Full text
COVID-19
Federal Efforts to
Support Behavioral
Health Programs
During the Pandemic
Report to Congressional Committees
February 2026
GAO-26-107748
United States Government Accountability Office
United States Government Accountability Office
Highlights
COVID-19
Federal Efforts to Support Behavioral Health Programs
During the Pandemic
GAO-26-107748
February 2026
A report to congressional committees
For more information, contact: Alyssa M. Hundrup at HundrupA@gao.gov.
What GAO Found
The Substance Abuse and Mental Health Services Administration (SAMHSA)
leads federal efforts to advance behavioral health. This includes providing grant
funding and technical assistance to states and behavioral health providers to
implement behavioral health prevention and treatment programs. Selected
SAMHSA state and provider awardees said they made various changes to
continue delivering behavioral health services during the COVID-19 pandemic.
Examples of Selected State and Provider Awardees’ Changes to Behavioral Health
Services During the COVID-19 Pandemic
SAMHSA also provided technical assistance and flexibilities to assist awardees
with grant administration and program implementation during the COVID-19
pandemic, according to agency documentation, as well as agency officials,
selected state and provider awardees, and national associations. For example:
•
SAMHSA provided one-on-one assistance, connected awardees with one
another and with partners, and disseminated resources including webinars
and published documents; nearly all selected awardees found this support
helpful during the COVID-19 pandemic.
•
SAMHSA provided grant administration flexibilities to help awardees meet
pandemic needs. For example, SAMHSA extended COVID-19 supplemental
funding project periods for its mental health and substance use block grants
to allow awardees additional time to complete grant-funded activities.
•
SAMHSA, in partnership with other federal agencies, provided program
flexibilities to help awardees deliver services during the COVID-19 pandemic.
Such flexibilities included allowing clinicians to prescribe certain medication
to treat opioid use disorder via telehealth.
Why GAO Did This Study
Behavioral health conditions, which
include mental and substance use
disorders, affect millions of people in
the U.S. and these numbers continue to
grow. The COVID-19 pandemic
exacerbated needs for behavioral
health services and affected service
availability and delivery.
In fiscal years 2020 through 2023,
SAMHSA awarded over $32 billion in
grant funding to support behavioral
health services. This included
approximately $8.3 billion in COVID-19
supplemental funding that SAMHSA
awarded to help grant awardees
address behavioral health needs due to
the pandemic.
The Consolidated Appropriations Act,
2023, includes a provision for GAO to
review SAMHSA programs and
activities to support the continued
provision of behavioral health services
during the COVID-19 pandemic. Among
other topics, this report describes how
selected SAMHSA awardees provided
services during the COVID-19
pandemic and how SAMHSA assisted
awardees to support their response to
the pandemic.
GAO reviewed documentation and
interviewed officials from seven states
and one territory (which we refer to
collectively as selected states) and 16
behavioral health providers about
experiences during the COVID-19
pandemic from January 2020 through
May 2023. GAO selected states to
obtain a mix of geographic regions,
among other criteria, and selected two
providers from each state to reflect
receipt of certain SAMHSA grants. GAO
also reviewed agency documentation,
interviewed SAMHSA officials, and
interviewed representatives from four
national associations with behavioral
health expertise.
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GAO-26-107748 Behavioral Health During COVID-19
Letter
1
Background
5
Advisory Councils and Policy Lab Provided Advice and Resources
to Support SAMHSA’s COVID-19 Response
12
Selected SAMHSA Awardees Made Various Changes to Service
Delivery During the COVID-19 Pandemic Amid Challenges
Such as Workforce Hiring and Retention
22
SAMHSA Provided Technical Assistance and Grant
Administration and Program Flexibilities to Support Awardees
During the COVID-19 Pandemic
33
Agency Comments
47
Appendix I
Objectives, Scope and Methodology
48
Appendix II
Summary of Selected SAMHSA Grant Programs During
COVID-19
52
Appendix III
Selected Grant Administration Flexibilities Allowed by
SAMHSA During the COVID-19 Pandemic
55
Appendix IV
GAO Contact and Staff Acknowledgments
57
Tables
Table 1: Selected Flexibilities Related to SAMHSA Awardees’
Program Implementation During and After the COVID-19
Pandemic
43
Table 2: Summary of Selected SAMHSA Grant Programs That
Supported Behavioral Health Services During the COVID-
19 Pandemic, Fiscal Years 2020–2023
53
Table 3: Overview of Selected Grant Administration Flexibilities
Allowed by SAMHSA During the COVID-19 Pandemic
55
Contents
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GAO-26-107748 Behavioral Health During COVID-19
Figures
Figure 1: SAMHSA Advisory Councils and Focus Areas During the
COVID-19 Pandemic, January 2020–May 2023
13
Figure 2: SAMHSA Policy Lab Considerations for Using
Telehealth to Treat Serious Mental Illness and Substance
Use Disorder
20
Figure 3: Examples of Selected State and Provider Awardees’
Changes to Behavioral Health Services During the
COVID-19 Pandemic
23
Figure 4: Examples of Locations for Behavioral Health Staff and
Clients to Connect Through Telehealth
25
Figure 5: Example SAMHSA Resource—Wallet Card on
Managing Stress During the COVID-19 Pandemic,
Published July 2020
37
Figure 6: Number of SAMHSA Awardees That Received Project
Period Extensions for Block Grant COVID-19
Supplemental Funding
39
Abbreviations
HHS
Department of Health and Human Services
MHBG
Community Mental Health Services Block Grant
Policy Lab
National Mental Health and Substance Use Policy
Laboratory
SAMHSA
Substance Abuse and Mental Health Services
Administration
SUBG
Substance Use Prevention, Treatment, and Recovery
Services Block Grant
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GAO-26-107748 Behavioral Health During COVID-19
441 G St. N.W.
Washington, DC 20548
February 25, 2026
The Honorable Bill Cassidy, M.D.
Chair
The Honorable Bernard Sanders
Ranking Member
Committee on Health, Education, Labor, and Pensions
United States Senate
The Honorable Brett Guthrie
Chairman
The Honorable Frank Pallone, Jr.
Ranking Member
Committee on Energy and Commerce
House of Representatives
Behavioral health conditions, which include mental health conditions and
substance use disorders, affect millions of people in the United States.1
During the COVID-19 pandemic, the number of drug overdoses and the
prevalence of mental health conditions both increased, amplifying the
need for behavioral health services.2 For example, in 2023, an estimated
85 million adults (33 percent) and 6 million adolescents (23 percent) had
a behavioral health condition, an increase from 74 million adults (29
percent) and 5 million adolescents (21 percent) in 2020, according to the
1We define behavioral health conditions as mental, emotional, and substance use
disorders, which are often co-occurring. Examples of mental health conditions include
anxiety disorders; mood disorders, such as depression; post-traumatic stress disorder;
and schizophrenia. Examples of substance use disorders include alcohol use disorder and
opioid use disorder.
2See GAO, Behavioral Health and COVID-19: Higher-Risk Populations and Related
Federal Relief Funding, GAO-22-104437 (Washington, D.C.: Dec. 10, 2021). The
Secretary of Health and Human Services declared a public health emergency in response
to COVID-19 on January 31, 2020, under section 319 of the Public Health Service Act; it
expired on May 11, 2023. We refer to this period as the COVID-19 pandemic for the
purposes of this report.
Letter
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GAO-26-107748 Behavioral Health During COVID-19
Substance Abuse and Mental Health Services Administration
(SAMHSA).3
The COVID-19 pandemic exacerbated longstanding concerns about the
availability of substance use treatment and mental health services and
affected the modes of service delivery, according to SAMHSA. For
example, SAMHSA reported that more than half of adults who received
mental health services in late 2020 had appointments moved from in
person to telehealth, and more than a third experienced appointment
delays or cancellations.4 The pandemic also increased concerns about
behavioral health workforce shortages, as some providers laid off
behavioral health staff and other providers closed because they did not
have the financial reserves to survive financial losses and increased
operating expenses, according to SAMHSA.
SAMHSA, an agency within the Department of Health and Human
Services (HHS), leads federal efforts to advance the behavioral health of
the nation.5 To do so, the agency provides grant funding and technical
assistance to states and behavioral health providers, among others, to
implement mental health and substance use treatment and prevention
programs. SAMHSA contributes to national behavioral health policy
3Substance Abuse and Mental Health Services Administration, Center for Behavioral
Health Statistics and Quality, Key Substance Use and Mental Health Indicators in the
United States: Results from the 2023 National Survey on Drug Use and Health (Rockville,
Md.: July 2024) and Substance Abuse and Mental Health Services Administration, Center
for Behavioral Health Statistics and Quality, Key Substance Use and Mental Health
Indicators in the United States: Results from the 2020 National Survey on Drug Use and
Health (Rockville, Md.: Oct. 2021).
4Specifically, among adults aged 18 or older who received mental health services in the
past year, 58.3 percent (26.6 million) had appointments moved from in person to
telehealth and 38.7 percent (17.7 million) experienced delays or cancellations in
appointments, according to SAMHSA data for quarter 4 of 2020 (October through
December). About 10.7 percent (4.9 million) were unable to access needed care resulting
in a perceived moderate to severe impact on health, according to these data. See
Substance Abuse and Mental Health Services Administration, Center for Behavioral
Health Statistics and Quality, Key Substance Use and Mental Health Indicators in the
United States: Results from the 2020 National Survey.
5On March 27, 2025, HHS announced that it would be restructuring the department,
including by consolidating SAMHSA into a new Administration for a Healthy America. See
U.S. Department of Health and Human Services, Office of the Assistant Secretary for
Public Affairs, HHS Announces Transformation to Make America Healthy Again (March
27, 2025). In May 2025, several states filed a lawsuit challenging the March 27
announcement; litigation is ongoing. See New York v. Kennedy, No. 25-cv-00196 (D.R.I.
May 5, 2025). As of February 2026, the transition to a new structure had not occurred and
accordingly, we refer to the agency as SAMHSA throughout this report.
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GAO-26-107748 Behavioral Health During COVID-19
efforts through its National Mental Health and Substance Use Policy
Laboratory (Policy Lab) and can draw on advice from the public and
behavioral health professionals through its advisory councils to advance
its goals.
