Lawmakers are facing increased pressure to pass a comprehensive mental health and substance use package but are unlikely to achieve an initial goal of advancing legislation before the implementation of a three-digit suicide hotline in July.

At least four congressional committees have committed to advancing a swath of bipartisan mental health bills under their jurisdiction, but lawmakers have not yet unlocked the puzzle of how to incorporate a growing laundry list of programs dedicated to treatment, prevention, education, crisis care, drug interdiction and the workforce.

The House Energy and Commerce Committee advanced its package to reauthorize grant programs under the Substance Abuse and Mental Health Services Administration, or SAMHSA, and Health Resources and Services Administration on May 18, but no date for a floor vote has been set. Those programs expire with the fiscal year. The Senate Health, Education, Labor and Pensions Committee, which also has jurisdiction over the programs, has not yet scheduled a markup.

The Senate Finance Committee released a discussion draft of the telehealth portion of its package on May 26. The Senate draft included two telehealth priorities that lawmakers on both sides of the aisle have emphasized.

One change would remove a Medicare requirement that a patient periodically see their provider in person. Providers have said this requirement had been a barrier for rural patients seeking care.

Another policy would allow patients to continue using audio-only mental telehealth under Medicare — another measure supported by rural providers. Lawmakers have had a bipartisan interest in retaining this policy but had previously had  concerns related to possible fraud.

The draft bill would also establish a “telemental health bill of rights” aimed at providing information on the availability of telehealth for mental health care. It would require Medicaid and Medicare to provide guidance on the availability of telehealth for mental care and incentivize the Children’s Health Insurance Program to invest in school mental health services.

The bill would also clarify that coverage of mental health assessments by telehealth under Medicare are included under a 2020 continuing resolution.

“These policies will help strengthen access, awareness and support for telehealth, including by creating a ‘bill of rights’ for information on the availability of telehealth for mental health care,” Finance Chair Ron Wyden, D-Ore., said in a statement.

He and ranking member Michael D. Crapo, R-Idaho, said they look forward to building on the telehealth section as the rest of the package is crafted in a bipartisan way.

A Senate Republican aide said it is difficult to nail down timing for the Finance package to move without the full bill. 

The Finance Committee is aiming for a package that will include efforts related to the workforce, care integration, mental health parity and access for young people, as well as furthering use of telehealth. The committee established bipartisan working groups for each area of behavioral health in February.

A Senate Democratic aide familiar with the working groups said they have finished initial drafting of legislative text and sent their products to the Department of Health and Human Services and the Centers for Medicare and Medicaid Services for technical assistance.

The House Ways and Means Committee has expressed bipartisan interest in a Medicare-focused bill but is in earlier stages than the other committees.

Remaining issues

Multiple lobbyists speaking with CQ Roll Call suggested the most likely path would be to form a package encompassing all four committees’ efforts, similar to a comprehensive 2018 law focused on the opioid epidemic. 

This year’s version would likely be attached to the omnibus, but neither chamber has released appropriations bills for fiscal 2023 yet – making July a tough sell.

Sarah Corcoran, vice president of government relations at Guide Consulting Services, said while some of the committees had originally intended to complete their bills before July 4, it’s not likely to happen.

“I still think the omnibus looks the most likely at the end of the year,” she said. “There is the hope [that] if there needs to be some sort of specific extra funding, they could follow the pathway that they did last year and put something into continuing resolution.”

The September 2021 CR included supplemental funding for the National Suicide Prevention Lifeline.

But Corcoran warned that an omnibus would also be contingent on the authorizing committees and appropriations committees both finishing by September.

Charla Penn, a principal at Winning Strategies Washington, said she expects one large bill but does not expect movement until the fiscal year deadline approaches.

She said the package is likely to get enough support from both chambers and parties if it is kept bipartisan and separate from other more contentious issues like the Democrats’ reconciliation bill or drug pricing overhaul. 

“As long as they can keep it separate then it’s one of the things that I think that you could, we could have an agreement on a big package on both sides of the Hill, both sides of the aisle,” she said. 

One lobbyist tracking the SAMHSA reauthorizations said they expect the House to bring that bill to the floor in July.  Two other lobbyists familiar with negotiations said that the Senate HELP Committee is likely to mark up its version of a grants bill by late June or July.

Lawmakers have not yet written a comprehensive bill in either chamber, and some Republicans have already expressed concerns about the costs of an eventual package.

House Energy and Commerce ranking member Cathy McMorris Rodgers, R-Wash., said May 18 that the panel’s bipartisan package would be fully offset and encouraged GOP support.

Some roadblocks have already been pushed aside. The Energy and Commerce package does not include more controversial policies like repealing a Medicaid provision called the IMD exclusion, which prohibits using Medicaid funding for care at inpatient facilities with more than 16 beds. The policy was a point of contention in crafting the 2018 opioid law.

“The pay-for is always going to be an issue, but one particular specific mental health or SUD issue doesn’t stick out to me,” said Penn, using the acronym for substance use disorders.

Crisis line

Advocates are still eyeing policies that may continue to contribute to the cost of the package. One key theme is the push for additional money for the 988 national suicide prevention hotline, both through appropriations and in reauthorizing related services.

“One of the areas that we are very focused in on with respect both to 988 implementation and thinking beyond that is that sustainability piece, again, recognizing that this is not something that the federal government is going to be able to do alone in an enduring fashion for the years to come,” John Palmieri, acting director of 988 at the Substance Abuse and Mental Health Services Administration, said at a May 17 briefing hosted by Education Development Center and the National Action Alliance for Suicide Prevention.

He pointed to working with states to consider using grant programs, implementing phone fees similar to 911, using Medicaid funds or using general revenue funding. 

“These are just some of the mechanisms that we have been drawing attention to as a way to build out that sustainability piece so that this isn’t seen as strictly a federal grant program that has a risk of kind of falling off with it, with administration changes,” he said. “We totally recognize that that’s a critical piece.”

Jessie Hellmann contributed to this report.