Why is it so hard to put better mental health policies in place? Part II

A continued look at what it takes to make mental health reform a reality, plus recommendations on where to focus our efforts.

Before diving right back into how laws are made, I want to take a brief pause to acknowledge and discuss something that happened earlier this week.

As I’m sure you’ve probably seen by now, Sunday night, Meghan Markle shared in a tell-all interview with Oprah Winfrey that while she and Prince Harry were working members of the U.K.’s royal family, she greatly struggled with her mental health – so much so that she said at the time she “didn’t want to be alive anymore.”

Markle said that after she built up the courage to ask for help, she was ultimately denied because it “wouldn’t be good for the institution.”

This is telling in a few ways. First, it shows that stigma is alive and well even across the pond. But even more than that, it reminds us that mental health issues don’t care who you are, where you live, or your socioeconomic status. Similarly, whether it’s stigma, geographic location or issues related to coverage, barriers to mental health care remain for the vast majority of us in some way, shape or form.

One way to remove them is through putting better mental health policies in place, a process I began to describe in my last post and will resume here.

I’VE GOT AN IDEA. I FOUND THE RIGHT PERSON TO TALK TO. WHAT’S NEXT?

There are several different levels of government through which we can pursue policy change (e.g. local, state, national), but there are some operational commonalities between all of them. Generally speaking, here's what that looks like.

CAUTION: Policy purists, there will be some detail and nuance here that is impossible to weave in without this post becoming a small book.

Once you’ve identified a problem, come up with a potential solution, and found an official who is equally passionate about your issue and willing to either take it from there or work with you to draft a bill, the next step is for that bill to be presented to other lawmakers.

With the exception of Nebraska, every state in the U.S. has a bicameral (two chambers) legislature that mirrors our federal legislature. The lower chamber is made up of representatives and is sometimes referred to as a state’s Assembly, and the upper chamber made up of state senators is referred to as a state’s Senate. Nebraska only has one chamber, whose history the most wonky of wonks can read more about here.

Every state has different rules about how a bill is to be presented, but at the federal level and in most state cases, a bill can be presented in either the House or the Senate unless the bill is “for raising revenue.” (See here for a lengthier, recent explanation of the Origination Clause’s Interpretation and Enforcement.)

If a Senator takes interest in your idea, they will present a related bill to the Senate for consideration. If a representative takes interest in your idea, they will present a related bill to the House of Representatives (or Assembly) for consideration. At the federal level, bills entering the U.S. House of Representatives are placed into a wooden box called “the hopper,” which is attached to the clerk’s desk.

WHAT HAPPENS ONCE THE BILL IS OUT OF MY REPRESENTATIVE’S/SENATOR’S HANDS?

After its initial presentation, the bill is reviewed by the head of the chamber in which it was presented. Since it is a common reference point for us all, I’ll demonstrate who does what in each chamber at the federal level.

If presented in the U.S. Senate, it will be reviewed by the President of the Senate – the President of the U.S. Senate is Vice President Kamala Harris. If presented in the U.S. House of Representatives, it will be reviewed by the Speaker of the House – the Speaker of the U.S. House of Representatives is Nancy Pelosi. However, the respective parliamentarians – Elizabeth MacDonough (Senate) and Jason Smith (House) at the federal level – play a big role here, often advising the President or Speaker on which committee the bill should be assigned and what can and can’t be done in accordance with the rules. For example, some may recall that the Senate Parliamentarian ruled against including an increase in the minimum wage that was to be included in the COVID relief bill due to it not meeting the guidelines under reconciliation. In addition, the Parliamentarian also removed the Medicaid reentry act from the COVID relief bill due to jurisdictional concerns, a major blow to many criminal justice advocates.

The bottom line: Parliamentarians makes sure that the rules are kept and that the appropriate committees have been assigned the appropriate bills.

Most states have committees similar to those in the U.S. House of Representatives (20 standing, 4 special/select, 4 joint) and U.S. Senate (16 standing, 5 special/select, 4 joint). The committees that have a tendency to review bills that contain mental health policies are those that focus on health or Medicaid. There is a Health, Education, Labor and Pensions committee, also referred to as HELP, but there is no federal committee explicitly focused on mental health or addiction.

Note, however, that there are a handful of states that realize that mental health underscores everything we do, every single day, and as such, that give mental health and related issues their own committee or subcommittee. New York’s state Assembly, for example, has a standing committee on mental health. (The chair of that committee just introduced “Daniel’s Law” in response to the death of Daniel Prude, a Black man who was experiencing a mental health crisis and died after an encounter with Rochester police.) Massachusetts has a joint committee on mental health, substance use and recovery. And Maryland has a joint committee on behavioral health & opioid use disorders.

Know that most committee hearings are open to the public, meaning you can show up and hear the discussion. In some cases, you can even offer written or oral testimony on the bill being discussed. Washington state makes it easy to fill out an online form to comment on any bill being considered in the state legislature.

Also know that if your state has a special committee or subcommittee on mental health, behavioral health or addiction, that can be great news, because committees can be bills’ worst enemy.

WHAT ROLE DOES A COMMITTEE PLAY IN POLICY CHANGE?

In short, a massive one.

You see, each committee has a chairperson, and it is up to the chairperson whether that bill will be considered and when, as the chairperson sets the committee agenda. Sometimes, the chairperson will do nothing with the bill and effectively kill it, a decision that yes, can be motivated by personal political ideologies. Others, the chairperson will assign the bill to be further investigated by a subcommittee, who will help determine whether a hearing is worthwhile. In the best-case scenario, the chairperson will schedule a hearing for the bill to be discussed by the committee.

If it is decided that the bill is worth hearing, the committee chairperson usually sets that hearing for at least a few weeks out. After the hearing, the committee can do three main things. One, they can release the bill with a recommendation for the rest of the House or Senate to pass it as-is – when they do this, the committee is said to “report out the bill” because their recommendation comes in the form of a report. Two, they can hold a mark-up session, revise/amend and then report out the ”clean bill” to the rest of the chamber. Three, they can kill the bill by tabling it and taking no further action.

Timing really is everything, is it? Even without an explicit “no” vote, a bill can die just because it’s set aside, marginalized – something we unfortunately know happens a lot for mental health.

That's why I encourage you to to keep reading. We have to know more about the policymaking process in order to begin to work to make change, because without a deeper understanding of it, we are also left on the sideline watching policy change happen - or not happen - without getting involved.    

I’ll talk more about timing and the ongoing marginalization of mental health in America – through congressional action and commentary from some of our nation’s greatest leaders – in my next post, because as Megan just reminded us, stigma still runs rampant and has real-world impact no matter who you are or where you live.