In fiscal years 2020 through 2023, SAMHSA awarded over $32 billion
through its annual budget authority to support programs that provided
substance use treatment, substance use prevention, or mental health
services, according to agency data. This included approximately $8.3
billion in COVID-19 supplemental funding that SAMHSA awarded to help
address behavioral health needs that resulted from the pandemic.6
The Consolidated Appropriations Act, 2023, includes a provision for us to
review SAMHSA programs and activities to support the continued
provision of mental health and substance use disorder services and
related activities during the COVID-19 pandemic.7 In this report, we
describe
1. how SAMHSA’s advisory councils and Policy Lab supported the
agency’s COVID-19 response;
2. how selected SAMHSA awardees provided services during the
COVID-19 pandemic and what challenges they experienced; and
3. how SAMHSA provided assistance to awardees to support their
response to the COVID-19 pandemic.
To address our first objective, we reviewed documentation and
interviewed SAMHSA officials. Specifically, we reviewed reports and
meeting minutes and interviewed officials about SAMHSA’s advisory
councils and committees—which we refer to as advisory councils for the
purposes of this report—and the Policy Lab. We reviewed activities that
6SAMHSA received $8.5 billion in COVID-19 supplemental funding in fiscal years 2020
and 2021, according to agency officials. Some of this funding was appropriated to
SAMHSA from March 2020 through March 2021 through the CARES Act, Pub. L. No. 116-
136, div. B, tit. VIII, 134 Stat. 281, 556 (2020); the Consolidated Appropriations Act, 2021,
Pub. L. No. 116-260, div. M, tit. III, 134 Stat. 1182, 1913 (2020); and the American Rescue
Plan Act of 2021, Pub. L. No. 117-2, tit. II, subtit. H, 135 Stat. 4, 45–48. Unless otherwise
stated, references to the Consolidated Appropriations Act, 2021, in this report refer to the
COVID-19 supplemental funding in Division M of that act (Coronavirus Response and
Relief Supplemental Appropriations Act, 2021). See GAO-22-104437. SAMHSA also
received supplemental funding through interdepartmental funding, according to agency
officials.
7Pub. L. No. 117-328, § 2112(e), 136 Stat. 4459, 5722 (2022).
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GAO-26-107748 Behavioral Health During COVID-19
took place from January 2020 through May 2023, the timeframe of the
COVID-19 public health emergency, which we refer to as the COVID-19
pandemic for the purposes of this report. (See app. I for additional details
on the scope and methodology.)
To address our second and third objectives, we reviewed documentation
from and interviewed officials and representatives from SAMHSA, four
national associations, and a nongeneralizable sample of SAMHSA
awardees. Selected awardees included seven states and one territory—
which we refer to collectively as selected states—and 16 behavioral
health providers in the selected states. The eight selected states are
Michigan, Mississippi, Montana, Oregon, Pennsylvania, Puerto Rico,
Texas, and Vermont.8 We use the following modifiers to quantify
awardees’ responses:
•
“Nearly all” represents seven states when we are referring to just the
states we interviewed, 12 to 15 providers when we are referring to just
the providers we interviewed, or 18 to 22 awardees (i.e., the total
across states and providers we interviewed).
•
“Many” represents five to six states, eight to 11 providers, or eight to
17 awardees.
•
“Some” represents two to four states, three to seven providers, or
three to seven awardees.
The experiences of the selected awardees are not generalizable across
all SAMHSA awardees. However, the information we obtained from them
illustrates a variety of experiences with SAMHSA grants and assistance
during the COVID-19 pandemic. We selected states and providers that
received funding through a selection of SAMHSA grants, including block
grants and others, to obtain variation in rurality and geographic region,
8Puerto Rico is counted both as a state awardee and a behavioral health provider
awardee because officials spoke with us about their experiences both as a state agency
and as an operator of a behavioral health provider organization receiving SAMHSA grants
during the COVID-19 pandemic. Counting Puerto Rico as a single awardee, we
interviewed a total of 23 selected awardees.
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GAO-26-107748 Behavioral Health During COVID-19
among other factors.9 Together, these selected grant programs represent
over three-quarters (approximately 78 percent) of SAMHSA’s total
funding awarded to support behavioral health services from fiscal years
2020 through 2023. (See app. I for additional details on our scope and
methodology, including how we selected SAMHSA grant programs and
awardees for this review; app. II contains summary information on the
selected SAMHSA grant programs.)
We conducted this performance audit from July 2024 to February 2026 in
accordance with generally accepted government auditing standards.
Those standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our
findings and conclusions based on our audit objectives. We believe that
the evidence obtained provides a reasonable basis for our findings and
conclusions based on our audit objectives.
SAMHSA leads federal public health efforts to advance the behavioral
health of the nation. SAMHSA is responsible for, among other things,
providing federal funding through grants to states, local communities, and
private entities to support community-based mental health and substance
use treatment and prevention services. SAMHSA also provides technical
assistance to help states, territories, Tribes, and other behavioral health
providers develop and strengthen behavioral health services.
Several SAMHSA offices—including four centers, nine advisory councils,
and the Policy Lab—supported and coordinated the work of the agency
during the COVID-19 pandemic from January 2020 through May 2023.
•
Centers. SAMHSA carries out most of its programs and activities
through four centers—the Center for Behavioral Health Statistics and
Quality, the Center for Mental Health Services, the Center for
Substance Abuse Prevention, and the Center for Substance Abuse
Treatment—and its other offices. The centers support state and local
efforts through funding and technical assistance; they do not directly
9We focused our review on six SAMHSA grant programs: Community Mental Health
Services Block Grant (MHBG); Substance Use Prevention, Treatment, and Recovery
Services Block Grant (SUBG); State Opioid Response; Emergency Grants to Address
Mental and Substance Use Disorders During COVID-19 (Emergency COVID-19 grants);
Certified Community Behavioral Health Clinic Expansion; and Community Mental Health
Center grant programs. Block grants are noncompetitive, formula grants mandated by
Congress.
Background
SAMHSA Programs and
Activities
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GAO-26-107748 Behavioral Health During COVID-19
deliver treatment services. The centers administer SAMHSA’s major
block grant programs and most of SAMHSA’s other grant programs.
•
Advisory councils. SAMHSA’s advisory councils provide advice to
SAMHSA on various topics such as women’s services, tribal health,
and the coordination of behavioral health activities across the federal
government.10 Advisory councils are made up of members of the
public and behavioral health professionals. Some of SAMHSA’s
advisory councils may also review applications submitted for certain
SAMHSA grants and recommend projects for approval.11
•
Policy Lab. The Policy Lab supports SAMHSA’s efforts to implement
policy changes, coordinate its programs, and disseminate information
regarding evidence-based practices.12 The Policy Lab collaborates
with entities within and outside of SAMHSA on various activities,
including efforts to develop evidence-based practice written products
and implementing legislation. The Policy Lab also manages
SAMHSA’s Evidence-Based Practices Resource Center, a searchable
online database of mental health and substance use information
supported by scientific research. These resources provide
communities, clinicians, policymakers, and others with information
and tools to incorporate evidence-based practices into communities or
clinical settings.
SAMHSA funds various grant programs that support the direct provision
of behavioral health services, including during the COVID-19 pandemic.
For example, two of SAMHSA’s largest grant programs—the Community
Mental Health Services Block Grant (MHBG) and the Substance Use
Prevention, Treatment, and Recovery Services Block Grant (SUBG)—
awarded funds to states, territories, and the District of Columbia, which, in
10SAMHSA’s advisory councils were authorized by the Public Health Service Act in
accordance with the Federal Advisory Committee Act, according to the agency. See 42
U.S.C. § 290aa-1; 5 U.S.C. ch. 10. According to SAMHSA’s website, three of the nine
advisory councils had been terminated by the agency as of September 2025.
11See 42 U.S.C. § 290aa-3.
12See GAO, Behavioral Health: Activities of the National Mental Health and Substance
Use Policy Laboratory, GAO-24-106760 (Washington, D.C.: May 16, 2024). Evidence-
based practices are interventions that promote individual-level or population-level
outcomes and are guided by the best research evidence with practice-based expertise,
cultural competence, and the values of the people receiving the services, according to
SAMHSA.
Selected SAMHSA Grant
Programs
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GAO-26-107748 Behavioral Health During COVID-19
turn, may have distributed funds through subawards to local government
entities and behavioral health service providers, among others.13
The MHBG supports the development, implementation, and maintenance
of community mental health services for both adults with serious mental
illness and children and adolescents with serious emotional disturbance.14
The SUBG supports the planning, implementation, and evaluation of
activities for prevention, treatment, and recovery from substance use
disorders. Both block grants allow flexibility for recipients to address the
mental health and substance use disorder needs of their populations,
according to SAMHSA. In addition to its two block grant programs,
SAMHSA also funds prevention, treatment, and recovery support services
for opioid use disorder through its State Opioid Response grant
program.15
SAMHSA also awarded grant funding directly to community behavioral
health systems and provider organizations, referred to as behavioral
health providers for the purposes of this report, during the COVID-19
pandemic. For example, SAMHSA awarded funding through its Certified
Community Behavioral Health Clinic Expansion grants to clinics that have
met or can meet certification criteria and provide coordinated
comprehensive mental health and substance use services regardless of
an individual’s ability to pay. These grants supported behavioral health
providers in establishing new community clinics that comply with
certification criteria, such as providing crisis management services 24
hours a day, 7 days a week. The grants also supported existing certified
community behavioral health clinics in expanding and improving
13We refer to states, territories, and the District of Columbia as states for the purposes of
this report. SAMHSA also awarded SUBG funding to one Tribe. SAMHSA awards block
grant funding using a formula specified in statute that takes into account three factors: (1)
population of the state, (2) costs of services in the state, and (3) fiscal capacity of the
state. All states have minimum allotments. See 42 U.S.C. § 300x-7; 42 U.S.C. § 300x-33.
