6

Funding for Prevention of Mental, Emotional, and Behavioral (MEB) Disorders

To date, approaches to addressing mental, emotional, and behavioral (MEB) health and well-being in society have focused on providing clinical services to individuals rather than focusing on factors that promote positive mental, emotional, and behavioral health outcomes. This is reflected in the U.S. funding landscape for behavioral health (BH), where a modest number of preventive services delivered in health care settings are sometimes reimbursable by insurers, while the majority of preventive interventions delivered in communities (e.g., schools, community centers, human services settings) is supported by a patchwork of federal grants, state and local funding, and smaller amounts of private-sector support. Better and more sustainable funding for prevention of MEB disorders could lead to better outcomes (e.g., healthy MEB development in children, prevention of some mental illnesses, of suicide, and of substance use disorders), help lessen the need for treatment and recovery services, and reduce the societal and economic cost of these disorders. As an example, investing $1 in the Good Behavior Game school-based, teacher-delivered intervention returns $64 dollars in benefits (WSIPP, 2024a). Benefits of investing in children through evidence-based interventions may include gained lifetime earnings, averted involvement with the juvenile criminal legal system, and saved health care costs (PTTC, 2024). Most compelling, research on the adolescent brain shows its greater vulnerability to the negative effects of substance use (nicotine, alcohol, and drugs) and greater likelihood of long-term consequences (Hsiung et al., 2022). This underscores the importance of primary prevention (i.e., before any symptoms of MEB disorders).

The sources of funding for MEB health are siloed between mental health (MH) and substance use disorders (SUDs) spread out across multiple agencies and not well coordinated (especially for MH, which has no central point of federal coordination). Chapter 5 highlights the array of agencies that support MEB health research and services, with separate units in the Substance Abuse and Mental Health Services Administration (SAMHSA) providing support to address SUDs or MH. Similarly, most BH funding sources are focused on treatment and recovery rather than prevention. The status quo must be changed because the need to prevent MEB disorders is substantial and growing. Sustained investment and enhanced coordination to lessen the administrative burdens on federal grant recipients (e.g., state BH agencies) are needed to build and maintain the other components of the infrastructure described in this report. For example, coordination among different funders of school-based prevention services—including SAMHSA, Centers for Disease Control and Prevention (CDC), Health Resources and Services Administration (HRSA), and Centers for Medicare & Medicaid Services (CMS)—could lead to aligning and simplifying performance measurement, reporting, and other requirements (see for example Brown et al., 2019). The gap between research and practice, especially with a focus on improving outcomes for underserved communities or groups and enhanced implementation support, as discussed in Chapter 2, also requires a much higher level of funding commitments.

This chapter provides an overview of the funding available to prevent MEB disorders, drawing in part on a comprehensive review of primarily federal funding sources developed by a consultant and provided in Appendix C. The funding approaches discussed would largely support and scale universal (i.e., directed at the entire population) policies and programs—those that have a broad reach and are intended to reduce risks and strengthen protective factors widely (see for example PTTC Network, 2024; Stelmach et al., 2022). Some of these may be more cost effective (i.e., lower cost for equivalent greater gains) than treating a diagnosed disorder, but the benefits associated with prevention go beyond health care savings and include economic productivity and improved quality of life. There are also cost-effective selective interventions—targeted at families of or directly at children with behavioral problems (McDaid et al., 2019). Funding is also needed to support all aspects of their implementation, and ensure necessary resources for workforce, data systems, governance and partnerships.

The chapter also discusses economic analyses of MEB disorder prevention, describes the range of funding needs and gaps relevant to the various components of the prevention infrastructure, and identifies potential sources to generate sustainable funding for it.

VALUE OF PREVENTION IN BEHAVIORAL HEALTH

Usually, no one knows that a problem was averted because of a preventive service. Undervaluing of prevention may explain in part why the Prevention and Public Health Fund established by a provision of the 2010 Affordable Care Act (ACA) has not been spent as intended, but used for nonprevention and non-public health purposes (CRS, 2024; Fraser, 2019). The underfunding of the nation’s public health infrastructure has been detailed in reports from the National Academies and others (IOM, 2012; TFAH, 2024). In general, the funding devoted to prevention and population health improvement efforts, including promoting BH, has been estimated at approximately a few cents per dollar spent on treatment (Martin et al., 2023¹), e.g., just under 5 percent of health spending reflected in the 2022 National Health Expenditure Accounts (CMS, 2024-b).

It is well established that population-based prevention of chronic health conditions is cost effective in broad terms and can even yield positive return on investment (ROI) (TFAH, 2017). Despite a robust evidence base for the effectiveness of preventive interventions in BH, evaluation of their economic impact is more limited and generally uses measures different from those in other areas of health care and public health (Kaplan et al., 2019; WSIPP, 2024b; The Pew Charitable Trust, 2024). Benefits of applying cost-effectiveness analysis and ROI studies to BH interventions include expanding funding sources, encouraging reimbursement by third-party payors, and spurring new funding opportunities. Cost-utility analysis (CUA)—which compares the incremental cost of a program to the incremental value in terms of quality adjusted life years—is uniquely well suited to comparing approaches as varied as school-based, clinical care, and social determinants of health (SDOH) interventions. Chapter 7 provides a broad discussion of social and economic policies that shape trajectories toward BH disorders (macrolevel interventions), and Chapter 2 discusses the evidence for interventions at the individual, family, and community levels. CUA permits comparing investments in a wide range of interventions to guide public policy.

Both programs and policies can provide ROI, making the case for the value of investing in prevention broadly and prevention of MEB disorders in particular (Le et al., 2021). Moreover, investing with health equity in mind is needed, given the economic cost of racial and ethnic health disparities. LaVeist and colleagues estimated the cost of health disparities in 2018 to be $451 billion (using Behavioral Risk Factors Surveillance System data) or $421 billion (using Medical Expenditure Panel Survey data) (LaVeist et al., 2023).

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¹ $187.6 billion in public health activity is just over 3.6 percent of the $4,255 trillion national health expenditure (Martin et al., 2023).

A systematic review of economic analyses of BH interventions along the life course found that school-based screening plus psychological interventions, such as cognitive behavioral therapy, were highly cost effective at preventing MEB disorders in children and adolescents, and parenting and workplace interventions were effective for adults (Le et al., 2021). School-based substance use prevention programming also has considerable evidence of cost effectiveness. For example, LifeSkills Training had an ROI of $21 for every $1 spent delivering it (Miller, 2012). Expanded diagnosis and treatment of depression returns $7 for every $1 invested (Miller, 2012). Clear interconnected benefits are yielded by investing in prevention with a public health focus: improving health and well-being, preventing onset of mental illness and substance use (and the associated suffering and loss of human potential), and saving resources. More economic analyses are needed to inform investments in protective factors that support MEB health.

One challenge with public- and private-sector investments is that savings from investing in proven interventions in one domain may accrue to a different sector or agency—the wrong pockets problem—but there are potential solutions (see Box 6-1).

