5

Governance and Partnerships

Governance¹ is a component of the prevention infrastructure at all levels—from the array of federal agencies that fund research and practice, to state agencies that channel federal funding to communities and provide workforce support, certification, and other resources, to local government, community-based organizations, community members, and a wide array of academic, association, and other partners. The infrastructure supports the delivery of evidence-based programs (EBPs) and policies to reduce risk factors and strengthen protective factors (both upstream and downstream) along the life course. This infrastructure needs to bring together various sectors at different levels of government (federal, state, tribal, and local) and other partners, connect these components, and be guided by a vision of health equity—“the state in which everyone has a fair opportunity to attain their full potential for health and well-being, and no one is disadvantaged from doing so because of social position or other socially defined circumstances” (NASEM, 2023). As in programs and in policies, implementation science (IS) approaches are key to making governance effective.

The national mental, emotional, and behavioral (MEB) disorder prevention infrastructure is embedded in existing systems, including the public health, health care, and human services infrastructures (the latter includes

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¹ Governance, as defined by the United Nations, is “participatory, consensus oriented, accountable, transparent, responsive, effective and efficient, equitable and inclusive, and following the rule of law” (WHO, 2021).

child welfare and aging services). Partnerships with other sectors also are crucial, including with education and criminal-legal settings. The guiding principles of implementation science and health equity (in the context of governance, the latter refers to tailoring to local and cultural contexts and prioritizing community-driven partnerships) are necessary to inform each component, i.e., reach each “gear” by “flowing” throughout the infrastructure as illustrated in Figure 1-1. Attention to these principles will drive each gear forward and ensure that this infrastructure will meet the needs—and integrate the experience and voice—of all communities, including those that have been historically excluded or marginalized.

This chapter provides an overview of federal, state, territorial, tribal, and local governance mechanisms (government leadership focus) and governance supports, including those from the private sector to the work of delivering interventions that prevent MEB disorders and promote MEB health. Governance in public health has been described through six functions (Carlson et al., 2015), which apply broadly to governance in the prevention domain examined in this report:

1. Policy development (e.g., Substance Abuse and Mental Health Services Administration (SAMHSA) or state agency regulations),
2. Resource stewardship (e.g., block grants and other grant programs),
3. Continuous improvement (through well-supported evaluation, e.g., via government–academic and community–academic partnerships),
4. Partner engagement (e.g., through the National Prevention Network, relationships with national associations of state directors),
5. Legal authority (derived from Title V of the Public Health Act), and
6. Agency oversight.

Funding and sustainability—of both financing and effective programming—are crucial outputs of an effective governance structure. The committee asserts that to explore and make recommendations about strengthening funding and sustaining resources and efforts, it is necessary to articulate a vision of the attributes of governance that are needed: more connected, more cohesive, better coordinated, and integrated where appropriate.

Governance of the prevention infrastructure for MEB disorders is primarily shared by U.S. federal and state government agencies, although a wide range of public-sector entities at the federal, state and territorial, tribal, and local levels perform functions that include funding, providing oversight, regulating, setting standards and holding accountable, and collaborating with varied private-sector entities. Any discussion of governance also requires attention to a list of partners, exploration of centralized authority/leadership, and the meaning of leadership in this complex context

and considering federalism and how it operates with regard to the MEB infrastructure. Federalism refers to “the division and sharing of power between the national and state governments.”² In the context of prevention, the federal role is one of funding, supporting, advising, and interacting with states as partners with primary responsibility for their populations. The federal government also interacts with states’ sometimes-divergent approaches, which can create both challenges (e.g., too much flexibility that leads to gaps in coverage) and opportunities (e.g., testing innovations) (Willison et al., 2021).

This chapter also discusses the issue of parity in the context of health care and how leadership action is needed to fulfill the promise of the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA), which “generally prevents group health plans and health insurance issuers that provide mental health or substance use disorder (MH/SUD) benefits from imposing less favorable benefit limitations on those benefits than on medical/surgical benefits” (CMS, 2024a). However, the Act only required that health plans and insurers avoid less favorable or more limited MH/SUD benefits; it did not require that they provide coverage for MH and SUD. That requirement was added by the Affordable Care Act of 2010 (ACA), included as part of a package of 10 essential benefits, leaving it up to the states to interpret this. While the U.S. health care delivery sector acknowledges the importance of BH parity, the reality does not align with the aspiration. In September 2024, the Departments of Health and Human Services (HHS), Labor (DOL), and Treasury released final rules on implementing MHPAEA to further improve parity, although outcomes of these changes remain to be seen (CMS, 2024a).

This resembles the value ascribed to prevention but the lack of follow-through with commensurate investment. On a more positive note, in the context of prevention, the spirit of parity seems to inform the integration of screening for MEB disorders in the Early Periodic Screening, Diagnosis, and Treatment benefit provided to children under 21 enrolled in Medicaid, and in Screening, Brief Intervention, Referral, and Treatment services delivered in primary care settings, emergency departments, and other community settings (Medicaid.gov, n.d.; SAMHSA, 2024a).