14Adults with serious mental illness are those aged 18 and older with a diagnosable
mental, behavioral, or emotional disorder—such as bipolar disorder, major depressive
disorder, or schizophrenia—that substantially interferes with their life and ability to
function, according to SAMHSA. Individuals with serious emotional disturbance are those
under age 18 with a diagnosable mental, behavioral, or emotional disorder that
substantially interferes with or limits the child’s role or functioning in family, school, or
community activities, according to SAMHSA.
15For more information on SAMHSA’s State Opioid Response grant program, see GAO,
Opioid Use Disorder Grants: Opportunities Exist to Improve Data Collection, Share
Information, and Ease Reporting Burden, GAO-25-106944 (Washington, D.C.: Dec. 17,
2024) and Opioid Use Disorder: Opportunities to Improve Assessments of State Opioid
Response Grant Program, GAO-22-104520 (Washington, D.C.: Dec. 9, 2021).
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GAO-26-107748 Behavioral Health During COVID-19
services.16 (See app. II for summary information on selected SAMHSA
grant programs that supported the direct provision of behavioral health
services during the COVID-19 pandemic.)
Additionally, SAMHSA funds various training and technical assistance
centers that offer free support to those working in behavioral health,
including SAMHSA awardees. Some of these centers provide support
specific to SAMHSA grant programs, such as a national training and
technical assistance center for certified community behavioral health
clinic awardees, while others provide general support on a specific topic
or population, such as disaster behavioral health. SAMHSA’s training and
technical assistance centers serve national audiences through webinars
and written resources; specific groups through topic-based virtual learning
collaboratives, communities of practice, or short-term training; and
communities, states, and Tribes through intensive individualized technical
assistance.
In addition to these grant programs that predated the COVID-19
pandemic, SAMHSA also funded various grant programs specifically to
address pandemic needs. Some of these programs are discussed below.
During an emergency such as the COVID-19 pandemic, SAMHSA is
responsible for providing technical assistance, training, consultation, and
operational support to federal, state, territorial, and tribal authorities to
address behavioral health needs.17 These needs can include addressing
the effect of disasters and emergencies on behavioral health critical
infrastructure and supporting population-level interventions to promote
coping with stresses, among others. SAMHSA is also responsible for
providing timely public health messaging to the general public to mitigate
stress caused by an emergency. According to SAMHSA, it is common for
people to experience behavioral health effects associated with disease
outbreaks such as COVID-19, natural disasters (e.g., hurricanes), and
other types of disasters or emergencies. For example, people may
16Substance Abuse and Mental Health Services Administration, Certified Community
Behavioral Health Clinic Certification Criteria (Rockville, Md.: Feb. 2023). For more
information on SAMHSA’s activities to support crisis response services, see GAO,
Behavioral Health: Federal Activities to Support Crisis Response Services,
GAO-25-107586 (Washington, D.C.: Sept. 4, 2025).
17See Department of Health and Human Services, All-Hazards Plan (Washington, D.C.:
June 2024).
SAMHSA’s Role During
the COVID-19 Pandemic
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GAO-26-107748 Behavioral Health During COVID-19
experience symptoms such as anxiety or sadness after such disasters.18
Not everyone with symptoms will go on to have a diagnosed condition.
Additionally, SAMHSA is responsible for supporting locally led recovery
activities to restore and enhance behavioral health supports and systems,
including populations experiencing post-disaster trauma.19 While some
people’s behavioral health symptoms resolve soon after a crisis, others
may experience longer-term effects.20 In addition, some people who have
no symptoms right after a crisis may develop delayed symptoms later
on.21
To help address the effects of the COVID-19 pandemic on behavioral
health, SAMHSA awarded approximately $8.3 billion in COVID-19
supplemental funding in grants to recipients that included states,
territories, the District of Columbia, Tribes, and nongovernmental
organizations.22 For example, SAMHSA awarded $3.1 billion to SUBG
awardees and $2.3 billion to MHBG awardees with supplemental funding
18See D.J. DeWolfe, Training Manual for Mental Health and Human Service Workers in
Major Disasters, Department of Health and Human Services Publication no. ADM 90-538,
(2nd ed.) (Rockville, Md.: Substance Abuse and Mental Health Services Administration,
2000); Substance Abuse and Mental Health Services Administration, Warning Signs and
Risk Factors for Emotional Distress, accessed July 25, 2025; and Substance Abuse and
Mental Health Services Administration, Survivors of Disasters Resource Portal, accessed
July 25, 2025.
19According to HHS, behavioral health recovery may include support for those grieving
losses, those with traumatic experiences, those with high levels of chronic stress, those
with substance use issues related to the post-disaster environment, and those with pre-
disaster clinical behavioral health needs.
20See D.J. DeWolfe, Training Manual for Mental Health; Substance Abuse and Mental
Health Services Administration, Tips for Survivors of a Disaster or Other Traumatic Event:
Managing Stress, Department of Health and Human Services Publication No. SMA-13-
4776 (Rockville, Md.: January 2013); and Substance Abuse and Mental Health Services
Administration, Warning Signs and Risk Factors.
21See E. Goldmann and S. Galea, “Mental Health Consequences of Disasters,” Annual
Review of Public Health, vol. 35 (2014).
22SAMHSA received the supplemental funding through appropriations from Congress in
the CARES Act, the Consolidated Appropriations Act, 2021, and the American Rescue
Plan Act of 2021, and through interdepartmental funding, according to agency officials.
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GAO-26-107748 Behavioral Health During COVID-19
from the Consolidated Appropriations Act, 2021, and the American
Rescue Plan Act of 2021.23
Additionally, SAMHSA used $1.3 billion in COVID-19 supplemental
funding for grants to support certified community behavioral health clinics
and used $823 million to create the new Community Mental Health
Centers grant program to enable community mental health centers to
support and restore delivery of clinical services affected by the COVID-19
pandemic.24 SAMHSA also used about $345 million in COVID-19
supplemental funding for the new Emergency Grants to Address Mental
and Substance Use Disorders During COVID-19 (Emergency COVID-19
grants) to help states, territories, and Tribes provide crisis intervention
services, mental and substance use disorder treatment, and other related
recovery supports for people affected by the pandemic.25 (See app. II for
more information on SAMHSA’s use of COVID-19 supplemental funding
to support selected grant programs during the pandemic.)
During a public health emergency such as the COVID-19 pandemic,
SAMHSA is permitted to extend or waive certain block grant requirements
for SUBG and MHBG recipients. For example, the Public Health Service
Act allows SAMHSA to provide extensions, waive application deadlines,
and waive compliance with other grant requirements as the
circumstances of the public health emergency reasonably require.26
Additionally, the Consolidated Appropriations Act, 2021, allowed
SAMHSA to waive grant requirements related to allowable activities,
23See Pub. L. No. 116-260, div. M., tit. III, 134 Stat. 1182, 1913 (2020); Pub. L. No. 117-2,
§§ 2701–02, 135 Stat. 4, 45–46. Awardees had until March 14, 2023, to expend
supplemental funding from the Consolidated Appropriations Act, 2021, and until
September 30, 2025, to expend supplemental funding from the American Rescue Plan Act
of 2021.
24The Consolidated Appropriations Act, 2021, specified that a certain portion of the
supplemental appropriations had to be used for community mental health centers. See
Pub. L. No. 116-260, 134 Stat. 1182, 1913 (2020). Eligible applicants for the grant funding
included nonprofit community mental health centers, as defined in the Public Health
Service Act, including those operated by state and local governments. See 42 U.S.C. §
300x-2(c). The centers may or may not also be certified community behavioral health
clinics, according to SAMHSA officials.
25The CARES Act and the Consolidated Appropriations Act, 2021, specified that a certain
part of the supplemental appropriations had to be used for emergency response activities.
See 42 U.S.C. § 290aa(o).
26See 42 U.S.C. § 300x-67.
Grant Flexibilities Available
During COVID-19
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GAO-26-107748 Behavioral Health During COVID-19
timelines, or reporting for SUBG and MHBG COVID-19 supplemental
funding awards to help awardees respond to COVID-19.27
Starting in March 2020, the Office of Management and Budget also
allowed federal awarding agencies, including SAMHSA, to implement
certain exceptions to government-wide grant requirements.28 These
exceptions—referred to as grant administration flexibilities for the
purposes of this report—were intended to provide awardees with the
administrative and financial relief necessary to complete grant-related
activities during the COVID-19 pandemic, according to Office of
Management and Budget guidance. The Office of Management and
Budget authorized agencies to provide 16 flexibilities during the COVID-
19 pandemic.29 For example, agencies could extend awardees’ grant
project periods by up to 1 year—referred to as a no-cost extension—to
allow them to continue implementing program activities. Agencies could
also allow awardees to spend grant funds on normally unallowable costs
to meet pandemic needs. Federal agencies, including SAMHSA, could
decide to make these flexibilities available to awardees as they deemed
appropriate and to the extent they were permitted by law.
27See Pub. L. No. 116-260, div. M, tit. III, 134 Stat.1182, 1914 (2020). On May 18, 2021,
SAMHSA provided guidance establishing its ability to waive these same requirements for
MHBG and SUBG COVID-19 supplemental funding awards authorized by the American
Rescue Plan Act of 2021. See Substance Abuse and Mental Health Services
Administration, Letter to Single State Authority Directors and State Mental Health
Commissioners (Rockville, Md.: May 18, 2021).
28For more information on COVID-19-related grant flexibilities, including their broader use
within HHS, see GAO, Grants Management: OMB Should Collect and Share Lessons
Learned from Use of COVID-19-Related Grant Flexibilities, GAO-21-318 (Washington,
D.C.: Mar. 31, 2021).