FEDERAL FUNDING FOR PREVENTION OF MEB DISORDERS

Most federal prevention funding for MEB disorders comes from the Department of Health and Human Services (HHS), primarily in SAMHSA and Centers for Disease Control and Prevention (CDC). It is harder to identify the funding available for preventing MH disorders compared to that for substance use prevention. Some reasons for this asymmetry are discussed in Chapter 5 (Governance and Partnerships): unlike MH, substance use has a central point of coordination in the White House Office of National Drug Control Policy (ONDCP). Moreover, it is far easier to define, characterize, test for, and measure substance use. The line between normal and pathological in the MH domain is less clear-cut and can be viewed as a continuum from mental emotional well-being to mental illness, thus complicating identification of the relevant programs and interventions and the funding available for them (see Appendix C for further discussion). The committee worked with a consultant to gain a clearer understanding of federal government spending on MH and SUD—both treatment and prevention.

Appendix C provides calculations that show the federal amounts spent on MH ($2.7 billion) and SUD ($1.8 billion) prevention. Also, it is likely that private-sector funding for MH and SUD prevention is small—likely from philanthropic sources. For context, total U.S. spending across the health care sector, public and private, on BH treatment tripled between 2000 and 2021, from $40 billion to $140 billion according to the Bureau of

Economic Analysis (BEA, 2021).^2,3 Although the Bureau of Economic Analysis data⁴ are not broken down by public and private sources, SAMHSA

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² See here for a more detailed discussion of how the BEA Blended Account data in the Health Care Satellite Account are gathered: https://apps.bea.gov/scb/pdf/2015/01%20January/0115_bea_health_care_satellite_account.pdf (Dunn, Rittmeuller, and Whitmire, 2015).

³ Note that the Bureau of Economic Analysis uses a different methodology from that used by SAMHSA (2019) in its Behavioral Health Spending and Use Accounts (Dunn, A., personal communication, December 11, 2024). The estimate for total behavioral health spending in 2015 provided in the SAMHSA report was $212 billion.

⁴ See Bureau of Economic Analysis data visualization for “mental disorders,” including mood disorders, anxiety disorders, alcohol-related disorders, substance-related conditions, and other disorders: https://apps.bea.gov/data/special-topics/health-care/viz/diseases/ (accessed January 2, 2025).

TABLE 6-1 SAMHSA Breakdown of Spending on Treatment Services for Substance Use Disorders and Mental Health in 2015

SOURCE: SAMHSA, 2019.

did include such breakdowns in their calculations for 2015 (the last year for which SAMHSA seems to have provided behavioral health spending and use accounts). (See Table 6-1 for an overview of the total spending on treatment services in 2015.)

The 2023 drug control budget overseen by ONDCP indicates that $21.6 billion and $2.7 billion went to SUD treatment and prevention, respectively (other spending is largely on interdiction and law enforcement) (ONDCP, 2023). However, the committee was unable to identify equivalent figures for the federal portion of spending on MH treatment and prevention, as discussed in more detail in Appendix C.

Appendix C shows that when setting aside prevention research funding and Department of Defense drug interdiction activities from the $2.7 billion above, approximately $1.8 billion (6 percent) of the ONDCP budget was devoted to substance use prevention, with roughly four-fifths allocated to SAMHSA and CDC and one-fifth for SUD prevention programs delivered by the Departments of Defense, Education, Interior (Bureau of Indian Affairs), Justice (e.g., Bureau of Prisons), Labor (e.g., Office of Workers’ Compensation Programs), and Transportation (Appendix C). For federal-level prevention of MH disorders in 2023, Appendix C provides an estimate of $2.7 billion.

Substance Abuse and Mental Health Services Administration

SAMHSA provides both nondiscretionary (e.g., its two block grants—the Substance Use Prevention, Treatment, and Recovery Services Block Grant (SUBG) and Community Mental Health Services Block Grant (MHSBG)—which allocate funding to states according to a formula), and discretionary funding through a variety of grants for MH, substance use treatment, and SUD prevention programs (e.g., Strategic Prevention Framework—Partnerships for Success, Tribal Behavioral Health).

SAMHSA’s total funding in 2023 was $7.5 billion, and Appendix C estimates that $638 million of that was devoted to SUD prevention—composed of the $236 million for the Center for Substance Abuse Prevention (CSAP)

and the required 20 percent prevention set-aside from the SUBG administered by the Center for Substance Abuse Treatment in collaboration with CSAP. Notably, CSAP funding rose from $200 million in 2009 to only $236 million in 2023, not even keeping up with inflation, let alone meeting the need for adequate and sustained support for prevention efforts in communities.

The funding for prevention of mental disorders is more difficult to calculate for the reasons noted; the committee’s estimate, based on Appendix C, is $912 million, although $617 million is devoted to suicide prevention, so only $395 million is available to fund (primary) preventive interventions. The SAMHSA Mental Health Services Block Grant is solely devoted to funding treatment for serious mental illness. Calls for creating a set-aside for prevention out of the MHBG have been made in the 2019 NASEM report, and in the 2024 Early Action and Responsiveness Lifts Youth (EARLY) Minds Act⁵ introduced by Representative August Pfluger of Texas calling for a 5 percent set-aside from the Mental Health Services Block Grant to fund prevention and early intervention for children and youth.

Centers for Disease Control and Prevention

“CDC does not have a single enabling statute that defines its overall mission and structure” (CRS, 2023, p. 1). Because many CDC programs are based in general authorities, Congress often uses the appropriations process to fund CDC’s programs and would therefore be in a position to direct more funding to BH prevention through the appropriation process.

Trust for America’s Health (TFAH) has called for increases to CDC’s FY 2025 budget for programs important to promoting MEB health (TFAH, 2024):

• Division of Adolescent and School Health (DASH): increase from $57 million to $100 million
• Suicide Prevention: increase from $30 million to $80 million
• Adverse Childhood Experiences (ACEs): increase from $9 million to $33 million

DASH supports the implementation of school-based programs to improve parent engagement and increase access to health services, but DASH programs only reached 7 percent of middle and high school students in 2022 (TFAH, 2024). Suicide prevention efforts target the highest levels of suicide since 1941 (49,000 deaths in 2022), but funding did not increase from 2023 and the Comprehensive Suicide Prevention program needs to

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⁵ EARLY Minds Act, HR 7808, 118^th Congress, 2^nd sess., (March 22, 2024).

be strengthened to achieve intended reductions in suicide and in suicide attempts “among populations that are disproportionately affected by suicide, including veterans and rural communities” (TFAH, 2024, p. 38). Increasing the investment in prevention and mitigation of ACEs would contribute to preventing 21 million cases of depression and would enable the program’s expansion to 30 new states, territories, tribes, and localities (TFAH, 2024).

Other called-for increases would also benefit prevention of SUD and mental disorders, including increases to the public health infrastructure and capacity, public health data modernization, social determinants of health (from $6 million to $100 million), and Racial and Ethnic Approaches to Community Health and Healthy Tribes (from $69 to $103 million) (TFAH, 2024).

