County officials don't usually get to say the federal policy stars are aligning, but at the recent National Association for Counties (NACo) Legislative Conference, that's exactly what the message was, and the evidence backs it up.
"Counties are on the front lines every single day," said panel moderator Greg Puckett, Commissioner of Mercer County, West Virginia. "Building a functional crisis system isn't just clinical, it's a governance and infrastructure challenge. Policy must match reality."
The federal foundation is already there
Before diving into what's needed, it's worth acknowledging what's already been built. Section 5124 of the Consolidated Appropriations Act of 2023 triggered updated Substance Abuse and Mental Health Services Administration (SAMHSA) National Behavioral Health Crisis Care Guidance, new CMS best practice frameworks, and the creation of a CMS National Training and Technical Assistance Center (NTAC) — a concrete federal resource counties can access right now to build evidence-based crisis continuums. SAMHSA's 2025 model definitions and standards have codified what a functioning crisis system looks like.
The CARE for behavioral health act
Right now, Medicare doesn't reimburse most community-based crisis stabilization services. That means crisis care for over 225 million Americans is patched together through Medicaid, block grants, and county budgets. The CARE for Behavioral Health Act, introduced in bipartisan fashion by Reps. Schweikert (R-AZ), Veasey (D-TX), and Fitzpatrick (R-PA), would create a Medicare pilot program to change that.
The bill also establishes standard definitions for Crisis Stabilization Facilities, addressing the wild variation in scope and quality that makes it nearly impossible to build consistent systems at scale. Connections Health Solutions is actively working to advance the bill in the 119th Congress.
"Federal alignment is essential," said Chris Santarsiero of Connections Health Solutions, a contributor to SAMHSA's 2025 National Crisis System Guidelines. "Counties simply can't absorb the full cost of these services."
Since 1965, Medicaid has been prohibited from covering long-term stays in mental health facilities with more than 16 beds, the IMD exclusion. The result: downsized facilities, inadequate capacity, and individuals falling through the cracks.
The Michelle Go Act, championed by Congressman Dan Goldman (NY-10), would raise that limit to 36 beds—more than doubling Medicaid-eligible psychiatric capacity—while requiring facilities to meet evidence-based standards of care.
The bill is named for Michelle Alyssa Go, killed in a New York City subway in 2022 by someone with untreated severe mental illness. Her death—and others like it—is the direct consequence of a system starved of the resources it needs.
What counties are asking for
Sustainable Medicaid reimbursement. Standard definitions. Medicare coverage for crisis services. These aren't big asks—they're the basic infrastructure that makes everything else possible.
As Supervisor Andrea Bailey of Prince William County put
it: "We need crisis systems that meet individuals where they are, any time of day, with compassion and care." The federal policy to support that already exists in draft form. Now it's time to pass it.
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