can reduce substance use and protect public health. However, governments often make decisions that are divorced from the research evidence. This issue is highlighted by papers that focus on alcohol and e-cigarettes as consumer products. Jernigan, for example, discusses the devolution of control to states on the regulation of alcohol, including taxation, advertising, and operation of alcohol retail outlets. Despite evidence on the effectiveness of taxes to reduce alcohol use, and lobbying to increase taxes, the value of alcohol taxes has substantially declined. Further, while alcohol outlet density has been shown to affect alcohol use and related harms, states have rarely used their powers to control density by limiting licenses or putting conditions on their operation, including limits on days and hours of sale. Sánchez and colleagues discuss a similar issue as it relates to the regulation of e-cigarettes: using Monitoring the Future data, they find that adolescents who use menthol-flavored e-cigarettes are disproportionately more likely to also use cigarettes, smokeless tobacco, cigars/hookah, and alcohol. Co-use of e-cigarettes with other substances places youth at greater risk for mental health problems and distress. Yet, menthol e-cigarettes are often exempt from federal, state, and local regulations on e-cigarettes, rendering the regulations ineffective for youth at risk of co-use. By closing exemptions and broadening flavor restrictions to all non-tobacco flavors, governments have the potential to accelerate reductions in vaping among a key at-risk population.

A contrast between scientific evidence and public policy also exists in the case of consumer products that are intended to protect public health. Such is the case with tools intended to reduce the harms associated with substance use. Davis and colleagues discuss the legal barriers to safer smoking equipment access. They present data showing a shift from injecting to smoking or inhaling drugs, and a subsequent increase in smoking-related deaths. This shift makes access to safe smoking equipment, to prevent health-related complications and the spread of infectious-disease associated with smoking, ever more vital. Syringe service programs provide a venue to distribute safer smoking supplies. Hence, removing legal barriers to accessing smoking supplies should be a policy priority. But laws do not follow the public health evidence. In fact, many states criminalize the sale, possession, and distribution of smoking supplies, thus posing a barrier to reducing smoking-related harms.

Several papers in this issue highlight the role that commercial interests play in public health in the United States, as private industry lobbies to loosen regulations of consumer products and uses its resources to market products such as alcohol, e-cigarettes, cannabis, and prescription opioids. Jernigan points out the imbalance between the resources available to private industry to lobby for regulatory changes, and the lack of funding, workforce capacity, and training available for the public health sector to advocate for public health-informed policy. Nevertheless, an opportunity exists to leverage state revenue from taxation of consumer products such as alcohol and cannabis, as well as opioid settlement funds, to create broad coalitions that pressure states to use the powers granted to them to regulate consumer products. Firearms is another pertinent example, with a powerful firearm industry influencing efforts to regulate access at the state and federal levels. Joyce and Swanson detail a risk-based firearm removal policy in Maine, the extreme risk protection order, as an example of a scalable policy approach shown to reduce suicide. While other states use this policy to support temporary removal of firearms from individuals exhibiting dangerous behavior due to any cause, Maine has a version of this law that specifically focuses on individuals deemed by a court to be at high risk of dangerous behavior due to mental illness. Implementation in this narrower, mental health context proves challenging, garnering tension between the mental health and law enforcement communities.

Social media has emerged, over the past decade, as a prime target for regulation. Thimm-Kaiser and Keyes consider the rapidly evolving landscape of state policies regulating social media use for adolescents, such as policies that place age restrictions for accessing social media platforms, and policies prohibiting algorithms that suggest content to minors. An important theme of this paper, which is relevant to many other papers in the special issue, is the challenge of policymaking in the face of limited and mixed evidence, particularly as evidence on the role of social media in mental health for teens and others—and the evidence on strategies to reduce negative impacts—is rapidly changing.

While the papers presented in this special issue capture the present state of the science, we need to go much further to ensure that the science serves to advance mental health and to ensure the reach and effectiveness of psychiatric and substance use disorder prevention, treatment, and recovery services for all affected populations. The shortcomings of existing state-level policies and interventions, as outlined in this collection of papers, must be further analyzed and evaluated in ways that are responsive to the challenges faced by state policymakers and that will lead to more effective policies and interventions capable of making a difference in the lives of those most affected by mental health and substance use harms. It is our hope that this special issue of the Quarterly will help point the way toward ever stronger scholarship and evidence-based policymaking.

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