The TFAH report also underscored the importance of the Prevention and Public Health Fund to CDC’s budget (13 percent of CDC’s budget comes from the Prevention Fund) with a smaller outlay for SAMHSA. But the fund’s resources have been halved from the original $2 billion per year, and also directed to nonprevention purposes, such as offsetting a cut in Medicare physicians’ payments and cutting $3.5 billion over 7 years to pay for the 21st Century Cures Act (APHA, n.d.).

Administrations for Children and Families and for Community Living

The Older Americans Act funds agencies, such as area agencies on aging, through the Administration for Community Living (ACL), that can directly provide or purchase BH services for their clients under Title III-D (Disease Prevention and Health Promotion). Recipients of Title III-D funding are required to implement evidence-based programs (EBPs) to address chronic disease and diabetes management, BH, and falls prevention (which can avert injuries that can contribute to poor MH outcomes) (Benson, 2024). The funding level for ACL was $2.76 billion in FY 2024, which, if divided by the 11.4 million people served, amounts to less than $240 per person. It is not sufficient to fund training, supervision, and support of lay MH workers interacting with older adults or support eliminating digital obstacles by enabling computer or tablet ownership and an Internet subscription. ACL employs 30,000 staff and works with hundreds of thousands of volunteers, many of whom are family caregivers.

The Administration for Children and Families (ACF), whose overall budget is $70 billion, oversees a considerable portion of the $2.7 billion federal government MH investment (not including Centers for Medicare & Medicaid Services CMS)—$1.126 billion for the prevention of child maltreatment (ACF, 2023; see Appendix C). But this funding is inadequate in the face of an ongoing workforce crisis in children’s services systems—low pay and high stress lead to high turnover, and the pandemic has

considerably exacerbated these challenges (Quality Improvement Center for Workforce Development, 2022; DiLorenzo and Lukich, 2020). Stressed and overworked providers may be less able to support the MEB health needs of children in the system.

Other Federal Funding

In 1999, the federal government began to provide funding under the Safe and Drug Free Schools and Communities program for drug prevention and school safety program coordinators, a specific category of prevention workers focused on middle schools; funding ended in FY 2004 (NCES, 2024). Per Appendix C, school-based prevention efforts are funded by a mix of Medicaid, block grants, such as the Title V Maternal and Child Health (HRSA), Social Services Block Grant (ACF), and Preventive Health and Health Services Block Grant (CDC), SAMHSA’s Project Advancing Wellness and Resilience Education, and the U.S. Department of Education Project Prevent. Recent legislation, including the American Rescue Plan Act and Bipartisan Safer Communities Act, provided funding to support and expand MH services in schools. Even so, over half of U.S. schools report that they experience staffing and funding constraints in responding to the MH needs of students (NCES, 2024).

School-based MH services can facilitate early identification and treatment of MH issues in a safe environment. It can also increase access for underserved populations, particularly children from low-income and minoritized communities. The 2022 Bipartisan Safer Communities Act⁶ allocated $500 million each for the School-Based Mental Health Services Grant (SBMH) Program and Mental Health Services Professional (MHSP) Demonstration Grant Program to increase the number of MH providers in schools and the necessary training for them.

In FY 2022 and 2023, the Department of Education provided $255 million to 264 grantees for the SBMH and MHSP programs, which were expected to help communities hire approximately 5,400 school-based MH professionals and train an estimated 5,500 more, doubling the workforce of social workers, counselors, and other MH providers (ONDCP, 2024). The pandemic-era and post-pandemic increases in funding are temporary, however, and the enhanced programming and workforce will not be sustained if funding declines to earlier levels, especially if the decline is precipitous and does not allow state and local health and education agencies to secure long-term funding.

Given the public health burden of BH disorders on the lives of individuals and their families and, more broadly, on the nation’s productivity, the committee finds that adequate, stable, and sustained funding for the

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⁶ Bipartisan Safer Communities Act, Public Law 117-159, 117th Cong. (June 25, 2022).

prevention infrastructure is needed, while preserving current levels of funding for treatment and recovery and adapting to follow the data.

CONCLUSION 6-1: Descriptions of major programs pair the words “prevention” and “treatment,” suggesting that prevention funding is more robust than it is. Also, additional research on funding needs for the prevention of MEB disorders could better inform funding decisions. Most of the funding for behavioral health services is currently directed toward treatment and addressing the opioid crisis; more is needed to support primary prevention.

It is critical to invest now in explicit prevention of acute and chronic MEB disorders; to stem the current crisis in behavioral health; and to strategically build and fund current and future infrastructure for governance, operations, workforce development, capital improvements and growth, standby capacity, and development and implementation of policies and programs targeted for general and special populations. It is imperative to seek federal funding and mobilize partners in government to move quickly, collaborate, marshal resources, permit regulatory flexibility, and expedite creative solutions. As noted earlier, expenditures may not reflect cost of actual or potential delivery of preventive initiatives or cross-agency collaboration that may be underappreciated for the complexity of their implementation and the full scope of the value they return.

Estimates of total federal expenditures for MEB prevention in this report are a compilation of expenditures reported by publicly available funding sources. In the committee’s view, the available information on funding and its use in MEB disorder prevention is fragmented, uneven, and incomplete. However, what is known indicates there are important unmet needs and gaps in funding. As seen in Appendix C, the contributions over time for individual programs and initiatives in different HHS agencies vary in absolute and relative amounts, over time, and are dependent themselves on financial resources available for reporting and data integrity. They are often unrelated to prior expenditures and are seldom adjusted for inflation measures, population characteristics, or need. Precision in funding estimates can be compromised by the number of sources of data, methods of collection, standardization of measures, and intensity of oversight of validity over time.

Given the public health burden and economic costs of MEB disorders and the importance of preventing them, the federal government could approach the problem in a transformative manner or a more incremental manner.

Increasing funding for prevention could be focused on the four agencies that provide the most support for prevention of MEB disorders: Administration for Children and Families (ACF), CDC, HRSA, and SAMHSA. More dependable funding could support implementation of evidence-based

programs (EBPs) and technical assistance from pre-implementation to sustainment as described in Chapter 2. More funding could also help strengthen the workforce as discussed in Chapter 3, facilitate greater access to and work with data to inform prevention work and show improved outcomes, as outlined in Chapter 4, and nurture greater coordination and collaboration through governance and partnerships at the state, tribal, and local levels discussed in Chapter 5. But improved governance is also a tool for better coordination, less fragmentation, and greater efficiency—which illustrates a feedback loop, or even a virtuous cycle, between governance and funding (two “gears” in the infrastructure graphic provided in Figure 1-1).