29The Office of Management and Budget issued this guidance in a series of five
memorandums. See Office of Management and Budget, Administrative Relief for
Recipients and Applicants of Federal Financial Assistance Directly Impacted by the Novel
Coronavirus (COVID-19), M-20-11 (Washington, D.C.: Mar. 9, 2020); Administrative Relief
for Recipients and Applicants of Federal Financial Assistance Directly Impacted by the
Novel Coronavirus (COVID-19) Due to Loss of Operations, M-20-17 (Washington, D.C.:
Mar. 19, 2020); Repurposing Existing Federal Financial Assistance Programs and Awards
to Support the Emergency Response to the Novel Coronavirus (COVID-19), M-20-20
(Washington, D.C.: Apr. 9, 2020); Extension of Administrative Relief for Recipients and
Applicants of Federal Financial Assistance Directly Impacted by the Novel Coronavirus
(COVID-19) due to Loss of Operations, M-20-26 (Washington, D.C.: June 18, 2020); and
Promoting Public Trust in the Federal Government through Effective Implementation of the
American Rescue Plan Act and Stewardship of the Taxpayer Resources, M-21-20
(Washington, D.C.: Mar. 19, 2021).
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GAO-26-107748 Behavioral Health During COVID-19
Additionally, certain federal agencies—including SAMHSA, the Drug
Enforcement Administration, and HHS’s Office for Civil Rights—issued
guidance allowing flexibilities in behavioral health program
implementation during the COVID-19 pandemic. These changes, referred
to as program flexibilities for the purposes of this report, were intended to
help SAMHSA awardees and others deliver behavioral health services
during the COVID-19 pandemic to meet pandemic needs.
Each of SAMHSA’s nine advisory councils that were active during the
COVID-19 pandemic contributed to the agency’s COVID-19 response,
including by providing advice, according to SAMHSA documentation and
officials.30 (See fig. 1 for a description of these councils.) SAMHSA
officials told us the agency took some steps to address councils’ advice,
though it is not required to do so under the federal act that governs the
advisory councils.31
30Advisory council members vote on formal recommendations during meeting
proceedings, according to SAMHSA officials. During a meeting, a member may propose a
formal recommendation, and in the subsequent meeting, the chair will follow up on the
formal recommendation for members to vote on, according to officials. For the purposes of
this report, we define “advice” to include all other advisory activities beyond formal
recommendations.
31The Federal Advisory Committee Act does not require agencies to respond to or
implement advisory council recommendations, and advisory councils are not required to
publish information on any agency response to recommendations. See 5 U.S.C. ch. 10.
See also GAO, Federal Advisory Committees: Actions Needed to Enhance Decision-
Making Transparency and Cost Data Accuracy, GAO-20-575 (Washington, D.C.: Sept. 10,
2020). Eight of SAMHSA’s nine advisory councils are governed by this act.
Advisory Councils
and Policy Lab
Provided Advice and
Resources to Support
SAMHSA’s COVID-19
Response
Advisory Council Advice
Related to COVID-19
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GAO-26-107748 Behavioral Health During COVID-19
Figure 1: SAMHSA Advisory Councils and Focus Areas During the COVID-19
Pandemic, January 2020–May 2023
aThe Drug Testing Advisory Board was terminated effective March 31, 2025, according to SAMHSA’s
website.
bThe Interdepartmental Serious Mental Illness Coordinating Committee was terminated effective April
9, 2025, according to SAMHSA’s website.
cAdults with serious mental illness are ages 18 and older with a diagnosable mental, behavioral, or
emotional disorder—such as bipolar disorder, major depressive disorder, or schizophrenia—that
substantially interferes with their life and ability to function, according to SAMHSA. Individuals with
serious emotional disturbance are those under age 18 with a diagnosable mental, behavioral, or
emotional disorder that substantially interferes with or limits the child’s role or functioning in family,
school, or community activities, according to SAMHSA.
dThe Interdepartmental Substance Use Disorders Coordinating Committee was terminated effective
May 6, 2025, as stipulated in the SUPPORT for Patients and Communities Act, according to
SAMHSA’s website. Pub. L. No. 115-271, § 7022, 132 Stat. 3894, 4010–12 (2018). In December
2025, the law was reauthorized and set September 30, 2030, as the new termination date for the
committee. SUPPORT for Patients and Communities Reauthorization Act of 2025, Pub. L. No. 119-
44, § 110(b), 139 Stat. 669, 677–78. See also 42 U.S.C. § 290aa note.
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GAO-26-107748 Behavioral Health During COVID-19
We found that all nine advisory councils discussed and advised SAMHSA
on the use of telehealth during the COVID-19 pandemic. We found that all
but one advisory council discussed and advised SAMHSA on specific
populations’ experiences during the COVID-19 pandemic, grant
implementation during the pandemic or program sustainability after the
end of the pandemic, and future agency priorities to recover from COVID-
19.32 Members discussed these topics during public meetings and
published meeting minutes and reports with advice related to COVID-19,
for example.
Telehealth. Advisory council members discussed and advised the use of
telehealth for mental health and substance use services during the
COVID-19 pandemic. For example, one advisory council published a
report to Congress in April 2022 that discussed the use of telehealth for
people with serious mental illness and serious emotional disturbance.33
The council reported that telehealth—including both video and telephone
appointments—improved access to care for these individuals. In this
report, the council advised federal agencies, including SAMHSA, to
promote the use of evidence-based telehealth and publish guidelines for
providing telehealth services.
Advisory council members also discussed the benefits and limitations of
telehealth. For example, some advisory council members said that
telehealth can reduce childcare and transportation barriers as well as
stigma related to receiving behavioral health care. However, some
advisory council members noted that telehealth may not work for all
clients, including those with limited internet access, computer literacy
skills, or privacy for appointments.
One council advised that SAMHSA continue research on benefits and
drawbacks of telehealth, as well as its effectiveness in different
socioeconomic and demographic populations. One council member
emphasized the importance of studying telehealth practices and gathering
population-level data to better understand how different communities
benefit from telehealth or experience barriers to its use. A member of
another council advised that SAMHSA research and evaluate telehealth
32The advisory council that did not discuss these topics—the Drug Testing Advisory
Board—had a narrower scope focused on forensic workplace drug testing and other
related topics.
33Interdepartmental Serious Mental Illness Coordinating Committee, Advances Through
Collaboration: Federal Action for a System That Works for All People Living with SMI and
SED and Their Families and Caregivers, Report to Congress (Rockville, Md.: Apr. 2022).
Federal Advisory Councils
Federal advisory councils and committees are
to inform public policy and government
regulations by advising the President and
federal agencies on national issues. Federal
advisory councils may be composed of
subject matter experts, representative
members, and federal government employees
who provide advice and recommendations to
help inform and improve executive branch
operations and programs.
Some of these councils—including eight of the
nine councils that advised the Substance
Abuse and Mental Health Services
Administration (SAMHSA) during the COVID-
19 pandemic—are governed by the Federal
Advisory Committee Act. This act requires
federal agencies to ensure that federal
advisory councils make decisions that are
independent and transparent to the public.
For example, councils can only deliberate and
decide on advice and recommendations to
agencies during meetings that are open to the
public, and they must make meeting minutes
publicly available.
Absent any statutory requirements, advisory
councils are advisory only. The act does not
require agencies to respond to or implement
advisory council recommendations, or to
publish information on any agency response
to recommendations.
Source: Information from U.S. General Services
Administration and SAMHSA; 5 U.S.C. ch. 10. |
GAO-26-107748
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GAO-26-107748 Behavioral Health During COVID-19
services and support compared to in-person services provided during the
COVID-19 pandemic. The member said that this research could help
inform the use of telehealth in future emergencies.
According to officials, SAMHSA responded to this advice by sharing
information with providers on using telehealth for behavioral health
services, supporting increased use of telehealth during the COVID-19
pandemic, and working to identify telehealth best practices and ways to
address limitations. For example, SAMHSA implemented a national
training and technical assistance program on telehealth with over 300,000
behavioral health provider participants, according to officials.34
Additionally, SAMHSA officials said the agency advocated for increased
access to telehealth through telephone-based behavioral health
appointments, rather than restricting services to video calls, to serve
households with limited internet access or technology. According to
SAMHSA, the agency partnered with the Federal Communications
Commission to inform the public about extended cell phone minutes for
individuals with severe mental illness who may need telephone-based
mental health services.
Specific populations. Advisory council members discussed and advised
SAMHSA on how the COVID-19 pandemic affected specific populations,
such as women, tribal communities, youth, and health care providers. For
example, some council members discussed factors that might have
contributed to increased alcohol use among women, such as parenting-
related stress. One council advised that SAMHSA collect data on
women’s behavioral health during the COVID-19 pandemic to help
explain why women were disproportionately affected. According to
SAMHSA officials, the agency added questions to the National Survey on
Drug Use and Health related to the receipt of telehealth services and the
effect of COVID-19 on behavioral health to allow for an improved
34Specifically, two SAMHSA-funded technical assistance centers—the Addiction
Technology Transfer Center Network and the Center for Excellence for Protected
Behavioral Health Information—and other organizations facilitated a learning series in
2020 that involved presentations, national online discussion, and resource sharing for
substance use disorder treatment providers and peer support specialists transitioning their
services to telehealth and videoconferencing during the COVID-19 pandemic, according to
one center’s website.
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GAO-26-107748 Behavioral Health During COVID-19
understanding of substance use and mental health patterns during the
COVID-19 pandemic.35
In 2021, another council advised that SAMHSA update its National Tribal
Behavioral Health Agenda to reflect the long-term effects of the COVID-
19 pandemic on tribal entities and incorporate post-pandemic needs.36
SAMHSA began updating the agenda in August 2022, according to
officials, by gathering agency and tribal leaders and citizens to explore
updates related to tribal behavioral health and COVID-19. In April 2023,
SAMHSA officials solicited feedback from the advisory council on whether
the agency should add a chapter to the agenda on the effects of COVID-
19 on tribal communities, including stress to the health care system and
workforce as well as a decline in life expectancy. Following multiple
listening sessions and consultation with this advisory council, SAMHSA
determined that the foundational elements of the agenda remained
relevant and continued to address ongoing needs without the addition of
information specifically addressing COVID-19, according to SAMHSA
officials.
Grant implementation and program sustainability. Advisory councils
discussed SAMHSA grants, including grant implementation, grant
requirements, and program sustainability after the end of the COVID-19
pandemic.37 For example, given the rise of mental illness during the
COVID-19 pandemic, one council advised that SAMHSA consider
increasing grant funding flexibility to allow awardees to serve individuals
35The National Survey on Drug Use and Health collects and provides nationally
representative data on the use of tobacco, alcohol, and illicit drugs; substance use
disorders; mental health conditions; and receipt of substance use and mental health
treatment, according to SAMHSA.
