- Foundations’ Role In Creating And Advancing Policies That Prevent Disease And Promote Mental Health And Well-Being
Deaths from drugs, alcohol, and suicide are driving the first reductions in life expectancy in the United States in the past two decades.
The United States still spends far more on health care than on social services compared to other Organization for Economic Cooperation and Development countries, even though research suggests social services are strongly linked to improved outcomes. And, despite how much we spend, our outcomes don’t stack up to those of other countries.
Thankfully, communities in the United States are working to push back against these trends by actively seeking better health and well-being—not just through their own actions but also by partnering with many others in pursuit of broader changes.
Foundations and their investments (for example, in grantees) often play a unique role in enabling this pursuit of better health. The functions and roles that foundations play are as varied as the communities they serve, and each foundation has a different mission, focus, and interest in policy.
Yet, despite these differences among funders, policy is the one thing that often undergirds foundations’ work across these concerted efforts to improve mental health and well-being. For instance, the financial backing of foundations often supports the innovation that started in communities. But that is not the end of the road—these efforts frequently live and die by the larger systems and policies that are needed to enable, support, scale, and sustain the work.
That said, while it is essential that foundations play a role in policy, it is often unclear how best for them to do so, and even less clear how to do so with other foundations, grantees, and partners. There appears to be a need for thoughtfully designed and tightly knit strategies that foundations can use to meaningfully affect policy. For example, consider the following case studies.
The Hogg Foundation for Mental Health in Texas launched its Mental Health Policy Academy and its Fellows programs in 2010. Policy fellows are placed at nonprofit, government, or higher education organizations across Texas to increase individual and organizational capacity to advance mental health policy in Texas and to better engage consumers in mental health policy development and implementation. In addition, the Hogg Foundation produces a Mental Health Guide, for advocates and policy makers, to coincide with each Texas legislative session (held every two years), and the foundation follows up after each session with a summary that provides an overview of mental health– and substance misuse–related legislation filed during that session.
The New Hampshire Charitable Foundation has invested in public policy and advocacy to reduce and prevent alcohol and substance misuse—its work has included launching and supporting New Futures, a nonprofit organization that “advocates, educates and collaborates to improve the health and wellness of all New Hampshire residents through policy change.”
The W.K. Kellogg Foundation has supported policy efforts including the development, implementation, and evaluation of a Mental Health Impact Assessment tool to assess the effect of public decisions and actions on the social determinants of mental health in low-income communities. (The Robert Wood Johnson Foundation (RWJF) and the Pierce Family Foundation also support the tool.) Additionally, Kellogg has supported a mental health policy development working group focused on promotion of mental health in schools, child care, and early education. That work has been described in prior Health Affairs Blog posts.
The Lutheran Foundation formed and launched the Regional Mental Health Coalition of Northeast Indiana in 2016, which aims to improve mental and behavioral health and wellness by advocating for policy and systemic changes, developing campaigns to reduce stigma, and ensuring collaboration across government, mental health, health care, judicial, education, faith-based, and workplace communities.
And, in 2017, Trust for America’s Health (TFAH) and Well Being Trustembarked on a joint effort to advance policy solutions to the drug, alcohol, and suicide epidemics. The first product of this partnership was a report, Pain in the Nation: The Drug, Alcohol and Suicide Epidemics and the Need for a National Resilience Strategy, funded by Well Being Trust and the RWJF, and published by TFAH.
That report focuses specifically on practice and policy solutions to reduce deaths from drugs, alcohol, and suicide—ranging from expanding the use and availability of rescue drugs, sterile syringes, and diversion programs, to limiting hours and density of alcohol sales, to supporting state suicide prevention plans, to expanding social-emotional learning and mental health services in schools. The report also calls for—and provides recommendations for building—a National Resilience Strategy, which would take an effective, comprehensive, continuum approach to addressing these epidemics, from prevention and early identification, to connection to services and supports, to treatment and recovery.
What We’ve Learned
The following highlights specific actions mentioned in the report that could be taken to solve some of the problems around substance misuse and mental health. We understand that there are multiple layers of policy action required at each level—local, state, and national—and that each layer will have different types of action that can be taken.
- Investing in prevention and creating more resilient families and communities must be a higher policy priority—especially for foundations.