A substantial, transformative investment across federal agencies delivering preventive services to children and youth (up to 18 years old) would include but would not be limited to ACF, CDC, HRSA, and SAMHSA. Why the focus on children? The onset for more than half of mental health conditions is before age 18 (Solmi et al., 2022). Also, intervening in early life offers the best opportunities for prevention and associated benefits (NASEM, 2019). The cost of mental health treatment in children has been estimated at approximately $4,361 (Loo et al., 2024). The public health and prevention portion of the 2021 National Health Expenditure Accounts (all health care spending) is approximately 5 percent (Martin et al., 2023). Five percent of $4,361 is $218 per individual. If $218 were spent on each of 73.2 million U.S. children 10 to 18 years old for a package of interventions that met their needs (from Nurse Family Partnership to family and school-based interventions), that would cost approximately $14 billion in new funding. This is a large investment but is potentially transformative given the evidence about intervening in early life on risk factors for MEB disorders. Such a commitment could ensure that every child in every community receives the package of interventions needed to address risk factors and support positive trajectories to MEB health.

Given the current challenging fiscal environment, the federal government could also consider funding increases that are more modest, such as inflation-adjusting specific funding streams, increasing the main sources of prevention funding in HHS. At a more modest level, providing a new additional outlay of $1.8 billion to the four key federal agencies responsible for prevention of MEB disorders includes adjusting for inflation for specific ACF and SAMHSA programs, and expanding the capacity of specific programs in CDC and HRSA. As shown in Appendix F, this amounts to a 40 percent increase from $4.57 billion to $6.37 billion. New funding would allow greater capacity of service delivery in settings across the life course, from preconception through older adulthood.

RECOMMENDATION 6-1: To secure adequate, sustainable, and locally responsive funding for the mental, emotional, and behavioral (MEB)

disorder prevention infrastructure, Congress should consider a range of funding options that include:

1. Providing $14 billion in new funding to the Department of Health and Human Services for interventions on early life risk factors for MEB disorders for all children birth to 18 years old.
2. At a time of funding constraints, providing $1.8 billion in new funding to the Administration for Children and Families, Centers for Disease Control and Prevention, Health Resources and Services Administration, and Substance Abuse and Mental Health Services Administration would help to increase capacity for MEB disorder prevention.

Detailed calculations describing each of the options above are provided in Appendix F. Some of the increases above can be achieved partly by restoring the Prevention and Public Health Fund to its original amount of $2 billion per year (it was $1.3 billion for 2024 (TFAH, 2024]) to support SAMHSA and CDC prevention programs.

Centers for Medicare and Medicaid Services

CMS is the nation’s largest payer and a key source of reimbursement for BH services (CMS, 2024c). It has long provided opportunities for states and providers to innovate. This includes a wide range of 1115 Medicaid waivers (referring to the authorizing section of the Social Security Act, the enabling statute for Medicaid and Medicare) that allow states to test novel approaches, and the work of the Center for Medicare and Medicaid Innovation (CMS, 2024a), which develops population health and alternative payment models (CMS, n.d.-a; CMS, 2024a; KFF, 2024). In April 2024, the Innovation Center issued a new Behavioral Health Strategy, which “focuses on three key areas: 1) substance use disorders prevention, treatment and recovery services, 2) ensuring effective pain treatment and management, and 3) improving mental health care and services” (CMS, n.d.-a.).

However, primary prevention, especially given the population-level interventions that are required, is generally not reimbursable by Medicaid (screening is one exception). One speaker noted at one of the committee’s public meetings that universal prevention, which is population-, not individual-, based, is routinely funded with appropriated dollars through SAMHSA block grants or through discretionary funding mechanisms. Thau (2024) added that universal prevention is not part of the medical care paradigm, and thus it generally has no diagnostic or billing codes and does not qualify for fee-for-service payment.

Screening is an important universal prevention strategy. The U.S. Preventive Services Task Force recommends screening adults for behavioral

disorders—depression, alcohol abuse, and drug abuse—in primary care settings. However, screening rates are low, perhaps due to lack of financing for behavioral health and inadequate behavioral health infrastructure for referral and follow up (NASEM, 2021; Mulvaney-Day et al, 2018; USPSTF, 2024). There is evidence that value-based payment reform has a positive association with improved behavioral health outcomes (e.g., reduced emergency department visits). Integrating screening in all value-based purchasing programs under Medicare and Medicaid could further prevention goals and also could serve as a health care quality metric.

Medicaid reimbursement is used for prevention services in clinical and other settings, including schools, but challenges include obtaining billable codes and securing enhanced reimbursement for group counseling. Medicaid and the Children’s Health Insurance Program play an important role in supporting BH services by reimbursing providers, but, as discussed in Appendix C, federal and state regulatory constraints on how Medicaid funds can be used affect application to a broader range of prevention activities. However, recent or emerging models exist for expanding the ability to use Medicaid to support primary prevention in community settings:

• Interventions to prevent the onset of diabetes occurred in clinical settings between patients and their health care providers, but in 2008, a research study demonstrated that the YMCA was a “promising channel” for delivering the evidence-based Diabetes Prevention Program (DPP) in group settings (Ackermann, 2008). Over the decade that followed, CDC developed the National DPP program, and further evidence emerged. Implementation was rolled out with several organizations delivering the interventions with CDC or state Medicaid funding (e.g., Montana and Minnesota). In 2018, CMS began covering the DPP program under Medicare.
• A second example of prevention services delivered in a group format, and with Medicaid reimbursement, is group prenatal care. Centering Pregnancy is the best-known and most extensively studied model (Liu et al., 2021; Rising, 1998), and eight states provide enhanced reimbursement (to cover more than just per-participant reimbursement and include provider preparation, etc.) for the group sessions. The EleVATE program (Washington University in St. Louis, Missouri) was successful in securing reimbursement for group prenatal care that incorporates trauma-informed care and BH services (Cohen Marill, 2022).

Barriers to obtaining Medicaid reimbursement for BH services have been described as a persistent issue in the field that contributes to access challenges (providers unavailable because of reimbursement issues). For example,

one study found that some providers listed in Medicaid directories had not seen any Medicaid patients in the previous year. Thus, including them in the directories may have given an inaccurate picture of provider availability (Giliberti, 2023).

Schools are one kind of community-based, non-health care setting of great importance to the infrastructure for delivering BH prevention (Panchal and Guth, 2023). In many states, school settings are a main site for primary prevention and participate in Medicaid for specific preventive services, including MH and BH services, primary care, and screenings. Federal Medicaid funding supports BH services in schools under the Individuals with Disabilities Education Act (IDEA) and for children who are Medicaid or Children’s Health Insurance Program beneficiaries, but only 16 states have Medicaid plans that allow reimbursement for Medicaid-eligible students in addition to those who qualify under IDEA (ED, 2024). School-based health centers (SBHCs) can play an important role in delivering BH services to children, but they only reach approximately 8 percent of students, and funding is a persistent challenge (Haeder, 2021; Heinrich et al., 2023). The Guide to Community Preventive Services recommends SBHCs as a strategy to improve child health (including reducing health risk behaviors) and school performance in low-income communities (Community Guide, 2015).