Examining the prevention infrastructure highlights the many levels of authority and responsibility characterizing federal, state, and local governance and difficulties in bringing them into coordinated, long-term efforts. Not only must key actors be identified; their existing spheres of influence and powers must be reconciled toward a common purpose. Overlapping,

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² https://constitution.congress.gov/browse/essay/intro.7-3/ALDE_00000032/ (accessed April 30, 2025).

sometimes competing, sources of authority and distinct organizational structures that should (but do not always) work in concert with local communities and actors can make large-scale preventive interventions difficult.

FEDERAL GOVERNANCE STRUCTURE

Federal departments, including HHS, Department of Veterans Affairs (VA), and the Department of Defense (DoD), support, oversee, and sometimes operate programs offering preventive interventions, or programs that might be adapted to integrate prevention components at the state and local levels. At federal, state, and local levels, the existing BH infrastructure is primarily in health care services (NASEM, 2024). Health care services examples can range from primary care settings where people may be screened for early signs of MEB disorders, such as anxiety, depression, or alcohol or substance use disorders, as well as clinicians providing cognitive behavioral therapy (which could serve as primary or secondary prevention). The infrastructure for preventing MEB disorders overlaps with the public health infrastructure and parts of the human services infrastructure (e.g., child welfare systems at the state and local levels, aging services). At the federal government level, governance of the prevention infrastructure is fragmented, with greater centralized attention and support for SUD compared to MH. The substance use domain has a central point of coordination in the White House Office of National Drug Control Policy (ONDCP), which works closely with other executive branch entities focused on substance use, while the MH domain has no central coordination.

HHS has several agencies with responsibilities relevant to MH and SUD. These include the Substance Abuse and Mental Health Services Administration (SAMHSA), the National Institutes of Health (NIH), Centers for Disease Control and Prevention (CDC), Health Resources and Services Administration (HRSA), and the Indian Health Service. SAMHSA’s administrator is also the assistant secretary for MH and SUD, an important but perhaps insufficient point of connection between the two sides of the agency, which has the Center for Substance Abuse Prevention (CSAP) and Center for Substance Abuse Treatment (CSAT) but only one Center for Mental Health Services (CMHS), which oversees both treatment and prevention. SAMHSA’s major funding outlays (discussed in Chapter 6)—its Substance Use Prevention, Treatment, and Recovery Services Block Grant (SUBG) and Community Mental Health Services Block Grant (MHSBG)—are similarly asymmetrical. Congress requires that 20 percent of the former be set aside for prevention, while the latter is entirely devoted to addressing serious mental illness (SMI) and may not be used for prevention (SAMHSA, 2017). In addition to the block grants, all three centers also provide discretionary grant programs known as the Programs of Regional and National

Significance (PRNS). PRNS grants from the CMHS are largely secondary/tertiary prevention and treatment oriented but include suicide prevention and Project LAUNCH (on child resiliency). PRNS for substance use prevention include the Strategic Prevention Framework and Sober Truth on Preventing Underage Drinking (STOP) grants. SAMHSA’s support for SUD is strengthened by ONDCP grant programs, such as the Drug Free Communities support program managed through an ONDCP partnership with CDC.

CDC includes the National Center for Injury Prevention and Control, whose priorities include preventing adverse childhood experiences, overdose and substance use–related harms, and suicide. It also focuses on preventing community violence—a risk factor for MEB disorders (McDonald and Richmond, 2008).

Multiple institutes, centers, and offices in NIH contribute to the research that informs the prevention infrastructure. These include National Institute on Drug Abuse, National Institute on Mental Health, National Institute on Alcohol Abuse and Alcoholism, National Institute on Child Health and Human Development, and the Office of Behavioral and Social Sciences Research, for example. The history of NIH is intertwined with the nation’s shifting views of mental illness, and the pendulum swinging between two ways of addressing these issues, from the biomedical approach to the psychosocial and public health approach. The historian Anne Harrington (2023) noted that the National Mental Health Act of 1946 marked a milestone in the nation’s recognition of mental illness as a public health problem, which began with the mental hygiene movement, and a shift from direct care to affected individuals toward prevention across the entire population. The act established National Institute of Mental Health, initially as a part of the Public Health Service. Reorganizations of the service, training, and research functions of federal agencies that focused on MH and SUD reflected broader societal preoccupations with these issues. Although the 1963 Community Mental Health Act fell short of fulfilling its promise, it reframed the focus from state psychiatric hospitals and toward community care settings (BPC, 2019). The 1965 launch of the first neighborhood health centers, later community health centers, supported by President Johnson’s War on Poverty, funded by the Office of Economic Opportunity, and offering comprehensive, community-based health care (including MH and SUD care) along with other social services, provided an early glimpse of health care services that prioritized closing the gaps in health affecting poor, rural, and minoritized communities, and were responsive to health-related social needs (e.g., for food, housing).

The history of the MH and SUD components of HHS is complex and multidimensional. It includes the War on Drugs, which, like President Kennedy’s Community Mental Health Act (intended to solve the problems with state mental hospitals), sought to fix the problem of drug use and

associated criminal activity. As the dialogue about prevention developed and federal resources grew considerably, an ecosystem of agencies and organizations (see Table 1-1) emerged and developed, representing services and research components, along with advocacy for prevention research, support for community engagement, and other extensive networks and interactions. The ecosystem includes the Society for Prevention Research, National Prevention Network, and CADCA—the membership organization for national (and some international) substance use prevention coalitions. This robust network is largely oriented around preventing substance use, while the ecosystem around MH issues is almost entirely devoted to treatment. While the Prevention Technology Transfer Centers (PTTCs) are the prevention counterpart to the Addiction Technology Transfer Centers, the analogous Mental Health Technology Transfer Centers (MTTCs) (ended in September 2024) focused almost entirely on treatment of MH.

