Assessing Whether Biden's Behavioral Health Initiative Aligns With Our Core Principles

President Joe Biden recently announced and then incorporated a major behavioral healthcare initiative into the administration’s fiscal year 2023 federal budget request. Over the past 2 months, I have presented an overview of his plan, followed by summaries of its 3 principal components:

• Growing the behavioral healthcare workforce
• Extending parity protections to all health insurance
• Expanding behavioral healthcare services into new community settings

Here, I would like to explore how the president’s initiative stacks up when assessed with some core principles for behavioral healthcare today.

>> READ: Mental Healthcare, Addiction Treatment Among Biden's 'Unity Agenda' Priorities

For most practical purposes, the principles I would like to employ for this assessment are intuitively obvious. They reflect years of discussion and development in all quarters of the behavioral healthcare field. There are 4 principles to be considered:

• Behavioral healthcare should be person-centered
• It should reduce all types of disparities and promote equity
• It should address the social and physical determinants of life
• It should span from community empowerment to full care integration

Below, I will elaborate on each of these principles, and then apply each of them to the 3 features of the president’s initiative.

Person-centered: It is of fundamental importance to recognize the whole person and that person’s needs throughout all phases of involvement with behavioral healthcare. Person-centeredness should take primacy over system-centeredness and provider-centeredness. Key phases where person-centeredness ought to be addressed include prevention of trauma due to social and physical life determinants, accessing care, assessment, care appropriateness and delivery, recovery, and rehabilitation.

Grow workforce: The president’s initiative provides additional resources to train more professionals, paraprofessionals, and peers. We will need to devote attention to the content of that training. Have curricula been developed and adjusted to address person-centeredness? Similarly, how about field training, clinical supervision, and managerial training? Community development initiatives?

Extend parity: We can address person-centeredness in parity extension. Have complex insurance forms and explanations been simplified? Have payers refocused their efforts on the person rather than on the payment? Does the entire parity process support the person in the effort to access and receive appropriate care, and achieve good outcomes?

Expand care settings: Expansion into new care settings potentially offers a major opportunity to increase person-centeredness because it brings care into places where people live every day. Has the care been well adapted to those new settings, both culturally and socially? Are the unique characteristics of persons in those settings recognized and elevated? Have the features of these settings that would diminish person-centeredness been addressed?

Reduce disparities and promote equity: This principle refers to the need to increase equity in all features of behavioral healthcare. Today, this care system exhibits many distinct types of disparity and lack of equity: Under-representation of minority providers and managers; care differences based upon insurance coverage and social status; exclusion of those from care who are without health insurance and those with public health insurance; care delivery that is not culturally adapted to minority groups; racial and ethnic disparities in care outcomes. And this list could be expanded.

Grow workforce: This feature of the president’s initiative offers many opportunities to promote equity. Some key questions include: Do all training programs that receive federal funding explicitly recruit trainees that represent racial, ethnic, gender, and age minorities? Have local training programs been developed for community health workers, peers, and other citizens to reflect the communities where they will work? Do all programs include specific training on the problems of disparities in care access, care quality, and care outcomes, and how to address each? Are managers trained in program development that addresses diversity, equity, and inclusion throughout their organizations?

Extend parity: Parity is intended to address disparity and lack of equity in insurance coverage. However, we also need to examine parity at a more refined level. Specifically, is this work being configured in a manner that addresses racial, ethnic, gender, and age disparities in care access, quality, and outcomes? What is being done for those who have no health insurance? Does parity address integrated care for those most in need?

Expand care settings: This feature of the president’s initiative has enormous potential to address disparities and promote equity. Do the sites selected reach those most in need and, specifically, minority populations who lack access to culturally responsive care? Are the professional and paraprofessional providers in these settings trained appropriately to offer culturally competent care? Do these providers reflect the characteristics of those who they are serving?

Address life determinants: This principle seeks to prevent behavioral health conditions before they occur and to reduce their impact after onset. It requires that providers have knowledge of how social and physical life determinants lead to trauma and subsequent behavioral and physical health conditions, as well as how to intervene to alter these relationships. It also requires that we design and implement systems capable of deploying population health management and implementing public health interventions to deconstruct and modify the life determinants.

Grow workforce: It will be essential that those being newly trained, as well as those in the continuing workforce, understand the life determinants, their effects, and how to intervene to alter them. Do the current training programs do this? How are these concepts incorporated into community placements, clinical supervision, and managerial training? Are professional and paraprofessional providers being trained in population health management and public health interventions?

Extend parity: Parity should not end with insurance coverage, but also serve as a broader conceptual frame for the field. How can we improve the parity of our interventions for those who experience different life determinants? Can parity be extended to include population insurance that covers population health management and public health interventions? How can we redesign our care system to link better with other systems that currently address the life determinants?

Expand care settings: Expansion of the range of care settings likely will offer many opportunities to address life determinants. Can the new care settings be selected specifically to reach communities known to be subjected to life determinants that lead to trauma and behavioral health conditions? Can the interventions in these new settings specifically address these life determinants? Can the effects of these determinants be mitigated in the future?

From community empowerment to integrated care: Our care system of the future must extend from community development and empowerment, through paraprofessional and professional services, to fully integrated care. Both nationally and internationally, much current work is being done to understand the powerful role of community empowerment in preventing and addressing behavioral health conditions. Similarly, we just are on the cusp of embracing paraprofessional community services by peers, community health workers, physician assistants, and other citizens. Professional services are changing as well, especially now that we have introduced virtual care, prescription digital therapeutics, and artificial intelligence through apps. Finally, fully integrated care is beginning to make major strides via virtuality and new payment models.

Grow workforce: Clearly, the training offered through the president’s initiative must address the full continuum of care. Do paraprofessional and professional providers have the skills to promote community empowerment that prevents and mitigates behavioral health conditions? Are paraprofessionals being incorporated into the behavioral healthcare workforce? Are providers trained in evidence-based practices? Do all providers have the skills to work in integrated care teams?

Extend parity: A fundamental issue is how parity relates to the full continuum of care. Can health insurance coverage be expanded to include the full continuum of care? Can paraprofessionals provide reimbursable services? Can professional services include a full range of community-based services? How does parity relate to fully integrated care?

Expand care settings: This area offers new horizons. Can empowered communities become the locales for new care settings? Are all features of the care continuum available in new care sites? How does the care continuum need to be adapted in new care sites that represent diverse cultures and populations?

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Two primary conclusions should be obvious to you at this point. First, the president’s behavioral healthcare initiative is fully compatible with the 4 key principles. Second, each element of the president’s initiative will require some adaptation to maximize the full implementation of the 4 principles. We should be very pleased with these findings.

Equally important, now the burden moves from the president to us to advocate so that the president’s initiative is enacted by Congress. It is through this advocacy step that many of the adaptations to the initiative can be implemented. Of immense importance, this will be an “all hands on deck” exercise for our entire field. I hope that you will be on deck with us.

I thank my colleagues from the College for Behavioral Healthcare Leadership (CBHL) who attended the working session on April 26 and shared their thoughts about the principles described here.   

Ron Manderscheid, PhD, is the former president and CEO of NACBHDD and NARMH, as well as an adjunct professor at the Johns Hopkins Bloomberg School of Public Health and the USC School of Social Work.

The views expressed in Perspectives are solely those of the author and do not necessarily reflect the views of Behavioral Healthcare Executive, the Psychiatry & Behavioral Health Learning Network, or other Network authors. Perspectives entries are not medical advice.