Medicaid Reimbursement for Health-Related Social Needs (HRSNs)

Over the past decade, CMS and private-sector payers and health care organizations have come to recognize that nonmedical factors, such as housing and food security, play important roles in shaping health status (Tsega et al., 2019) and have begun to explore financing strategies to cover related services and providers. CMS under both Medicare and Medicaid has developed models for providing reimbursement or other types of financing for services that address beneficiaries’ nonmedical needs, such as housing, food, and transportation.

Medicaid funding is available for both the point of care (reimbursement for secondary prevention, e.g., screening) and, more recently, HRSNs, such as assistance with finding housing (MACPAC, 2021). In 2017, CMS put forward a tool for screening for HRSNs, including housing, transportation, and exposure to interpersonal violence. The lens on the latter has widened to include community violence, in recognition of the fact that Medicaid is the largest payer for firearm-related injuries that create lifelong “medical and psychological complications” as discussed in Chapter 7 (CMS, n.d.-b; CHCS, 2023). In 2024, California, Colorado, Connecticut, Illinois, Maryland, New York, and Oregon allowed Medicaid to reimburse for violence prevention services (Barna, 2024). New York enacted legislation

directing the state Department of Health to apply to the federal government for including community violence prevention among the services available to Medicaid beneficiaries.⁷ The program would train violence prevention specialists and require training and certification in violence prevention through the state department of health.

There are arrangements under capitation or value-based purchasing where a community-based organization (CBO) works with a health care provider to support meeting a health or health care target by meeting an HRSN (e.g., enrolling person for Supplemental Nutrition Assistance Program, supporting a meal plan to control blood sugar). Medicaid can be said to indirectly pay for linkage (e.g., help with finding housing), although such a claim may be more difficult to file and have reimbursed.

CMS increasingly targets adverse social conditions (e.g., housing instability, homelessness, nutrition insecurity) that contribute to poor health (Hinton and Diana, 2024). Because fee-for-service arrangements do not permit federal Medicaid funds to pay the direct costs of nonmedical services, billing flexibility is needed. Movement away from these restrictions is evident: “The U.S. Playbook to Address Social Determinants of Health” proposed, as “Pillar 2” to “Support Flexible Funding for Social Needs” through Medicare and Medicaid (DPC and ONDCP, 2023).

Opportunities to fund HRSNs include state Medicaid programs using existing “state plan and waiver authorities (e.g., 1905(a), 1915(i), 1915(c), or Section 1115) to add certain non-clinical services to the Medicaid benefit package” (Hinton and Diana, 2024). CMS has approved 1115 waiver demonstrations focusing on flexible funding in seven states.

Another route to addressing HRSNs is through Medicaid managed care federal authorities (Hinton, 2024). This opportunity could reach many beneficiaries: more than 70 percent of beneficiaries have their benefit administered through Managed Care organizations (MCOs) providing comprehensive, risk-based managed care (KFF, 2021).

Through “in-lieu-of” authority, Medicaid MCOs can be given flexibility to pay for nonmedical services: services or settings when they act as substitutes for standard Medicaid benefits (Hinton and Diana, 2024). Recent CMS guidance clarifies that Medicaid MCOs can, within certain guidelines, pay for housing, nutrition support and certain other HRSN services as substitutes for standard Medicaid benefits (CMS, 2023).

Federal rules allow Medicaid MCOs to pay for nonmedical services when these are designated as “value added.” Value-added services are provided voluntarily outside of covered contract services and paid for from

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⁷ New York State Senate Bill S580, 2023-2024 Legislative Session. Relates to the provision of and payment for violence prevention programs. https://www.nysenate.gov/legislation/bills/2023/S580/amendment/A (accessed February 28, 2025).

contract administrative funds; however, they are sometimes counted in the MCO’s favor in calculating its “medical loss ratio” (Hinton and Diana, 2024).

MCO contracts can call for HRSN-related performance targets, with incentive payments for investments made in support of meeting these targets. For example, some states provide incentive payments for HRSN screening and establishing partnerships to ensure beneficiaries receive housing or other needed services. Incentive payments can be included in capitated rates, allowing MCOs to receive additional funding to address HRSNs (Hinton and Diana, 2024).

As MCOs contract with provider organizations, many negotiate flexible financing of value-based care that encourages addressing HRSNs to overcome barriers to effective delivery. About one-quarter of state Medicaid programs contract with Accountable Care Organizations (ACOs), long popular with Medicare as a delivery model (Kaufman et al., 2019).

ACOs are provider and health organization networks with shared responsibility to care for a defined population meeting agreed quality-of-care standards. Financing is incentive based, and this encourages addressing HRSNs as part of care meeting spending targets or within capitation rates (Rosenthal et al., 2023). Spending is flexible and can address HRSNs. Preliminary evidence indicates that 85 percent of ACOs report addressing some form of HRSNs (Niles et al., 2019).

These options exist within a wider push toward flexible financing. Through its Innovation Center, CMS has sought development of models reorienting Medicare and Medicaid payment from fee-for-service billing to pay for achieving mutually agreed-upon performance objectives even when attained by activities beyond office-based clinical practice (CMS, 2024a). The center has launched over 50 model tests between 2018–2020, reaching hundreds of thousands of providers and covering millions of patients. Its objectives call for, by 2030, all Medicare Part A and B beneficiaries to be cared for in a relationship defined by accountability, quality, and total cost rather than traditional billing practices.

Reimbursement for Different Types of Community Workers

CMS reimburses providers, including non-licensed, non-master’s-level SUD service providers (peers, counselors, etc.), to deliver group BH therapy and counseling, and there is a Medicaid reimbursement category for “Behavioral health prevention education” (H0025) (NASHP, 2019). However, it is unclear what proportion of the services these workers provide could be classified as primary or secondary prevention.

Options for reimbursement of community health worker (CHW) services—and potentially other types of unlicensed workers delivering

preventive interventions—could include Section 1115 demonstration waivers (under Medicaid) and payment reform structures, such as bundled payments for episodic or encounter-based payments for conditions. Several states have received approval for reimbursement of CHW services (D’Alessandro et al., 2024).

Alternative payment models

In addition to expanded opportunities for CHW reimbursement, CMS has a history of testing alternative payment models and allowing waivers that test novel approaches for improving outcomes. States’ experiences with 1115 waivers offers several examples of experimentation relevant to both population-based prevention and universal approaches that lead to improvements for non-Medicaid beneficiaries:

• In 2015, CMMI approved an 1115 waiver for Texas, and the San Antonio Metropolitan Health District partnered with health care entities and nonprofit organizations to invest in population-level changes that supported health, including built environment interventions (Schlenker and Huber, 2015).
• The Maryland Total Cost of Care 1115 waiver included “population health credits” the state could earn based on total population health improvements anticipated to save Medicare dollars, and measures included diabetes incidence in all Marylanders aged 45 years and older (HSCRC, 2017).
• North Carolina’s program, NCCARE 360, paid for infrastructure for screening and referral for HRSNs that is available to everyone, not just Medicaid beneficiaries (NCCARE360, 2024).