36Substance Abuse and Mental Health Services Administration, The National Tribal
Behavioral Health Agenda (Rockville, Md.: Dec. 2016). The agenda identifies priorities
and strategies to improve behavioral health for American Indian and Alaska Native
populations. SAMHSA’s Tribal Technical Advisory Committee devised the initial concept
for the agenda and helped shape and guide its development, which was a collaborative
effort among Tribes, leaders, organizations, and federal agencies.
37During the COVID-19 pandemic, three advisory councils continued to review grant
proposals for certain SAMHSA grants and cooperative agreements; they also served in
this role prior to COVID-19, according to SAMHSA officials. Specifically, peer reviewers
first evaluate grant applications for SAMHSA funding opportunities, and then some grant
programs are subject to a secondary review by an advisory council, according to the
agency website.
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GAO-26-107748 Behavioral Health During COVID-19
with less severe mental health diagnoses.38 In response, SAMHSA
included requests in its proposed budgets for fiscal years 2023 through
2025 that Congress designate a subset of MHBG funding to support
evidence-based programs that address early intervention and prevention
of mental disorders for at-risk youth and adults, according to SAMHSA
officials. One council member also described some awardees’ difficulty
meeting the Emergency COVID-19 grant requirement to spend 10
percent of funds to support health professionals with mental health
concerns and suggested this population may be reluctant to seek help.
Members of four advisory councils expressed concern about program
sustainability after the COVID-19 pandemic, including ensuring that
awardees maintain program quality. One council advised that SAMHSA
create a plan for states to continue and sustain behavioral health services
after COVID-19 supplemental funding ended. Another council member
advised that SAMHSA allow state and local awardees to use grant
funding to invest in behavioral health systems to prepare for the future
and long-term needs following the COVID-19 pandemic. SAMHSA
officials said that awardees could contact agency officials as needed to
discuss allowable expenses to support program sustainability.
Future priorities. Councils also advised SAMHSA on future priorities and
considerations for the agency to promote recovery from the COVID-19
pandemic. For example, several advisory councils discussed the long-
term effects of COVID-19 on behavioral health. During one meeting, a
member advised SAMHSA to prepare for a long process of behavioral
health recovery from the COVID-19 pandemic, given that people
experience delayed emotional responses, such as grief and psychological
stress, following a disaster.
SAMHSA officials also asked advisory council members for advice on
addressing long COVID—a chronic condition that can occur after COVID-
19 infection and may affect behavioral health—and received several
38For example, MHBG awardees must use funds to provide community mental health
services to adults with serious mental illness and children with serious emotional
disturbance. See 42 U.S.C. § 300x(b). The Emergency COVID-19 grant required
awardees to use 20 percent of funding to provide services to individuals with mental
disorders less severe than serious mental illness.
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GAO-26-107748 Behavioral Health During COVID-19
suggestions.39 One council member suggested that SAMHSA formalize
and disseminate protocols for diagnosing and treating long COVID.
Another member advised using existing knowledge about treating mental
health conditions such as depression, anxiety, and posttraumatic stress
disorder to treat long COVID.
Advisory councils also discussed lessons learned from the COVID-19
pandemic and made suggestions to improve future emergency response.
In April 2023, SAMHSA jointly convened members from six advisory
councils to discuss a range of topics, including lessons learned from the
COVID-19 pandemic to help prepare for the next public health
emergency. During this meeting, one council advised SAMHSA to clearly
document activities during emergencies, such as the COVID-19
pandemic, to help the agency mobilize quickly during future disasters. In
a report to Congress, another council advised that lessons learned from
the COVID-19 pandemic—including those related to mental health,
physical health, and health care delivery—should inform federal policies
and programs.40
SAMHSA engaged in various activities to address the long-term effects of
COVID-19 on behavioral health. For example, SAMHSA commissioned
an external national association to publish a series of 10 technical
assistance papers on mental health response during and beyond the
COVID-19 pandemic, including a post-COVID-19 vision for mental health
services.41 Topics covered included disaster behavioral health, suicide
prevention, and mental health system development in rural and remote
areas, among others. HHS, including SAMHSA, published a report
summarizing services and supports for longer-term effects of COVID-19,
including those related to mental health, substance use, and long
39Some of the most common behavioral health-related conditions associated with long
COVID include depression, anxiety, psychosis, obsessive-compulsive disorder, and
posttraumatic stress disorder, according to SAMHSA. Long COVID can also aggravate
pre-existing conditions or contribute to new mental health or substance use disorders. For
more information on long COVID, see GAO, Science & Tech Spotlight: Long COVID,
GAO-22-105666 (Washington, D.C.: Mar. 2, 2022).
40Interdepartmental Serious Mental Illness Coordinating Committee, Advances Through
Collaboration.
41National Association of State Mental Health Program Directors, Ready to Respond:
Mental Health Beyond Crisis and COVID-19, Reimagining a Sustainable and Robust
Continuum of Psychiatric Care (Alexandria, Va.: Sept. 2021).
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GAO-26-107748 Behavioral Health During COVID-19
COVID.42 SAMHSA also published various resources about long COVID,
including a literature review summary of the effects of long COVID on
behavioral health and an advisory resource with evidence-based
resources for treatment.43
We found the Policy Lab supported SAMHSA’s COVID-19 response by
publishing resources, providing information to Congress, coordinating
activities within SAMHSA and across the federal government, and in
some cases, deploying staff to assist with local COVID-19 response
efforts.
Publishing resources. The Policy Lab published resources on evidence-
based practices and service delivery models to help communities,
clinicians, policymakers, and others incorporate evidence-based practices
into their communities or clinical settings in response to COVID-19. For
example, in June 2021, the Policy Lab issued an evidence-based
resource guide on using telehealth to treat serious mental illness and
substance use disorders, including during the COVID-19 pandemic.44
This guide included an overview of telehealth, a summary of research
findings on its effectiveness for mental health and substance use
treatment, guidance for implementing evidence-based practices, and
resources for evaluation and quality improvement. (See fig. 2 for
telehealth implementation considerations and strategies to facilitate
effective implementation on multiple, interrelated levels, as described in
the Policy Lab resource.) This guide referenced COVID-19 because of
the increased need for and expansion of telehealth during the pandemic,
according to SAMHSA officials.
42Department of Health and Human Services, Services and Supports for Longer-Term
Impacts of COVID-19 (Washington, D.C.: Aug. 2022).
43Substance Abuse and Mental Health Services Administration, Overview of the Impacts
of Long COVID on Behavioral Health (Rockville, Md.: Mar. 2023) and Substance Abuse
and Mental Health Services Administration, National Mental Health and Substance Use
Policy Laboratory, Identification and Management of Mental Health Symptoms and
Conditions Associated with Long COVID (Rockville, Md.: June 2023).
44Substance Abuse and Mental Health Services Administration, National Mental Health
and Substance Use Policy Laboratory, Evidence-Based Resource Guide Series:
Telehealth for the Treatment of Serious Mental Illness and Substance Use Disorders
(Rockville, Md.: 2021).
Policy Lab Support During
the COVID-19 Pandemic
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GAO-26-107748 Behavioral Health During COVID-19
Figure 2: SAMHSA Policy Lab Considerations for Using Telehealth to Treat Serious
Mental Illness and Substance Use Disorder
Notes: See Substance Abuse and Mental Health Services Administration, National Mental Health and
Substance Use Policy Laboratory, Evidence-Based Resource Guide Series: Telehealth for the
Treatment of Serious Mental Illness and Substance Use Disorders (Rockville, Md.: 2021).
Additionally, the Policy Lab published an advisory resource on long
COVID that defines the condition, describes associated mental health
symptoms, and provides evidence-based tools for diagnosis and
treatment.45 For example, this resource describes treatment approaches
such as therapy to address new or relapsed psychiatric conditions related
to long COVID; peer support groups to build connections with others with
similar experiences; and physical rehabilitation to support recovery from
chronic fatigue.
Providing information to Congress. The Policy Lab’s Office of
Legislative Affairs provided technical assistance to Congress related to
COVID-19 legislation and supplemental funding, according to SAMHSA
officials. For example, SAMHSA officials said congressional staff
consulted Policy Lab officials when developing legislation such as the
CARES Act, the Consolidated Appropriations Act, 2021, and the
American Rescue Plan Act of 2021.46 We previously reported that the
Policy Lab responded to 298 inquiries from Congress, HHS, the
45Substance Abuse and Mental Health Services Administration, Mental Health Symptoms
and Conditions Associated with Long COVID.
46These COVID-19 relief acts appropriated over $8 billion to SAMHSA in COVID-19
supplemental funding, which SAMHSA used to support various behavioral health
programs and activities. See GAO-22-104437.
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GAO-26-107748 Behavioral Health During COVID-19
Congressional Research Service, and the Congressional Budget Office in
fiscal year 2022, according to SAMHSA officials.47 The Policy Lab
responded to 914 such inquiries in fiscal year 2023, according to officials.
Coordinating federal activities. The Policy Lab coordinated activities
within SAMHSA and across the federal government to support the
agency’s COVID-19 response. For example, beginning in 2022, the Policy
Lab coordinated cross-cutting activities between the agency’s training and
technical assistance programs, including assistance related to COVID-19,
according to SAMHSA officials.48 SAMHSA officials said that the Policy
Lab hosted bimonthly meetings with SAMHSA’s training and technical
assistance center program directors to discuss collaboration between
programs and the dissemination of evidence-based practices. Officials
from the Policy Lab also participated in a cross-governmental body that
coordinated collaborative work on long COVID across 14 federal
government agencies.49 Additionally, the Policy Lab continued to
coordinate SAMHSA’s nine advisory councils during the COVID-19
pandemic and supported their discussions and advice related to the
pandemic, according to SAMHSA officials. For example, Policy Lab
officials coordinated advisory council meeting agendas, speakers, and
participants; ensured public access to meetings and oversaw completion
of accurate meeting minutes; and modified advisory council meetings
from in person to virtual during the COVID-19 pandemic, according to
officials.