Interagency Coordination

There are several examples, both historic and current, of interagency entities established for the purpose of furthering aspects of prevention or well-being. Federal interagency coordinating entities on behavioral health, such as the Federal Executive Steering Committee for Mental Health, last active in 2009, can play an essential role in improving coordination (GAO, 2014). The existing Interagency Task Force on Trauma-Informed Care established in 2018 and chaired by the Assistant Secretary for Mental Health and Substance Use, includes in its membership multiple departments, including the Departments of Justice (DOJ), the Interior, Education (ED), VA, and Housing and Urban Development. The following problem statement and outcomes statement have been articulated for the Task Force:

Because trauma is a risk factor for MEB disorders, the Task Force has clear relevance to the coordination functions discussed below, including in Recommendation 5-1.

In the broader prevention domain, the ACA established the National Prevention, Health Promotion, and Public Health Council (National Prevention Council or NPC), which, with its National Prevention Strategy and led by the U.S. Surgeon General, provided “coordination and leadership among 20 executive departments and agencies with respect to prevention, wellness, and health promotion activities” (NPC et al, 2014, p. 3). Although it concluded its work in 2015, its examples of interagency coordination and partnership have lasting relevance. These include the Sustainable Communities Initiative (Lushniak et al., 2015), which was a partnership among the Departments of Housing and Urban Development and of Transportation and the Environmental Protection Agency that included coordinating on policies and programs and, even more germane to the topic of this report, how ED partnered with DOJ and HHS to launch a School Climate Transformation Grant Program in FY 2014 (HUD Exchange, n.d.; NPC et al., 2014).

In 2022, HHS spearheaded an interagency effort in response to the COVID-19 pandemic and a shared recognition of the need for coordination and partnership. The Office of the Assistant Secretary launched the Equitable Long-Term Recovery and Resilience (ELTRR) initiative and plan. Although it does not have an NPC-like “body” associated with it, it has an interagency coordination group. Its recommendations include, in the category of “Basic Needs for Health and Safety,” several that are relevant to promoting MEB health and well-being (see Box 5-1).

As noted, since the disbandment of the National Prevention Council (whose remit was public health and prevention, broadly conceived), there has been no equivalent whole-of-government effort to coordinate and collaborate on a prevention agenda—either broad or specific to MEB health. The ELTRR initiative is promising in its focus on the societal factors that shape health and well-being (e.g., education, housing), but its priorities go well beyond improving MEB health.

There is a “drug czar” in the public official who leads ONDCP, but no BH leader (with combined focus on MH and SUD) or entity that represents an organized “whole-of-government” effort across the federal executive branch to prevent BH disorders. HHS is the main department devoted to supporting and overseeing the delivery of BH interventions, with some siloing between MH and SUD activities in both SAMHSA and CDC. But multiple agencies across the federal government have prevention functions

and would benefit from coordination. These include the DoD, ED, DOJ, and VA. Given the fact that the prevalence of behavioral disorders is a national crisis, it requires top federal leadership to avoid higher economic and health care costs of MEB disorders. Furthermore, White House leadership is needed to spearhead and support coordination across departments.

Related to promoting better governance of the prevention infrastructure and interagency coordination across the federal government, the Foundations of Evidence-Based Policymaking Act of 2018³ requires federal

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³ Foundations of Evidence-Based Policymaking Act, Public Law 115–435, 115th Cong., 2nd sess (January 14, 2019).

agencies to develop evidence-building plans, called “Learning Agendas.” A 2024 search of these across the federal government for mentions of BH found that, besides HHS, four agencies and two cross-agency plans included priorities relevant to MEB health (Evaluation.gov, n.d.; Tsai, 2024). The analysis provides two insights relevant to preventing MEB disorders. First, the Learning Agendas underscore “a focus on promoting social and emotional well-being, particularly among school children (ED), veterans with disabilities, and veterans with military sexual trauma” (Tsai, 2024, p. 15). Second, they largely overlook the relationship between physical and mental health, “aside from the [USDA] which briefly mentioned the link between food security and mental health” (Tsai, 2024, p. 15). The Learning Agenda developed by executive branch agencies may offer a point of connection across agencies on promoting MEB health that could inform coordination and collaboration (see Box 5-2).