Medicaid reimbursement is a crucial source of funding for BH services, but there are barriers related to staffing, setting, benefits, and eligibility. Specifically, some types of workers, community settings, and population-level preventive interventions are difficult or impossible to pay with Medicaid dollars. Medicaid does not pay for population-level preventive interventions, such as public health communication campaigns. However, Medicaid amendments, authorities, flexibilities, and waivers offer opportunities for greater adaptability and experimentation.

CONCLUSION 6-2: Interventions to prevent mental, emotional, and behavioral (MEB) disorders and promote MEB health and well-being could be supported through a range of approaches that create more sustainable, coordinated, and adequate funding beginning with greater flexibility and innovation in the use of federal funding.

RECOMMENDATION 6-2: The committee recommends that the Centers for Medicare & Medicaid Services should

1. Encourage states to use Medicaid 1115 waivers to implement evidence-based approaches for prevention of mental, emotional, and behavioral (MEB) disorders. Potential approaches could focus on school-based strategies and the work of multisector partnerships in other community settings (e.g., accountable communities for health, faith-based, aging services) and that are implementing population-based universal interventions (e.g., environmental change, media campaigns).
2. Prioritize specific quality metrics relevant to prevention of MEB disorders, e.g., screening for alcohol misuse, depression, and anxiety in all value-based purchasing programs under Medicaid and Medicare.
3. Facilitate reimbursement of non-licensed non-clinical MEB prevention workers (e.g., prevention specialists, community health workers) considered qualified to deliver such interventions.

CMS could invest in states to support scale-up of evidence-based programs, similar to the Innovation Accelerator Program (2014) or integrate prevention of behavioral disorders as part of all-payer models that also involve Medicaid state agency buy-in, like the AHEAD (States Advancing All Payer Health Equity Approaches and Development) Model. Notably, CMS already encouraged states to submit waivers that involve billing on the basis of risk rather than diagnosis for MEB prevention in children, and as noted, for the use of CHWs. Also, prevention measures and incentives could focus on true prevention. One potential model is Maryland’s Diabetes Incidence Outcomes-Based Credit Methodology,⁸ which allows the state to compare its performance averting cases of diabetes and realize an outcomes-based credit.

State and Local Funding

State agencies support a variety of BH prevention activities with state funds and pass-through funding from SAMHSA. States have the ability to reimburse providers for Screening, Brief Intervention, and Referral to Treatment for substance use and alcohol, and in 2023, 38 states did so, in addition to providing reimbursement for other health education and counseling.

A noteworthy example of state funding innovations is found in the prevention of Adverse Childhood Experiences, major risk factors for

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⁸ See https://hscrc.maryland.gov/Documents/Modernization/OBC/Diabetes%20OBC%20Methodology%20Summary%209182019.pdf (accessed December 11, 2024).

BH disorders. States are doing this by braiding or layering funding from multiple sources, sometimes including private-sector support, to implement programming that addresses these risk factors (ASTHO, 2021). For example, South Carolina’s Nurse-Family Partnership Pay-for-Success program braids 1915(b) waiver funds with private philanthropic funding (ASTHO, 2021). The funds are safeguarded from changes in leadership by being held in escrow by an external trustee, and if the program is successful in achieving improvements across several outcomes, the state makes success payments to fund further services (Harvard, n.d.). However, recent findings from a study of the relationship between the Nurse-Family Partnership and a composite of adverse birth outcomes found that the program did not lead to improvement in those outcomes, and researchers noted several limitations (e.g., factors that affect pregnancy outcomes may be set in motion well before the intervention). Study is ongoing on other outcomes, but the financial structure in South Carolina is noteworthy for creating a potentially sustainable funding model of performance-based contracts. The literature on pay-for-success (or social impact bond) financing models has shown that the programs that succeed financially are ones that implement a proven intervention (Lantz and Iovan, 2018).

Tax policy offers another conduit to funding prevention more sustainably. Purtle and colleagues (2023) mapped the landscape of state and local funding dedicated to BH and found 207 different policies that illustrate the potential of earmarked taxes to generate sustainable funding for prevention. For example, California’s millionaires’ tax enacted in 2014 is used to support a range of BH programs, including in the state university and community college systems. The Washington State legislature enacted a law to allow counties to authorize and impose a sales and use tax of one-tenth of one percent “for chemical dependency or mental health treatment services or therapeutic courts.”⁹ Multiple counties have implemented such a tax. Surveys from California and Washington State have shown broad public support of the taxes, and respondents in California strongly agreed that the tax policy contributed to public awareness of BH and destigmatized the issue (Purtle et al., 2024).

Purtle and colleagues (2022) studied the potential of cannabis taxes and showed how a quarter of revenue in nine states with recreational cannabis excise taxes could be invested in MH, including in mobile psychiatric crisis unit and National Suicide Prevention Lifeline encounters.

As of August 2024, 21 states are collecting cannabis taxes: Alaska, Arizona, California, Colorado, Connecticut, Illinois, Maine, Maryland,

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⁹ Revised Code of Washington §82.14.46 Sales a use tax for chemical dependency or mental health treatment services or therapeutic courts. July 12, 2024.

Massachusetts, Michigan, Missouri, Montana, Nevada, New Jersey, New Mexico, New York, Ohio, Oregon, Rhode Island, Vermont, and Washington (Tax Policy Center, 2024). The revenues come from various types of taxation, including excise, sales, retail, and use taxes. In 2021, the first five states to legalize recreational cannabis (Colorado, Washington, Alaska, Oregon, and California) had collectively generated $2.78 billion in revenue from it. States are using the funds from cannabis taxes for traditional government programs, health care, substance abuse and drug education, law enforcement, education, other community needs determined by local jurisdictions (USAFacts, 2023). Purtle and colleagues (2022) noted the general consensus of the appropriateness of earmarking excise tax revenue for purposes that “offset externalities associated with the use of the good or engagement in the activity (i.e., when an individual’s use of the good or engagement in the activity produces consequences for others or society)” (p. 1). More recently, Thom (2022) conducted a synthetic control analysis of CDC National Vital Statistics System data to examine how California’s tax affected suicide deaths in the state and found beneficial effects on the death rate. Stadnick and colleagues (2024) surveyed officials from some of the 200 cities and counties that have implemented tax policies that earmark revenue for behavioral health services and found that most survey participants (82.7 percent, n = 225) agreed that the revenue provided by the tax increased funding for direct BH/social services and for improvements to BH/social services systems, but findings included concerns about “volatility of funding, inequities in the distribution of tax revenue, and, in some cases, administratively burdensome tax reporting.” Purtle and colleagues (2024) compared tax policy implementers from Washington State and California and found broad support of the tax policies for the flexible resources they generated, some concern about design features that made reporting onerous and brought unwanted attention to the work, and also appreciation for other benefits of the tax policy, such as greater public awareness of behavioral health and decreased stigma.