Deploying staff. SAMHSA deployed Policy Lab officials to Tribal Nations
and the U.S. Public Health Service Commissioned Corps Headquarters
47See GAO-24-106760.
48The Policy Lab assumed this training and technical assistance coordination role starting
in April 2022, when SAMHSA expanded the Policy Lab to better align with 21st Century
Cures Act designated roles, according to SAMHSA officials. See GAO-24-106760.
49The Long COVID Coordination Council was chaired by the Assistant Secretary for
Health and made up of representatives from 14 federal agencies, including SAMHSA. The
council published various resources that incorporated mental health and substance use
issues. See, for example, Department of Health and Human Services, Services and
Supports for Longer-Term Impacts of COVID-19. The Policy Lab continued its work on
long COVID after the end of the COVID-19 public health emergency, including by hosting
a Policy to Action Initiative meeting in May 2024 with researchers, clinicians,
representatives from national organizations, individuals with lived experience of long
COVID, and federal agency colleagues. During this 2-day meeting, participants discussed
challenges related to the behavioral health effects of long COVID and identified key
messages and strategies to raise awareness.
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GAO-26-107748 Behavioral Health During COVID-19
Command Center to assist with the COVID-19 response.50 For example,
officials provided behavioral health support and mental health crisis
response to staff at the Navajo Nation hospital and outpatient clinics in
New Mexico and Arizona in August 2020, according to SAMHSA officials.
Two Policy Lab officials supported the Headquarters Command Center,
including by leading efforts to identify and safely deploy U.S. Public
Health Service officers to support various local COVID-19 response
efforts, according to SAMHSA officials.
We found the 23 selected state and behavioral health provider awardees
included in our review implemented a range of changes to their SAMHSA-
funded behavioral health services to be able to continue providing
services during the COVID-19 pandemic. These changes included using
telehealth to deliver services, implementing COVID-19 safety measures
for in-person services, expanding services to meet client needs, and
developing new community and agency partnerships. (See fig. 3.)
50The U.S. Public Health Service Commissioned Corps is a uniformed service branch of
public health professionals. Commissioned Corps emergency response teams are trained
and equipped to respond to public health crises and national emergencies, according to
HHS. Commissioned Corps Headquarters is responsible for the administration and
response coordination of the U.S. Public Health Service Commissioned Corps.
Selected SAMHSA
Awardees Made
Various Changes to
Service Delivery
During the COVID-19
Pandemic Amid
Challenges Such as
Workforce Hiring and
Retention
Selected Awardees
Increased Telehealth to
Maintain Services and
Expanded Some Services
to Address COVID-19
Needs
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GAO-26-107748 Behavioral Health During COVID-19
Figure 3: Examples of Selected State and Provider Awardees’ Changes to
Behavioral Health Services During the COVID-19 Pandemic
Increased use of telehealth. All 23 selected awardees reported using
telehealth to maintain behavioral health services during the COVID-19
pandemic. Some awardees said they used telehealth prior to COVID-19,
but on a more limited basis.51 When the COVID-19 pandemic began in
2020, nearly all awardees said they increased telehealth capacity so they
could continue to provide services while it was unsafe to provide them in
person.
Nearly all awardees said they used video platforms such as Zoom, audio-
only phone calls, and text messaging to provide services. Some
awardees said they used SAMHSA funding to purchase equipment for
providers to administer telehealth services. For example, one state used
SAMHSA funding to supply providers with laptops, tablets, computer
monitors, and videoconferencing equipment, according to a progress
report submitted to SAMHSA.
Selected awardees used telehealth to provide behavioral health services
such as counseling, peer support, case management, and crisis response
51In reporting selected awardees’ responses, we use “nearly all” to represent 18 to 22
awardees, “many” to represent eight to 17 awardees, and “some” to represent three to
seven awardees.
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to clients during the COVID-19 pandemic.52 For example, one state
installed telehealth kiosks in local emergency rooms to facilitate crisis
screening and assessment and to allow for virtual face-to-face contact
between the clinician and client, according to the state’s progress report
submitted to SAMHSA. Another state’s residential treatment programs
used telehealth to connect clients to off-site medical and psychiatric
services, including medication-assisted treatment for substance use
disorder, according to its progress report.53 One provider said they
provided coaching through telehealth to clients recovering from substance
use disorders to help meet client needs when clients were unable to
attend appointments in health care facilities due to COVID-19 restrictions.
Selected awardees used telehealth in a variety of locations. Some
behavioral health staff delivered services from their homes, while others
delivered telehealth services from clinics, according to providers. Clients
received telehealth services at home, at clinics that were more accessible
than those where behavioral health staff were located, or in private
community locations with internet access, according to awardees. (See
fig. 4.) For example, one provider said they set up telehealth
infrastructure in rural clinics to connect clients to behavioral health staff at
clinics in metropolitan areas. Some of these rural clinics were located
hours away from metropolitan areas where providers were located, so
this “hub-and-spoke” model helped clients in more remote areas receive
care.
52According to SAMHSA, counseling may involve licensed professionals or peers working
with and advising individuals, families, couples, or groups on a range of issues related to
mental health and substance use. Peer support involves nonclinical activities provided by
individuals with lived experience in recovery from a mental or substance use disorder.
Case management is a coordinated approach to the delivery of health, substance abuse,
mental health, and social services, linking clients with appropriate services to address
specific needs and achieve stated goals. Behavioral health crisis response services
provide access to behavioral health professionals for individuals experiencing mental
health or substance use-related crises and offer an alternative to emergency departments
and law enforcement intervention.
53Residential treatment programs allow clients to stay at a facility for a few weeks to a few
months while receiving treatment for mental health conditions or substance use disorder,
according to SAMHSA. Medication-assisted treatment combines behavioral therapy and
the use of certain medications, such as buprenorphine, to reduce the misuse of or
addiction to opioids and to increase treatment retention.
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Figure 4: Examples of Locations for Behavioral Health Staff and Clients to Connect
Through Telehealth
Notes: Telehealth can connect clients and providers in multiple locations such as at a home, private
space in a clinical setting, or another location in the community, according to SAMHSA. Some
telehealth appointments may connect a client in their home to behavioral health staff working from a
clinic or from their own home. In other cases, clients may connect to behavioral health staff from a
clinic site or private community location equipped with telehealth infrastructure, which can help
address connectivity barriers. For example, clients and behavioral health staff can connect from
separate rooms in the same clinic site to reduce COVID-19 spread, or from different clinic sites closer
to each party’s home to reduce geographic barriers to care. See Substance Abuse and Mental Health
Services Administration, National Mental Health and Substance Use Policy Laboratory, Evidence-
Based Resource Guide Series: Telehealth for the Treatment of Serious Mental Illness and Substance
Use Disorders (Rockville, Md.: 2021).
Many selected awardees said that clients benefitted from the increased
use of telehealth to deliver services during the COVID-19 pandemic.
Some awardees said that telehealth allowed them to serve more clients
compared to before the COVID-19 pandemic began in 2020. Specifically,
some awardees said client engagement and attendance improved as
telehealth reduced some previous barriers to accessing services. Many
awardees said telehealth helped clients in rural communities and areas
with limited transportation who no longer had to travel long distances to
access services. Some awardees also said that telehealth was
particularly useful for adults who were technologically savvy and adjusted
easily to virtual services.
Some selected awardees said that text messaging and audio-only
telehealth helped clients with limited access to computers, internet, or
smartphones to receive services during the COVID-19 pandemic. For
example, one provider said they used SAMHSA funding to purchase work
cell phones for behavioral health staff so that they could deliver services
and conduct client outreach via text message. This provider said text
messaging was useful for engaging with younger people, including young
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parents, who were comfortable with texting but did not always return
phone calls.
Some selected awardees said behavioral health staff also benefitted from
the use of telehealth, for example, because it allowed them to deliver
services to clients while limiting their exposure to COVID-19. Some
awardees said that behavioral health staff appreciated the convenience of
telehealth, including the opportunity for remote or hybrid work. Telehealth
also increased staff efficiency, according to representatives from one
national association.54 For example, one provider said that telehealth
made it easier for clinicians to communicate with staff at other agencies,
which allowed them to more efficiently coordinate their clients’ care.55
Implemented safety measures for in-person services. Nearly all
selected awardees said they provided at least some services in person in
addition to telehealth during the COVID-19 pandemic, and adjusted
service delivery protocols to limit COVID-19 spread. Many awardees said
that telehealth was not always the best option to provide certain types of
services. For example, one provider said they met in person with clients
who benefitted from face-to-face appointments, including clients receiving
substance use treatment, to help ensure their safety. Additionally, some
awardees said they generally continued to provide community-based
services, such as assertive community treatment, in person to reach
54According to SAMHSA, telehealth can make behavioral health visits more efficient by
allowing staff to see more patients in a shorter period of time and by reducing costs
associated with in-person care. See Substance Abuse and Mental Health Services
Administration, Advisory: Using Technology-Based Therapeutic Tools in Behavioral Health
Services (Rockville, Md.: 2021).
55Care coordination helps people navigate behavioral health care, physical health care,
social services, and other systems they are involved in, according to SAMHSA. For
example, care coordination might involve helping clients schedule appointments or helping
them access or enroll in benefits. SAMHSA requires certified community behavioral health
clinics to provide care coordination to clients. See Substance Abuse and Mental Health
Services Administration, Certified Community Behavioral Health Clinic Certification
Criteria.
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clients and maintain their connection to care while using safety measures
to protect behavioral health staff and clients.56
Nearly all selected awardees increased use of safety and infection
prevention measures, including personal protective equipment such as
masks, to limit COVID-19 spread, according to state officials and
providers. For example, one state used SAMHSA funding to purchase air
purifiers and replacement filters for use by behavioral health staff to
improve air quality and decrease COVID-19 risk, according to a progress
report submitted to SAMHSA. This state also used SAMHSA funding to
buy masks, COVID-19 testing kits, and cleaning and disinfecting supplies
for staff delivering behavioral health services. In addition, some awardees
said they reconfigured their clinics and waiting rooms to promote social
distancing, including by installing clear plastic barriers.57
Additionally, many selected awardees said behavioral health staff met
with clients in outdoor settings, such as pavilions, parks, and client yards,
which allowed staff to safely check on clients and ensure they continued
to receive services and support in convenient locations. For example, one
state used SAMHSA funding to set up covered outdoor areas where
behavioral health staff could meet with clients with reduced risk of
COVID-19 spread, according to officials. Officials from this state said staff
used these spaces to host youth and other mental health support groups
that otherwise would not have had a safe space to meet and interact.