Intradepartmental Coordination

The committee notes the existence of an HHS Behavioral Health Coordinating Council (BHCC) announced in 2021 and described as an intradepartmental effort to “facilitate collaboration and strategic planning” on behavioral health issues.⁴ However, the committee has found little information about BHCC and its work, and the few references suggest the focus is primarily to address behavioral treatment needs.^5,6 Based on publicly available information, the committee was not able to ascertain the extent to which the BHCC focuses on BH prevention. The BHCC or a similar body is needed to ensure a greater focus on MEB prevention, for example, in integrating MH promotion and substance use prevention objectives in the way funding opportunities are developed, and in the technical assistance and other support provided to states. An earlier iteration of the BHCC was in existence in 2009 and 2011, with indications that it included subcommittees, such as a subcommittee on primary care and behavioral health integration.⁷

In 2023, CDC established a Behavioral Health Coordinating Unit, whose mission is to “elevate, advance, and coordinate CDC’s public health approach to promote mental well-being and prevent mental distress, substance use,

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⁴ https://www.samhsa.gov/newsroom/press-announcements/202105181200 (accessed January 13, 2025).

⁵ https://www.apa.org/news/press/releases/2021/05/hhs-behavioral-health-coordinating-council (accessed January 13, 2025).

⁶ https://www.naatp.org/advocacy/public-policy/hhs-creates-behavioral-health-coordinating-council/may-18-2021 (accessed January 13, 2025).

⁷ https://crs.od.nih.gov/CRSPublic/View.aspx?Id=5278; https://crs.od.nih.gov/CRSPublic/View.aspx?Id=2501 (accessed January 13, 2025).

overdose, and suicide. This includes a focus on behavioral health as a necessary component of well-being across the life course, particularly during early childhood and adolescence” (Abad, 2024, p. 12). This mechanism suggests a focus in CDC to integrate disparate prevention-oriented BH efforts into a more cohesive and coordinated whole. With regard to community partner engagement, the agency’s Centers for Substance Abuse Prevention, Substance Abuse Treatment, and Mental Health Services each have advisory committees, but all members appear to be federal officials or professionals in the BH field; none of the committee members were identified as community members with lived experience (SAMHSA, n.d.-a).

The federal government lacks coordination on MEB disorder prevention, both between agencies with separate and somewhat siloed units on MH and substance use and among all federal entities with a role in MEB health. Establishing a central point for improving coordination—at the highest level of the federal government, at the department level, and at the agency level, i.e., in SAMHSA—will be helpful across multiple dimensions of prevention, from research, to funding, to supporting the workforce development and functioning.

The committee found that it is a coordination challenge that SAMHSA, like the entire BH enterprise, is asymmetrical in its structure, with greater attention to preventing substance use than promoting MH. It has separate centers for substance use prevention and SUD treatment but only one center for MH with functions in both treatment and to a far lesser extent, prevention; there is a 20 percent prevention set-aside from the SUBG but no analogous set-aside from the MHBG, which is devoted to treating SMI. For a well-functioning prevention infrastructure, greater integration or at least collaboration is needed between the MH and SU prevention functions of SAMHSA.

A multi-layered approach is needed to strengthen coordination, collaboration, and support for prevention. The committee believes it is reasonable to assume that a stronger locus in SAMHSA for prevention efforts related to MH would be helpful, including for the purpose of (at a minimum) greater coordination and (ideally) integration between prevention efforts in mental health and substance use, and ultimately, for creating conditions for improving population level MEB outcomes. In the current structure, the governance for MEB disorder prevention is uneven, with greater attention in SAMHSA and elsewhere in the ecosystem to prevention of substance use than to promotion of mental health. An integrated prevention infrastructure requires similar level of attention to substance use and mental health along with greater collaboration and ideally integration, with better interagency coordination among all agencies working on aspects of MEB disorder prevention, and with top federal leadership to drive change.

RECOMMENDATION 5-1: To strengthen capacity and coordination to promote mental, emotional, and behavioral (MEB) health and population well-being, governance structures for prevention should be added at each level in the Executive Branch.

1. The White House could establish a central point for MEB prevention capacity and coordination. There are two options for doing this: appointing a special assistant on MEB disorder prevention to the president who serves on the Domestic Policy Council, or establishing a new office on MEB prevention in the White House. Either the special assistant or the new office would coordinate with the Office of National Drug Control Policy and the Office of Management and Budget, and convene all executive branch departments with a role in prevention, perhaps through an interagency task force. An office would require more resources than a special assistant, but could support a more robust portfolio of efforts to streamline and enhance coordination throughout the Executive Branch. There is a history of interagency task forces spearheaded or called for by an Administration to help implement a strategic objective. The relevant executive branch departments include Health and Human Services (HHS), Department of Education, Veterans Affairs, Department of Defense,⁸ U.S. Department of Agriculture, Department of Justice, and Department of Labor and Department of Treasury;
2. The HHS Behavioral Health Coordinating Council (or similar intra-departmental entity) could establish a workgroup on promoting MEB health and preventing MEB disorders and adopt strategies to engage individuals with lived experience; and
3. Congress could expand the Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) ability to support state, tribal, and local MEB disorder prevention efforts by either establishing a Center for Prevention of Behavioral Disorders that integrates the agency’s prevention activities, or by establishing a Center for Mental Health Promotion (equal to and working closely with the existing Center for Substance Abuse Prevention). In addition, the SAMHSA administrator, who is also the Assistant Secretary for Mental Health and Substance Use, should appoint a prevention advisor to support and report on state efforts to prioritize prevention.