Private-Sector Funding

Philanthropic funding has long played an important role in many aspects of public health and human services, and the philanthropic landscape for BH has grown and become more coordinated in recent years (KP, 2023; Sapatkin, 2024; Center for High Impact Philanthropy, 2020). The Well Being Trust and several partners helped to spark or intensify a movement for addressing the MH and SUD crises, and one of the movement’s innovations was the creation of Mindful Philanthropy in 2020 to “catalyze impactful funding in mental health, addiction, and well-being” (Mindful Philanthropy, 2024).

There are numerous examples of the role of philanthropy in behavioral health, including as conveners and facilitators of collaboration. The Texas Behavioral Health Funders Collaborative brings together a variety of philanthropic organizations, including faith-based entities, to support a variety of collaborative efforts such as the South Texas Trauma-Informed Care Consortium, and in system transformation efforts with partners such as the Texas Association of Community Health Centers (MHM, 2020). The funders collaborative has also supported school districts in implementing peer-to-peer suicide prevention programming (CCC, 2023).

The Health Partners health system and community health plan in Minnesota supports school MH through its foundations. For example, the Park Nicollet Foundation has provided funding for grief support programming in 125 schools across 16 school districts and delivered tele-MH therapy to children who lack access to BH care, including teaching skills to manage negative feelings in three school districts (Park Nicollet Foundation, n.d.). Kaiser Permanente has been supporting educators and students in 10 Colorado school districts through its Thriving Schools Resilience in School Environments program to build resilience by integrating social and emotional wellness into the classroom. It provided more than $6 million in grants over the last 6 years and, in 2023, announced $3 million over the following 3 years (KP, 2023). The community-led programming supported by the grants has improved school climates and improved self-reported MH among teachers, staff, and students (KP, 2023).

MEETING THE NEED FOR SUFFICIENT AND SUSTAINABLE FUNDING

What does prevention funding support? In addition to supporting workforce and data components broadly, such as to help state governments implement their plans for prevention, funding is needed for the implementation costs of EBPs. Although it generally flows to the cost of programs or policies, there are associated costs that may not be sufficiently understood and addressed by decision makers. These include costs for initial deployment, the infrastructure to keep things going (implementation support, technical assistance), the workforce for specific programs, and updating the data infrastructure for specific community needs.

The cost of prevention programs, such as Family Check-up, can be a barrier to receiving or delivering services in community settings. Family Check-up costs $4,225 for an initial onsite 2-day training for one trainer and up to six trainees (e.g., a CBO that serves families with young children), and start-up costs are $4,400–6,500 (Blueprints for Healthy Youth Development, n.d.). Implementing the Good Behavior Game in classroom settings has an initial online training cost of $2,545 for up to 30 participants

(or $200 each with a live instructor, or a self-paced training for $240 each). Teachers participating in the training must each obtain the Teacher Kit for $320–340. The initial in-person training costs $5,000 for up to 40 participants (IES, 2023).

Unlike with clinical preventive services, such as screening for alcohol or substance use, Medicaid does not reimburse EBPs such as these. That is the case with the vast majority of primary prevention services, whether they are training or other health-promoting interventions delivered to individuals or groups or population-based interventions, such as public health communication campaigns (Community Guide, n.d.).

Communities may receive some funding from SAMHSA through their state BH agency to, for example, support the work of a community coalition and a prevention specialist, but funding is often not available to finance data collection on community needs; the work of researching and selecting an EBP; and its implementation, evaluation, and sustainment. There are several potential ways to make the case for sustainable support for family and community-based primary prevention. Relatedly, payment considerations must include, in addition to the cost of the intervention, the cost of preimplementation steps and the implementation process (Dopp et al., 2020).

OTHER, NONGOVERNMENTAL FUNDING OPPORTUNITIES

Health systems and hospitals that are tax exempt, which account for 58 percent of U.S. hospitals, are required by law to provide a community benefit commensurate with their tax exemptions (Godwin et al., 2023). These funds are used for a variety of purposes, including training and research, but the $28 billion in federal, state, and local tax exemptions in 2023, for example, did not contribute much to community health improvement efforts (DiGioia, 2022; Godwin et al., 2023). The Internal Revenue Service (IRS) provides guidance and enforces compliance with community benefit rules. Annual monitoring of community benefit spending is done through IRS Schedule H (Form 990). Hospitals failing to comply risk losing their tax-exempt status.

A critique of community benefit spending has been growing in the literature and in policy circles, along with a recognition that hospitals can serve as anchor institutions, such as investing in their local communities and playing an active role in workforce development and creating jobs, contributing to community development efforts (Koh et al., 2020; Healthcare Anchor Network, n.d.). Some hospitals have engaged in innovative and fruitful cross-sector partnerships to invest resources in programs and initiatives that address community conditions, such as building affordable housing (Affordable Housing Finance, 2018). Community benefit funding could serve as a potential resource for the promotion of MEB health directly by funding prevention and promotion programming in communities (which

could, for example, yield dividends by reducing the need for hospitalization and costly treatment—a savings under value-based payment models). Community benefit funds could also benefit MEB health by being directed (and evaluated accordingly) to supporting the social determinants of BH and well-being (Carroll-Scott et al., 2017).

Under a provision of the ACA, tax-exempt hospitals are also required to conduct community health needs assessments, which can identify indicators of local risk and resilience (Carroll-Scott et al., 2017). By monitoring community needs assessments and encouraging partnership with public health officials, greater community linkage can be realized through existing mechanisms tied to protecting tax-exempt status with its associated tax breaks.

RECOMMENDATION 6-3: Congress should adopt and support the implementation of new or innovative funding mechanisms to generate sustainable and sufficient resources for promoting mental, emotional, and behavioral (MEB) health, and for prevention, particularly primary, of MEB disorders by

1. Offering incentives, such as tax credits, for large-scale social impact investing that supports universal prevention
2. Directing the Internal Revenue Service (IRS) to provide guidance on how tax-exempt hospitals can use community benefit funding to support MEB disorder prevention in communities where behavioral disorders are priority health needs within the mandated Community Health Needs Assessment. Specifically, the IRS should modify Lines 3, 6, 7, and 8 of Part II of IRS Schedule H (Form 990) that is used to monitor community benefit spending, to specifically include mental, emotional and behavioral disorder prevention. (see below; text in italics added to the text in Schedule H)

The changes to lines in IRS Schedule H (Form 990) are shown in italics.

• Line 3. “Community support” can include, but isn’t limited to, childcare and mentoring programs for vulnerable populations or neighborhoods, neighborhood support groups, violence prevention programs, mental, emotional and behavioral disorder prevention programs, and disaster readiness and public health emergency activities, such as community disease surveillance or readiness training beyond what is required by accrediting bodies or government entities.
• Line 6. “Coalition building” includes, but isn’t limited to, participation in community coalitions and other collaborative efforts with

• the community to address mental, emotional and behavioral health, and other health and safety issues.
• Line 7. “Community health improvement advocacy” includes, but isn’t limited to, efforts to support policies and programs to safeguard or improve public health, address mental, emotional and behavioral health, access to health care services, housing, the environment, and transportation.
• Line 8. “Workforce development” includes, but isn’t limited to, developing the prevention workforce for mental, emotional and behavioral health, recruitment of physicians and other health professionals to medical shortage areas or other areas designated as underserved, and collaboration with educational institutions to train and recruit health professionals needed in the community (other than the health professions education activities entered on Part I, line 7f).

