Shifting the Paradigm: How Medicaid Can Strengthen Behavioral Health Crisis Response

Police respond to a wide range of situations beyond crimes — everything from traffic stops to domestic disputes to homelessness. They are also generally the first responders in situations involving mental health or substance use crises. This unexpected, largely unrecognized role reflects an unmet need for behavioral health care, gaps in community-based services for mental health and substance use disorders, and policies that criminalize mental illness.

This is why, as communities across the country try to reduce violence during police encounters, access to mental health and substance use services for people who are experiencing crises must be part of the solution. Medicaid is a primary coverage source for crisis and other behavioral health services, making it a key policy lever. What’s more, Medicaid was just strengthened in the American Rescue Plan Act of 2021, which offers a new financial incentive for states to provide mobile crisis response to people experiencing mental health or addiction crises.

Although circumstances and outcomes vary, two situations illustrate how the mismatch between the needs of someone experiencing a mental health crisis and the response provided by police can be devastating. Daniel Prude, a 41 year old man in Rochester, New York, died in March 2020 after police responded to a call from his brother, who reported that Daniel was experiencing a psychotic episode. Last fall in Salt Lake City, Utah, a thirteen year old boy with Asperger’s was shot multiple times by police after his mother called seeking help with her son’s crisis, which she said was precipitated by separation anxiety.

In both cases, the victims were experiencing behavioral health crises. Behavioral health crises are situations in which a mental health or substance use issue disrupts—or risks disrupting—safety and stability. In addition to the direct harm these incidents cause, prioritizing law enforcement responses to behavioral health conditions contributes to the U.S.’ disproportionately high incarceration rates.

Behavioral health crises require behavioral health solutions. This is where crisis services come in.  Crisis services provide stability to a person in crisis and an access point to necessary treatment and care. They include crisis phone lines that people can call when they or someone else is in crisis, mobile crisis teams that travel to address needs that arise in the community, and crisis stabilization, which are services provided in non-hospital settings to de-escalate crises. These are the three core elements of crisis response that the Substance Abuse and Mental Health Services Administration (SAMHSA) recognized in national guidelines issued last year.

Medicaid can cover crisis response services for beneficiaries, as well as services like peer supports, therapy, and diagnostic services that can maintain personal health and wellbeing.  With support from Well Being Trust, we examined how states can use Medicaid to cover behavioral health crisis services. The results are in our new report, “Building Blocks: How Medicaid Can Advance Mental Health and Substance Use Crisis Response.”  The news is good: There are many different building blocks for states to use, from longstanding flexible authorities like the rehabilitative services option to more recent section 1115 demonstration models that encourage states to build a continuum of care for adults with serious mental illness and children with serious emotional disturbance.

Building on these existing tools, the federal government is offering a new incentive for states to expand one mode of crisis response in particular – mobile crisis services. The American Rescue Plan, enacted in March by Congress and the Biden Administration, encourages states to provide 24/7 mobile crisis services for kids and adults that are multidisciplinary and focus on behavioral health. States that take it up will receive an 85 percent federal matching rate for the first three years of their programs. Congress authorized planning grants that will be available this year; the matching rate takes effect next April. The specifics of the incentive can be found in our report.

Notably, some states have already used Medicaid to develop specific crisis response models for children. New Jersey’s Mobile Response and Stabilization Services (MRSS) program tries to intervene as early in a child’s crisis as possible, and focuses on providing a fast response by a behavioral health professional, with an emphasis on de-escalating a situation, promoting stability, connecting children and families to resources, and prevention. MRSS helps avoid the need for more intensive interventions, including foster care placement and psychiatric hospitalizations. A program in Milwaukee, Wisconsin, Wraparound Milwaukee, provides services and develops a care plan for youth who have serious behavioral health needs. Child-focused crisis response programs may be particularly crucial right now, as COVID-19, school disruption, and family financial stress have placed increased pressures on kids.

Mental health and addiction challenges in the U.S. are serious and growing, so the need to act is urgent. Among adults, rates of some mental health conditions are four times higher than they were before the pandemic, and overdose deaths have reached new highs. Stronger community-based behavioral health services—starting with crisis response—are needed to advance public safety and community health. State and local officials, advocates, and consumers should work together to take up the new Medicaid mobile crisis incentive and build stronger systems to address mental health and addiction. The results may be lifesaving.

Vikki Wachino is principal of Viaduct Consulting, LLC and is the former Deputy Administrator and Director of the Centers for Medicaid and CHIP Services. Natasha Camhi (Georgetown University McCourt MPP ’20) is a research and policy analyst focusing on the intersections of criminal justice, healthcare, and housing.