Officials from one state said behavioral health staff worked out of their
cars to reach clients in more rural areas and met with clients on the
street. They delivered supplies and necessities, including sack lunches, to
clients to maintain relationships and keep them connected to care. Many
awardees said behavioral health staff met outdoors with clients at their
56Assertive community treatment is designed to provide comprehensive community-based
services to people with a serious mental illness. Assertive community treatment programs
use a variety of treatment and rehabilitation practices, including medications; behaviorally
oriented skill teaching; crisis intervention; support, education, and skill teaching for family
members; supportive therapy; cognitive-behavioral therapy; group treatment; and
supported employment. Under the assertive community treatment model, services are
delivered by a mobile, multidisciplinary treatment team. These services are to be available
24 hours a day, 365 days a year. See GAO, Serious Mental Illness: HHS Assessments of
Assisted Outpatient Treatment Have Yielded Inconclusive Results, GAO-25-107526
(Washington, D.C.: July 10, 2025).
57Social distancing, also known as physical distancing, is a way to keep people from
interacting closely or frequently enough to spread an infectious disease such as COVID-
19, according to SAMHSA. The Centers for Disease Control and Prevention defines
physical distancing as putting physical distance between people to lower the risk of
spreading a respiratory virus.
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homes for one-on-one or group meetings. For example, one provider said
they delivered peer support, individual and group therapy, and counseling
services in clients’ backyards.
Expanded services. Nearly all selected awardees said they expanded
some of their behavioral health services during the COVID-19 pandemic,
for example, by offering new services, increasing the reach of existing
services, or targeting specific populations to address new or increased
needs. Many awardees said they expanded peer support services during
the COVID-19 pandemic. For example, one state expanded their peer
support program to serve 26 of the state’s 36 counties, an increase from
only a few counties served prior to COVID-19, according to officials.
During the COVID-19 pandemic, this state’s peer support specialists
served clients in community locations such as homeless encampments
and laundromats, rather than only within hospital facilities, because fewer
clients went into hospitals to receive services during the pandemic. Many
awardees also expanded their crisis support services during the COVID-
19 pandemic, such as crisis center hotlines, mobile crisis response
teams, and walk-in crisis services located in clinics. For example, one
state used SAMHSA funding to add a second staff member to each of
their mobile crisis teams, which allowed them to provide services in
people’s homes rather than solely in public settings such as schools and
emergency departments.
Many selected awardees provided targeted services to certain
populations that experienced increased needs during the COVID-19
pandemic, such as youth, people with co-occurring mental health and
substance use disorders, tribal populations, health care professionals,
and individuals experiencing homelessness. For example, one provider
said they used SAMHSA funding to support a trauma-focused therapy
program for children and adolescents to address trauma and disruption
experienced during the COVID-19 pandemic. Another provider said they
enhanced group programming and other services for clients with co-
occurring mental health and substance use disorders to serve clients with
more severe conditions, as they found this was increasingly common
during the COVID-19 pandemic. Additionally, one provider said they
enhanced culturally appropriate wellness services for tribal populations
and worked closely with tribal leadership to coordinate behavioral health
care for these clients. Some selected awardees said they provided
services targeted to health care professionals, who experienced
emotional strain due to the pandemic. For example, officials from one
state said they hired clinical professionals to provide therapy and
coaching for health care workers.
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Developed or expanded partnerships. Nearly all selected awardees
said they developed or expanded partnerships with community and faith
groups, universities, or state and local governmental agencies to improve
outreach during the COVID-19 pandemic. For example, one state
partnered with faith-based organizations to educate congregants on
addiction and mental illness and connect them to services and resources,
according to officials. The state developed this partnership to reach the
many residents who were already seeking support from faith leaders
during the COVID-19 pandemic, officials said.
Many selected awardees said they developed or expanded partnerships
with state and local government agencies, including public health and law
enforcement agencies. For example, officials from one state and one
provider said they partnered with other stakeholders, including law
enforcement, to distribute the opioid overdose-reversal drug naloxone
during the COVID-19 pandemic.58 The state also worked with nonprofit
organizations to help distribute naloxone, according to officials, to
address COVID-19-related disruptions to the state’s original distribution
plan. Some awardees also said they partnered with local law enforcement
agencies to help de-escalate and intervene in situations involving people
with severe mental illness and connect them to mental health services.
For example, one state supplied police officers with internet-connected
tablets they could use to connect people to crisis screening and
intervention staff while responding to 911 calls, according to its progress
report submitted to SAMHSA. Additionally, one provider said they
delivered a crisis intervention training program to teach law enforcement
officers about mental illness and proper intervention techniques during
mental health emergencies.
The 23 selected state and behavioral health provider awardees in our
review identified various challenges in providing behavioral health
services during the COVID-19 pandemic. Awardees said they
experienced challenges with workforce hiring and retention and the use of
telehealth, among others, and that challenges affected service delivery.
Workforce hiring and retention. All 23 selected awardees experienced
challenges hiring and retaining behavioral health provider staff during the
COVID-19 pandemic, according to state officials and providers.
58Naloxone is a medication designed to quickly reverse the effects of opioid overdoses,
according to SAMHSA. Overdose prevention services may involve distributing naloxone to
individuals at risk of overdose, or to those who are likely to respond to an overdose of
another individual.
Selected Awardees
Experienced Workforce
Hiring and Retention and
Telehealth Implementation
Challenges That Affected
Service Delivery
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Behavioral health provider workforce shortages existed prior to the start
of the COVID-19 pandemic in 2020, and many awardees said that the
pandemic exacerbated these challenges.59 For example, some awardees
said that state agency and provider staff were overwhelmed by having to
take on additional responsibilities; struggled with burnout and fear of
COVID-19 infection; and in some cases, left to work in other sectors that
paid more, allowed remote work, or were less emotionally challenging.
Additionally, one provider said that they experienced difficulties hiring
community-based positions, such as case managers, that did not have a
remote work option. Another awardee cited challenges hiring staff who
were required to work in person, such as nurses and counselors. Officials
from one state also said that some state behavioral health officials were
reassigned to support the state’s pandemic response, causing staffing
shortages at their agency.
Some selected awardees specifically struggled to hire staff to work in
rural areas, according to state officials and providers. For example,
officials from one state said that rural behavioral health clinics
experienced challenges attracting qualified applicants, and one rural
provider said they struggled to compete with providers in urban areas that
could offer higher salaries. Some tribal communities also struggled to find
licensed behavioral health staff willing to commute to isolated areas,
because they tended to prefer living in larger cities and could find jobs
closer to home, according to representatives from one national
association.
Many selected awardees said that workforce shortages delayed grant
implementation or interrupted service provision during the COVID-19
pandemic. For example, officials from one state said some of their
subawardees took longer to begin implementing SAMHSA-funded
behavioral health activities because they were understaffed and had to
hire, train, and retain staff to administer services.60 Officials from another
state said that some clinics had to suspend enrollment in medication-
assisted treatment services because they did not have enough staff to
sustain services. Additionally, one provider said they delayed
implementation of their peer support program due to staffing shortages.
59We previously reported on behavioral health workforce shortages and federal efforts to
address them. See GAO, Behavioral Health: Available Workforce Information and Federal
Actions to Help Recruit and Retain Providers, GAO-23-105250 (Washington, D.C.: Oct.
27, 2022).
60For some SAMHSA grants, state awardees distribute funding to subawardees, such as
individual healthcare clinics providing behavioral health services directly to patients.
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Another provider experienced challenges sustaining sufficient behavioral
health staff—including those with a master’s degree—to provide mobile
crisis services in a rural area for 24 hours a day, 7 days a week.
Selected awardees said they responded to workforce hiring and retention
challenges in various ways, for example, by using SAMHSA grant funding
to pay for new positions, increase salaries and provide bonuses, and
implement staff wellness programs to improve morale. One provider said
they used SAMHSA funding to hire 50 additional employees, including
nurses, therapists, and prescribers such as physician assistants, which
allowed the provider to serve more clients and meet the demand for
services during the COVID-19 pandemic. In addition, this provider said
they increased nurse and physician salaries to match market rates, gave
sign-on bonuses to new hires, and gave referral bonuses to staff who
helped with recruitment. One state also used SAMHSA funding to
increase salaries for certain clinical staff that were difficult to hire and
provided staff incentive payments, such as 6-month retention bonuses
and tuition reimbursement, according to its progress report submitted to
SAMHSA. Also, some awardees said they used SAMHSA funding to
support workforce wellness efforts such as mindfulness coaching to
address staff burnout, anxiety, and trauma that contributed to turnover
during the COVID-19 pandemic.
Telehealth implementation. Many selected awardees said they
experienced challenges using telehealth to provide behavioral health
services during the COVID-19 pandemic, including issues with clients’
telehealth equipment and connectivity. For example, awardees said that
some clients did not have access to telehealth devices, such as personal
computers or smartphones, and some did not have consistent internet
connection to join appointments. These challenges were more common in
rural areas and among individuals with lower incomes or experiencing
homelessness, according to some awardees. In rural areas, inconsistent
broadband internet connectivity and cell phone service prevented some
clients from receiving care; for example, one provider said that some rural
clients experienced video call interruptions during telehealth sessions due
to poor internet connection. Some awardees also said that behavioral
health staff, especially those in rural areas, did not initially have access to
devices to accommodate telehealth at the start of the COVID-19
pandemic in early 2020 but were generally able to quickly get the needed
technology and equipment to provide services.