State, territorial, tribal, and local legislatures could consider different approaches to generate or maximize resources available to promote MEB health and well-being. The national opioid settlements have provided a much-needed, time-limited (e.g., 18 year) funding source for state opioid responses, but the funding is inadequate to meet all the specific costs of necessary services, and not all communities will receive it (Ban, 2024). State opioid settlement funding is variable, and while the settlements have expanded state coffers for addressing SUDs, it is unclear what proportion, if any, of the 70 percent required in the settlement agreement to be used for future opioid remediation (or abatement, term not defined by the settlement) is going to substance use prevention (Whaley, 2024). There are variations across settlements with different companies and differences in how the money is being paid out, and there is little public information about how states are investing it (Whaley, 2024). Several academic and research organizations have provided guidance on using the settlement funding, including for prevention, but more research is needed to inform the path forward (RAND, 2025; Johns Hopkins Bloomberg School of Public Health, 2025; Duke Margolis Institute for Health Policy, 2024; Faherty et al., 2020).

A variety of funding mechanisms are already in use in some states, such as California’s 2004 tax on incomes over $1 million, which was established and continues to generate funding for MH services (Scheffler and Adams, 2005). These include excise taxes that account for the negative externalities—especially BH harms (e.g., of revenue streams from sales of alcohol, cannabis, and social media advertising¹⁰)—and financial instruments, such as bonds, that allow states and municipalities to develop a funding source

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¹⁰ Refers to general advertising of any good or service on social media, as a potential funding source to account for negative externalities related to social media.

for an EBP or set of EBPs in anticipation of ROI (Chaloupka et al., 2019; Bloom et al., 2024; Lantz and Iovan, 2018; Raikov and Kalapchiev, 2023). Other options include mechanisms for coordinating and blending or layering funding sources from public and private entities with shared interests in improving the outcomes of a specific population, such as children (Weiner, 2022). Children’s cabinets, for example, are an approach employed by many cities seeking to develop cradle-to-career pathways for supporting child and youth development and growth (Reville, 2020).

It is important for decision makers to weigh the evidence of benefits and challenges associated with each of these options for their specific context.

RECOMMENDATION 6-4: State and territorial legislatures and tribal councils, respectively, should adopt and support the implementation of new or innovative funding mechanisms to generate sustainable and sufficient resources for promoting mental, emotional, and behavioral (MEB) health and prevention, particularly primary, of MEB disorders.

Such mechanisms could include the following:

• Enact new or revise current excise taxes to earmark funding to MEB health promotion programs.
  • New potential sources of funding include sales of recreational cannabis and social media advertising taxes.
  • Revise alcohol excise taxes to bring them up to inflation-adjusted levels.
• Establish prevention and wellness funds, which are pools of resources raised to support community prevention efforts (Local Wellness Funds, n.d.; TFAH, 2018).
• Establish children’s cabinets and equivalent mechanisms to more effectively coordinate multiagency funding toward a shared mission.
• Use bonds, including social impact bonds (also known as pay for success financing), to support MEB prevention interventions (Segal et al., 2024).

Given the social, public health, and economic effects of BH disorders, promoting MEB health needs to be seen as a major national priority. The trajectories to these disorders begin early in life and as discussed in Chapters 2 and 7, are shaped by factors both distal (e.g., policies that affect poverty and economic mobility at a population level) and proximate to individuals (e.g., growing up in deep poverty and with caregivers who lack support and/or are experiencing BH disorders). Economic modeling that takes into consideration the multiplicity of causes and effects will be informative about the returns on investment in specific policies and major programs across different agencies.

There are several relevant bodies of work and entities. Yale University has a new Budget Lab that can inform policy making with a longer time horizon using a microsimulation tax model and open-source models. The Washington State Institute for Public Policy conducts cost–benefit analyses of policies and programs across multiple domains relevant to MEB health (e.g., education, adult and juvenile criminal legal, child welfare, health care, and MH) to guide policy making in Washington State (WSIPP, 2024b). But these are separate analyses for each intervention to inform policy makers about whether it is a good value. National Institutes of Health (NIH) has given increasing support to economic research relevant to MH and SUDs. A 2015 NIH Notice of Priorities for Health Economics Research signaled the agency’s focus on the topic, and in 2023, National Institute of Mental Health and National Institute on Drug Abuse cohosted a conference on health economics. The NIH policy on funding health economics research calls for research that has “health outcomes and health-related behaviors as the primary focus, and the connection between the subject(s) of the study and improved understanding of health must be clear and explicit” (Humensky et al., 2024). None of these activities provide or are positioned to provide insights about the downstream effects on other federal agencies of investing in prevention in various domains and through various policies. That is a unique opportunity for HHS, which conducts economic impact analyses and modeling and simulation under the Assistant Secretary for Planning and Evaluation (often clinically oriented) and in 2012 prepared the report A Review and Analysis of Economic Models of Prevention Benefits (Miller et al., 2012).

RECOMMENDATION 6-5: The Assistant Secretary for Planning and Evaluation should work with relevant experts to develop a comprehensive economic model that tests the downstream effects of investments in mental, emotional, and behavioral disorder (MEB) prevention. The model should include a range of inputs (e.g., quality early care and education), beneficiary federal agencies (e.g., Department of Health and Human Services/Centers for Medicare & Medicaid Services), and private-sector entities (employers/payers) that will reap the savings from enhancing mental, emotional, and behavioral health at a population level and eliminating MEB health disparities.

The Congressional Budget Office could refer to this model in informing the work of policy makers, in addition to their own work of scoring proposed prevention-oriented legislation.

The committee heard from several speakers at its information-gathering meetings about the burden of reporting and other requirements associated with SAMHSA and other funding sources (see Box 6-2). There are

numerous examples of innovative coordination and of flexibility in federal programs. Examples exist in the history of federal (and state) interagency cooperation of different agencies integrating data and reporting requirements to ease the difficulties of grantees and achieve both greater coordination and efficiency. The Sustainable Communities Initiative may offer a

model for such coordination. This partnership among the Department of Housing and Urban Development, Environmental Protection Agency, and Department of Transportation offers a helpful example for several reasons: it facilitated coordination among the three different federal entities, promoted a holistic, cross-sectoral approach, and centered the needs and experience of communities and engaged them (Bates and Zapata, 2013). “Regional planning bodies like MPOs were to develop and extend their regional planning frameworks to integrate affordable housing and community and economic development into their land use and transportation plans” (Bates and Zapata, 2013, p. 15). In another compelling example, the Washington State Community Prevention & Wellness Initiative requires localities applying for funding to submit a single source application instead of several, one for each funding stream. See Box 6-3 for implementation considerations specifically related to funding MEB disorder prevention and health promotion programs.

REFERENCES