Given the societal and economic costs of behavioral disorders and the existence of many evidence-based programs to prevent them, elevating MEB

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⁸ DoD’s prevention integration initiative is illustrative of high-level attention to prevention in domains external to HHS. https://www.prevention.mil/ (accessed October 1, 2025).

disorder prevention in this manner could have a profound impact. Also, the Domestic Policy Council comprises all domestic cabinet secretaries and advises the President on domestic and economic initiatives important to a given administration (Troy, 2025), and special assistants to the President play a key role in advising the President on a given issue of national importance.⁹ For example, President Bill Clinton’s DPC “led the effort to develop and pass welfare reform and the crime bill,” while President George W. Bush’s DPC “was the leading force behind the enactment of ‘No Child Left Behind’” education reform effort (Weinstein, 2008, p. 67-68). Clearly DPC leadership on an issue can drive policy change.

Past and current examples of federal interagency task forces, on which a task force for MEB disorder prevention could be modeled, are discussed above.

Regarding (b), an entity such as the Behavioral Health Coordinating Council (BHCC) could facilitate coordination among multiple agencies in HHS that conduct and fund a variety of activities related to behavioral health prevention. Coordination could help address fragmentation in addressing this topic of great national interest, and could improve efficiency of programs (GAO, 2014).

Regarding (c), CSAP¹⁰ works with state, tribal, local, and private sector organizations engaged in prevention efforts, and serves as a central point for thought leadership on substance use prevention, technical assistance, oversight of prevention-focused grants, and development of prevention strategy. For mental health promotion, it is not evident that the Center for Mental Health Services is able to play the same range of roles. The CMHS¹¹ has a division of Children and School Mental Health which includes a Mental Health Promotion Branch, but there is no other mental health promotion unit, suggesting limited capacity to support mental health focused prevention for other age groups and settings. Establishing a CSAP-equivalent Center for Mental Health Promotion or a joint Center for Behavioral Disorder Prevention would help ensure that prevention of mental illnesses is being at least well-coordinated with prevention of substance use, and ideally, that these are integrated. Finally, the SAMHSA prevention advisor’s role could include using the levers of the block grants to incentivize state health agencies to enhance prevention efforts, supporting (e.g., through funding, technical assistance) prevention leaders in states. As noted later, it is important that this strengthened governance structure be linked with state-level leadership for prevention.

If establishing a new center—which requires an amendment to Title V of the Public Health Service Act—proves unfeasible, other approaches could

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⁹ For examples, see The American Presidency Project https://www.presidency.ucsb.edu/ (accessed January 13, 2025).

¹⁰ https://www.samhsa.gov/about/offices-centers/cmhs (accessed January 13, 2025).

¹¹ https://www.samhsa.gov/about/offices-centers/cmhs (accessed January 13, 2025).

be considered to strengthen coordination and collaboration between promotion of mental health and efforts to prevent substance use disorders. Also, it is important to note that the SAMHSA National Mental Health and Substance Use Policy Laboratory (Policy Lab) could play a role in the coordination and to some extent, integration, of mental health and substance use prevention efforts in SAMHSA. The Policy Lab “coordinates cross-SAMHSA and inter-agency policy efforts and promotes coordination and collaboration of SAMHSA programs” (GAO, 2024). It has two teams relevant to this issue: the Evidence-Based Practices Innovation and Dissemination Team and the Policy Analysis, Development, and Implementation Team.

The leaders to be appointed in Recommendation 5-1 will need training and expertise in identifying and addressing health disparities and in implementation science. Establishing a Center for Mental Health Promotion will require attention to functions and capabilities analogous to those of CSAP and a mandate and resources for coordination and collaboration with CSAP—including in grant requirements, guidance for data collection, integration, and reporting (including sharing with communities). Like CSAP, the new center could have divisions for primary prevention, targeted prevention, workplace or community programs, prevention communications and public engagement, innovation, and program analysis and coordination (SAMHSA, n.d.-b).

The alternative option of a joint Center for (MEB Disorder) Prevention would need to bring together existing functions of CSAP with equivalent functions for mental health promotion. A center that integrates prevention functions related to both mental health and substance use would present some advantages, such as potential for true integration and not just coordination both internally in SAMHSA and in relationship to the state agencies working on substance use and mental health. The siloed funding channels for mental health and substance use would be a considerable barrier to overcome, as would the requirements associated with the funding (e.g., limited ability to use substance use prevention funds for mental health promotion) (SAMHSA, 2017).

There are some advantages and disadvantages to the two options proposed. Organizations and individuals who champion substance use prevention may fear that integrating MH and SU could mean decreased attention to SU. On the other side, there may be people or organizations that worry that having a center for promoting MH in SAMHSA and taking a set aside from the Community Mental Health Services Block Grant may decrease attention to serious mental illness. Dialogue among all partners and constituencies could address concerns, but it must be emphasized that the status quo is suboptimal for a coherent and well-coordinated national prevention infrastructure.

STATE GOVERNANCE STRUCTURE

Given the U.S. federalist system of government, the federal government cannot compel states to work in furthering prevention or any other health improvement efforts. Federal agencies partner with states, providing funding, technical assistance, and other incentives to engage in best practices, follow standards, or coordinate with various partners. The structure of state and local governance of prevention varies (SAMHSA, 2017). Some states have a public health agency and a separate BH agency; in others, public health agencies include BH functions, such as assessment of risk factors and partnerships with relevant community organizations, such as anti-drug coalitions.