In recognition that many of the issues we face as a society around mental health and substance misuse are grounded in social factors, simply dedicating our attention to working on closing the treatment gap (which is important but is being addressed by many other organizations) is insufficient.
Well Being Trust and our grantees, including TFAH, are investigating policies that can go upstream and prevent mental health and substance misuse problems from even beginning in the first place. We will help support the investment, policies, and practices necessary to enhance protective factors and close the prevention gap.
- Foundations can be instrumental in helping their communities create consistent standards for identifying and treating mental health and substance misuse for multiple conditions and across community and clinical delivery settings.
Currently, there are no consistent standards for mental health and substance misuse treatment in the United States. This means that receiving care differs greatly depending on certain critical variables like insurance type, location of service, and type of clinician providing care.
One of the first steps for creating a more equitable and comprehensive system is to have consistent standards for mental health across multiple clinical settings. Foundations and grantees have a critical role to play in identifying these standards and advancing the policies that codify them in practice.
- We must make accessing services for mental health and substance misuse conditions easier and make services more affordable for everyone.
Utilizing mental health and substance misuse services requires access to the appropriate clinician and ability to afford the care and treatment. Sadly, both of these items remain problematic in the United States.
The country must consider novel approaches to improve access, rather than simply depending on a referral to a mental health or substance misuse clinician. Redistributing mental health and substance misuse clinicians throughout the health care system is one way to increase access.
And, when we consider that mental health and substance misuse services remain unaffordable for many people, both access and affordability will require us to rethink our strategy and develop innovative policies and solutions.
Certain populations face particular barriers to access. Blacks, Latinos, and American Indians are more likely to be uninsured. Those living in rural areas may not live near treatment and other services. And low-income residents throughout the United States face a number of obstacles to care including the potential loss of income when seeking treatment.
- Mental health and substance misuse benefits, services, and policies must be at or above parity for medical benefits, services, and policies.
Undergirding much of what transpires in health care delivery are the benefits that each of us carry through our respective insurer. In many cases, how mental health and substance misuse benefits have been structured make it truly challenging to integrate care in a systemic way. And, in other cases, mental health and substance misuse benefits are not even offered at parity despite federal law mandating it.
Clearly, policies can be strengthened and created to ensure that people have access to the benefits that will help them to realize their fullest potential.
- We must redesign how we pay for mental health and substance misuse treatment so as to prioritize prevention, team-based care, and quality and outcomes.
Currently, health care is often driven by disease and sickness. Additionally, fragmented financing keeps mental health and substance misuse services isolated. For the country to solve problems as complex as the deaths of despair, there must be a comprehensive approach that includes simultaneous clinical, operational, and financial changes. As such, alternative delivery and payment models for mental health and substance misuse should be studied, shared, and scaled by foundations. Thankfully, there are new examples emerging each day that highlight innovation in payment reform.
While investing in evidence-based practices and programs—as many foundations are currently doing—is critical to improving health and well-being, a comprehensive, scalable, and sustainable approach requires a greater focus on local, state, and federal policy solutions. Through their grant making, foundations can help change policies or regulations that have implications for health and well-being, as well as influence the direction of government funding in this arena.
In addition, foundations must go further. They need to take risks and be willing to fail.
Government cooperation (and grantmakers’ funding) is, in most cases, critical to having the population-level impacts necessary to close the prevention gap. Yet, government is often required to fund models with an evidence base, which might not always be the most innovative approaches.
At the same time, philanthropies have more leeway to take risks and can put themselves on the line to reduce the risk inherent in certain programs (for example, needle exchange) for government and other foundations. As such, we have to be willing to fail. Not every innovative program is scalable—what works in one town might not work in another town. But we must share our lessons learned—and move forward in a meaningful way together.
Further, to truly move the needle, we must be policy-influencers and advocates. Foundations can harness the power of our endowments through impact investing—using our knowledge of the financial world to ensure that everyone can realize their fullest potential.
It is critical that foundations invest in cutting-edge policies, learn from the case studies highlighted above, and develop novel strategies to engage in this work. Such investment is fundamental to improving mental health and well-being in a comprehensive, scalable, and sustainable way.
This blog post is based on a presentation by the authors at the Grantmakers In Health annual conference, in June 2018, in Chicago.