State public health agencies can play an important role in establishing baseline infrastructure in localities in the state. Funding for public health efforts needs to include attention to promoting BH and preventing MEB disorders. Public health agencies integrate MEB health promotion efforts in collaboration with schools at the state and local level.

States play a central role in delivering prevention services along the life course and providing or contracting with other entities for extensive and ongoing technical assistance. However, as with other components of the existing infrastructure, state oversight and support of MH and SUD differ markedly, with the latter being far more prevention oriented in focus, funding, organization, oversight, and supports to local providers and workforces. Presentations to the committee by the National Association of State Alcohol and Drug Agency Directors (NASADAD) and the National Association of State Mental Health Program Directors highlighted those differences. The former’s remarks highlighted aspects of a robust multilevel prevention infrastructure for SUD, while the latter reflected a focus on mental illness (including community and carceral care settings) and crisis care and suicide prevention (supporting the implementation of the 988 Suicide and Crisis Lifeline).

Single state authorities (the state agencies that received SAMHSA funding for substance use prevention) provide oversight of regional, county, and local providers (NASADAD, 2023). State health authorities oversee the allocation of federal grants, but states vary in their capacity and resources to provide regional oversight, coordination, and training and technical assistance. The committee reviewed three state-level examples: New York, Pennsylvania, and Washington. These each provide robust support to the state’s SUD infrastructure through a range of activities, including Pennsylvania’s partnership with the Evidence-Based Prevention and Intervention Support Center, which includes supporting a staff position;¹² New York’s

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¹² Personal communication, Grace Kindt, May 2024.

six regional prevention resource centers; and Washington’s State Prevention Enhancement Policy Consortium, which hosts the Athena Forum, a resource that provides training and technical assistance to prevention providers and communities (The Athena Forum, 2024; PSU, 2020; OASAS, n.d.).

As a condition of SAMHSA prevention funding, states could be asked to appoint prevention leads (both SUD and MH) to ensure funding is used effectively and coordination and collaboration between the SUD and MH silos is maximized in program delivery. This would allow the governance structure described in Recommendation 5-1 to expand beyond the federal government. As noted in Chapter 6, SAMHSA prevention funding is primarily for SUD prevention, and includes the 20 percent prevention set-aside in the SUBG and the Strategic Prevention Framework—Partnerships for Success Grant Program.

State departments of BH and/or public health play a key role in what Wandersman and colleagues call the “Interactive Systems Framework for Dissemination and Implementation” (Wandersman et al., 2012). This three-part framework outlines the roles and relationships among the entities that develop, select, and support the implementation of evidence-based preventive interventions. This includes the Prevention Synthesis and Translation system that “designs interventions and creates tools for their widespread implementation” by the “Prevention Delivery System” (e.g., local health department, community organizations), which is in turn supported by and receives technical assistance from the “Prevention Support System” (e.g., state health department, universities). The prevention support system includes research institutions that have created models to build, support, and evaluate the effectiveness and implementation of community coalitions and prevention programming that are well positioned to support these training needs. These models include the network of PTTCs¹³ that can provide implementation support and technical assistance on SUD prevention and the network of CDC-funded prevention research centers,¹⁴ some of which have an MEB health promotion focus. In government–academic partnerships, universities support state efforts to promote MEB health—providing research support and using state funding to provide training and technical assistance. The MHTTCs offered training and technical assistance largely for providers of MH treatment services and, to a lesser extent, those in education, child welfare, and law enforcement systems (MHTTCN, 2024).¹⁵

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¹³ https://pttcnetwork.org/ (accessed January 13, 2025).

¹⁴ https://www.cdc.gov/prevention-research-centers/php/index.html (accessed January 13, 2025).

¹⁵ Personal communication, H. Gotham, July 26, 2024.

TRIBAL GOVERNANCE

The United States’ complex relationship with the American Indian and Alaska Native (AIAN) population is relevant to the infrastructure for MEB disorders for two reasons. One is functional, given the fact that 574 federally recognized AIAN tribes are recognized sovereign nations—allowing self-governance—and their interactions with the federal government are government-to-government interactions (NCAI, 2020). The other reason is the historic trauma that has affected generations of AIAN people (NASEM, 2023). Different departments (HHS, Interior, and Justice) and health agencies (e.g., IHS, SAMHSA, CDC) in the federal government interact with tribal leaders. HHS has a Tribal Advisory Committee, and SAMHSA has an Office of Tribal Affairs and Policy and an Office of Indian Alcohol and Substance Abuse (SAMHSA 2024b; 2024c). Also, the Indian Health Service Division of Behavioral Health interacts with tribal governments, and it initiates Tribal Consultation and Urban Confer events to solicit comments on the distribution of annual behavioral health initiative funding. The Division’s National Tribal Advisory Committee on Behavioral Health convenes regularly to make recommendations based on the input IHS receives from the Tribal Consultation and Urban Confer.

In 2016, SAMHSA and IHS developed a National Tribal Behavioral Health Agenda (NTBHA) with extensive input from tribal leaders with the assistance of the National Indian Health Board (SAMHSA and IHS, 2016). At the department level, HHS has a Tribal Advisory Committee, which also played a role in informing the NTBHA. The agenda’s three components include the American Indian and Alaska Native Cultural Wisdom Declaration (CWD), sections that provide background information, and a section that articulates the substance of the agenda (SAMHSA and IHS, 2016). Notably, and echoing the discussion provided in Chapter 2 about attention to cultural context and practice-based evidence, the CWD’s purpose is to “ensure that cultural wisdom and traditional practices are taken into account and supported as fundamental elements of programs, policies, and activities that are designed, or contribute, to improvements in behavioral health” (SAMHSA and IHS, 2016). The TBHA consists of five foundational elements (see Figure 5-1): historical and intergenerational trauma, sociocultural-ecological approach, prevention and recovery support, behavioral health systems and support, and national awareness and visibility. Community engagement and collaboration is a throughline in the report.

The research component of the tribal governance ecosystem is the Native American Research Centers for Health (NARCH) program, a collaboration between NIH and IHS. With greater engagement in both research and practice, “a growing number of tribes have initiated their own Tribal review processes to

govern research efforts undertaken on Tribal lands and with Tribal members” to further Tribal knowledge and public health (SAMHSA and IHS, 2016).

In addition to federal collaboration with Tribal governments, there are multiple examples of states partnering with tribes to deploy funding to improve behavioral health. For example, the Oregon Health Authority partners with tribes to support and expand access to behavioral health services, and to an array of resources that include Tribal Behavioral Health Resource Networks (Gooding et al., 2024). Oregon, along with three other states (HHS, 2024), has received CMS approval for a section 1115 demonstration amendment that allows “Medicaid and Children’s Health Insurance Program (CHIP) coverage of traditional health care practices provided by I/T/U [Indian Health Service, Tribes and Tribal organizations, and urban Indian organizations] facilities” (CMS, 2024b). In Oklahoma, 13 tribes partnered with the state’s Department for Mental Health and Substance Abuse Services to use SAMHSA Tribal 988 grant funding for suicide prevention programs (SAMHSA, 2024d; Gooding et al., 2024). Although no details about these programs were easily accessed, the IHS website provides an overview of funded tribal Substance Abuse and Suicide Prevention programs by state and indicates that several Oklahoma tribal authorities have implemented evidence-based, practice-based, strengths-focused, culturally sensitive suicide prevention programs.¹⁶

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¹⁶ https://www.ihs.gov/sasp/fundedprojects/oklahoma/ (accessed January 13, 2025).

REGIONAL AND LOCAL GOVERNANCE STRUCTURE

At regional and local levels, public agencies can and do play key roles in preventing MEB disorders, though the way these efforts are organized may differ substantially across different jurisdictions. For example, while San Francisco and Philadelphia are similar as both cities and counties, San Francisco’s BH services are located within the public health department, while the City of Philadelphia’s Department of Behavioral Health and Intellectual disAbility Services is distinct from public health. The latter model affords the BH department an unobstructed focus on MEB issues, including prevention, but for all city residents to enjoy optimal MEB health, collaboration and coordination between two separate departments is required. Many communities also have a variety of nonprofit organizations, government agencies, coalitions or partnerships, and community entities, including congregations, that work together to promote MEB well-being. Also, organizations that play the role of community integrator may serve as both a governance mechanism for collective impact initiatives and facilitator for partnerships, capacity building, and funding (McHale, 2014).

Implementation, Partnerships, and Collaboration

Multisector community partnerships can weave together efforts to develop and implement interventions to prevent MEB disorders and promote population well-being. Some examples of partnerships are found in accountable communities for health, which are “multisector, community-based partnerships that bring together health care, public health, social services, other local partners, and residents to address the unmet health and social needs of the individuals and communities they serve” (FFAH, n.d.). The Funders Forum on Accountable Health at the George Washington University Milken School of Public Health hosts a database of 185 accountable communities for health. Table 5-1 offers examples of governance approaches among these partnerships.

Models of Shared Governance

Models of governance articulated by various experts are applicable to the prevention infrastructure for MEB disorders. Fishbein and Sloboda (2023) describe a community-based comprehensive prevention service system that delivers evidence-based SU prevention services by certified providers in a variety of settings—they identify micro-level environments in which interventions may take place as family, school, peer, faith-based, and workplace. They describe the importance of matching community need to accessibility of services, ensuring quality, addressing ethical issues in research, and conducting cost–benefit assessment and analysis. These highlight key

aspects of governance. Fishbein and Sloboda propose a system with an advisory council that represents a mechanism not only for “interagency-institution coordination” but also for engaging key organizations and communities (see Figure 3 in Fishbein and Sloboda [2023]). The ecosystem they describe around that advisory entity includes Drug-Free Communities grantees, the PTTCs, NASADAD and the National Prevention Network, the Society for Prevention Research, and the National Prevention Science Coalition.

The Bipartisan Policy Center has made recommendations related to public health governance, and many have relevance to the prevention infrastructure for MEB disorders. The report defined governance as the “legal authority and responsibility to protect and promote the health of populations” that sets “the structure and boundaries in which public health interventions and policies are developed, implemented, and evaluated”

(Armooh et al., 2021, p. 38). Public health governance varies, the report noted, with both centralized (state) and decentralized (local) authority models. The report recommended collaboration with communities, calling for funding “public health departments for community collaboration and develop[ing] output measures that account for progress toward building trust and working in partnership” (Armooh et al., 2021, p. vii). It also calls for public health leaders to “engage in routine Tribal consultation to support intergovernmental public health planning that recognizes Tribal authority, autonomy, and self-governance” (Armooh et al., 2021, p. vii). The committee notes that engaging with tribes in consultation also applies to the behavioral health context, as discussed above.

Additional resources and discussion of the role of community input and expertise in informing federal policy, including specific guidance for integrating community representation and advisory practices in accountability measures and enforcement mechanisms, are provided in NASEM, 2023 (a relevant recommendation from that report is highlighted in Box 5-3).

Models of Collaboration

Over the past 2 decades, the attention to cross-sector partnerships has grown, along with some examples of government initiatives that support this, such as the proliferation of health in all policies efforts and projects. These range from the short-lived but important National Prevention Council and ongoing Health in All Policies Taskforce of the California Strategic Growth Council, to the Accountable Care Act and Internal Revenue Service (IRS) requirement that tax-exempt hospitals provide a community benefit equivalent to their tax exemption. IRS also calls for a description of community health improvement and community building activities that hospitals and health systems in IRS Schedule H (Form 990) along with conducting a triennial community health needs assessment.

Long-standing models and frameworks from the public health and population health fields outline the structure and processes for community-based health planning and population health improvement efforts. These include the Mobilizing for Action Through Planning and Partnership from the National Association of County and City Health Officials and accountable communities for health multisector partnership models being used around the country to link and generate collective impact among health care, public health, and social sector organizations. Community-based participatory research and related approaches have been fruitful.

Several community coalition–based prevention models work as delivery systems or implementation support systems for preventive interventions in MEB health and related issues. These include Communities That Care, PROmoting School-community-university Partnerships to Enhance Resilience, Getting to Outcomes, and the Icelandic Model (Blueprints for Healthy Youth Development, n.d.; RAND, 2024.; Kristjansson et al., 2020; Miller, 2017; Spoth et al., 2013). These models provide structured processes and resources for working with community and cross-sector partners to assess needs, identify solutions (i.e., evidence-based interventions), and implement, evaluate and improve, and sustain the interventions over time. Each of these models is evidence based and has evidence of its effectiveness in the implementation of interventions for specific outcomes, either MEB health related or other health risk topics (e.g., teen pregnancy) (Chinman et al., 2018).

Models for Involving Communities People with Lived Experience in Governance

Local communities are the places where the work of prevention unfolds, and community members use their lived expertise to co-create and contribute to the success of prevention efforts. Building community capacity should

be a central guiding principle by which federal, state, and tribal entities aim to implement EBPs and practices and identify community-defined evidence. Even with a robust and supportive infrastructure, people on the ground need the skills and knowledge to drive and support community coalitions, inform the identification of EBPs and practices and community-defined evidence, enable fidelity to implementation, maintain integrity to data collection and sharing principles, and review data along with communities to support quality improvement (NACCHO, 2023).

Good governance is shared governance, which requires sharing power. It includes community partnerships and people with lived expertise, and, as noted, there are many models and examples of community governance in health promotion, public health, and community health settings, ranging from state-level advisory councils that include community members and people with lived expertise to federally qualified health centers that are required to have at least 51 percent of board members drawn from their patients. The Youth Wellness Hub is a “community governance model for integrating delivery and financing systems for youth behavioral health and wellness services” using three social policy tools that are evidence-based or promising: community governance, public health education campaigns, and blending of funding sources for service delivery (SFA, 2023). Another model is the community coalition board that governs the Morehouse School of Medicine Prevention Research Center. It comprises neighborhood residents (who are the majority and hold all leadership seats), academic institutions, and social service providers. The board oversees the school of medicine’s community health needs assessment, and community members develop research questions and identify health strategies (Henry Akintobi et al., 2020). Another example is found in the State of Maryland Behavioral Health Advisory Council, which includes “individuals who are consumers, family members, professionals, and involved community members” (MDH, n.d.).

Including community members and people with lived expertise in governance of the prevention infrastructure is an important strategy for ensuring that resources are flowing to areas with greatest need—such as communities with higher rates of MEB disorders and high level of risk factors and low levels of protective factors (see Box 5-4 for implementation considerations relevant to governance and partnerships). Community members are also crucial to conducting effective community health needs assessments. The many excellent examples include Chicago’s West Side United, which is a collaboration of multiple hospitals, health systems, and community members and organizations. In 2017, when the effort was launched, the assembled community members called for shared governance. The resulting 16-member collaborative planning committee was designed to include eight community members, four institutional representatives, two

government officials, and two citywide nonprofit leaders (RUMC, 2017). The partnership has contributed to community health needs assessments. In 2020, partners learned that 10 percent of Chicago adults surveyed said they were experiencing serious psychological distress, an increase from 7 percent 2 years earlier, and MH was a major concern in every focus group. In response to the need, partners added two new school-based health centers to provide primary care and MH services and conducted community-based training for faith communities that provided MH first aid training to 300 people (RUMC, 2022).

REFERENCES