Selected awardees said they addressed clients’ telehealth equipment and
connectivity challenges, for example, by setting up spaces in clinics or
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community locations where clients could access internet-connected
telehealth devices. As a result, clients experiencing barriers to
participating in telehealth from home could travel to a clinic or other
facility and join telehealth appointments from that location. One state
equipped rural mobile crisis response units with internet-connected
tablets so behavioral health staff located in other areas could screen and
assess rural clients, according to officials. Some awardees said
behavioral health staff used audio-only phone calls to deliver services to
clients who could not join video calls.
Many selected awardees also said that some clients, such as children
and older adults, experienced challenges navigating telehealth platforms
or participating in appointments outside of private settings. For example,
some awardees said that clients sometimes joined telehealth
appointments from public spaces or while family members were present.
One provider said that the lack of privacy could affect certain clients’
ability to discuss confidential behavioral health issues as well as their
safety, for example, from domestic violence. In response to challenges,
some awardees said they taught clients how to use telehealth platforms
and emphasized the importance of maintaining privacy and confidentiality
during telehealth sessions. Some awardees said they resumed in-person
services for clients who struggled to use telehealth when it was safe to do
so.
Other challenges. Some selected awardees cited various other
challenges to providing behavioral health services during the COVID-19
pandemic. These awardees said they experienced challenges meeting
the increased demand for behavioral health services, including serving
clients with more severe behavioral health needs that worsened during
the COVID-19 pandemic. For example, officials from one state said they
saw an increase in youth and college students with anxiety and
depression, and two providers said that clients experienced increased
trauma during the COVID-19 pandemic. Additionally, officials in one state
said some clients who had been in long-term recovery relapsed during
the COVID-19 pandemic. The increased demand for services strained
awardee resources; for example, one provider said they had to waitlist
clients.
Some selected awardees also expressed concern about the sustainability
of services after the end of the grant project period. For example, officials
from one state said local behavioral health clinics were reluctant to apply
for subaward funding due to sustainability concerns, such as having to lay
off staff when the state’s SAMHSA award ended.
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Officials from one selected state and one selected provider said they
experienced supply chain challenges during the COVID-19 pandemic that
affected delivery of behavioral health services. For example, officials from
one state said they experienced challenges in acquiring air purifiers, hand
sanitizer, and masks for residential treatment facilities to protect clients
and staff from COVID-19 infection. Additionally, one provider said they
experienced difficulties securing computers, laptops, and cellphones,
which delayed onboarding new staff and preparing them to deliver
behavioral health services.
SAMHSA provided one-on-one technical assistance, connected
awardees with one another or with partners, and disseminated resources
such as webinars and published documents to assist awardees during the
COVID-19 pandemic, according to SAMHSA officials, selected state and
behavioral health provider awardees, and representatives from national
associations.61 Officials from all states and nearly all providers said
61We interviewed a nongeneralizable sample of SAMHSA awardees, including eight
selected states and 16 behavioral health provider awardees in the selected states
(Michigan, Mississippi, Montana, Oregon, Pennsylvania, Puerto Rico, Texas, and
Vermont). Selected state awardees received MHBG, SUBG, State Opioid Response, and
Emergency COVID-19 grants from SAMHSA. Selected provider awardees participated in
SAMHSA’s Certified Community Behavioral Health Clinic Expansion or Community Mental
Health Center grant programs, or both programs. We also interviewed representatives
from four national associations.
SAMHSA Provided
Technical Assistance
and Grant
Administration and
Program Flexibilities
to Support Awardees
During the COVID-19
Pandemic
Technical Assistance
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GAO-26-107748 Behavioral Health During COVID-19
SAMHSA technical assistance and resources were generally helpful
during the COVID-19 pandemic.62
Providing one-on-one technical assistance. SAMHSA officials said
they continued to hold monthly video calls with each awardee during the
COVID-19 pandemic and provided one-on-one awardee assistance on
various topics through these meetings and in response to ad hoc
inquiries. For example, SAMHSA officials advised awardees and
answered questions on using COVID-19 grant flexibilities, determining
allowable grant expenditures, building telehealth capacity, and enhancing
mobile support services, according to agency officials. SAMHSA also
established an electronic resource mailbox for recipients to submit
COVID-19-related grants management questions, according to agency
officials.
Among selected awardees, officials from all states and nearly all
providers said they found one-on-one technical assistance helpful during
the COVID-19 pandemic, and nearly all awardees said that SAMHSA
officials were responsive and available to address their questions. For
example, one provider said that SAMHSA officials helped them revise
degree requirements for a grant-funded position, which helped them
successfully hire staff. Officials from one state said SAMHSA officials
shared strategies other states used to keep patients engaged in services
during the COVID-19 pandemic.
SAMHSA provided individualized assistance to each awardee that was
tailored to their unique circumstances or community needs, according to
agency officials. Officials said that SAMHSA hired additional staff to help
manage the increased number of awards the agency was administering
because of the COVID-19 supplemental funding.
However, some selected awardees shared that they experienced
challenges related to staff turnover with their assigned SAMHSA points of
contact, and many selected awardees identified topics for which they
would have liked more robust, clearer, or additional technical assistance
from SAMHSA during the COVID-19 pandemic. For example, one
provider said that SAMHSA staff turnover made it difficult to identify the
62To characterize awardees’ responses throughout this report, “nearly all” represents
seven states, 12 to 15 providers, or 18 to 22 awardees (i.e., the total across states and
providers); “many” represents five to six states, eight to 11 providers, or eight to 17
awardees; and “some” represents two to four states, three to seven providers, or three to
seven awardees.
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GAO-26-107748 Behavioral Health During COVID-19
correct SAMHSA point of contact to answer questions. Additionally, one
provider located in a rural area said they could have benefitted from
resources that were tailored to rural settings, such as resources on
addressing transportation barriers for clients, and another provider said
they would have appreciated additional technical assistance on clinical
topics, such as delivering therapeutic interventions using telehealth.
SAMHSA officials acknowledged that awardees likely experienced
challenges during the COVID-19 pandemic, including related to SAMHSA
staff turnover. To address these challenges, SAMHSA ensured grantees
had consistent access to SAMHSA staff through the agency’s resource
mailboxes; provided direct technical assistance support to awardees,
including through SAMHSA-funded training and technical assistance
centers; and produced specialized technical assistance products and
resources, according to agency officials.
Facilitating awardee connections. SAMHSA and the training and
technical assistance centers it funds connected awardees with other
awardees or behavioral health partners for networking and support during
the COVID-19 pandemic, according to officials from SAMHSA,
representatives from national associations, and selected state and
provider awardees.63 Agency officials said SAMHSA provided peer
learning opportunities and monthly meetings during the COVID-19
pandemic where state awardees presented best practices. For example,
the SAMHSA-funded Certified Community Behavioral Health Clinic
Expansion Grantee National Training and Technical Assistance Center
hosted awardee learning communities for certified community behavioral
health clinic awardees during the COVID-19 pandemic, according to
representatives from one national association. This center also facilitated
a mentorship program between newer clinics and more experienced
certified community behavioral health clinics during the COVID-19
pandemic, according to representatives from one national association and
some selected providers that participated in the program.
Officials from nearly all selected states and many provider awardees said
that these connections were helpful, including in helping them address
common challenges and figure out how best to provide services during
the COVID-19 pandemic. For example, officials from one state said that
63SAMHSA-funded training and technical assistance centers offer free support to those
working in the behavioral health field—including SAMHSA awardees—on topics across
the behavioral health spectrum, according to the agency. This includes assistance for
states, Tribes, nonprofits, communities, health care professionals, and behavioral health
specialties including licensed clinicians and peer support specialists.
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GAO-26-107748 Behavioral Health During COVID-19
awardees shared ideas for how to manage COVID-19 outbreaks in
residential treatment facilities during one awardee meeting. Officials from
another state said they discussed topics such as transportation barriers
for patients and workforce shortages during SAMHSA-organized
meetings with other state officials. Additionally, one provider said they
used meetings to exchange ideas with other providers on topics such as
best practices for providing medication-assisted treatment through
telehealth during the COVID-19 pandemic. One provider said their
connections with other awardees turned into ongoing relationships that
continued after the COVID-19 pandemic ended.
Disseminating information and other resources. SAMHSA
disseminated information to awardees and the public through webinars,
published resources, and technical assistance centers during the COVID-
19 pandemic, according to officials from SAMHSA, selected awardees,
and representatives from national associations. SAMHSA’s COVID-19
webpage provided guidance and resources to assist individuals,
communities, states, and behavioral health staff, including our selected
state and provider awardees. For example, SAMHSA provided resources
to assist awardees with grant administration, such as a sample COVID-19
revised budget document and a list of COVID-19 Frequently Asked
Questions on grants management. In addition, SAMHSA published a
range of resources to help awardees better deliver behavioral health
services during the COVID-19 pandemic. For example, SAMHSA
published guidance on using telehealth to treat serious mental illness and
substance use disorders, and the SAMHSA-funded Disaster Technical
Assistance Center published information on adaptations and innovations
in behavioral health services during the COVID-19 pandemic.64 (See fig. 5
for an example of a SAMHSA resource provided during the COVID-19
pandemic.)
64See Substance Abuse and Mental Health Services Administration, Telehealth for the
Treatment of Serious Mental Illness and Substance Use Disorders; and Substance Abuse
and Mental Health Services Administration, Disaster Technical Assistance Center
Supplemental Research Bulletin: Adaptations and Innovations for Delivering Mental
Health and Substance Use Disorder Treatment Services During the COVID-19 Pandemic
(Rockville, Md.: Aug. 2022).
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Figure 5: Example SAMHSA Resource—Wallet Card on Managing Stress During the
COVID-19 Pandemic, Published July 2020
Officials from all selected states and nearly all provider awardees said
they benefitted from these resources. For example, awardees said they
used SAMHSA resources on topics such as grant flexibilities; data
collection, analysis, and reporting; COVID-19 updates; and clinical topics
such as worker burnout and providing services safely in person or via
telehealth during the COVID-19 pandemic. Officials from one state said
SAMHSA’s webinars on co-occurring disorders helped them address
increased needs among people with these conditions during the COVID-
19 pandemic. One provider said SAMHSA compiled information and
guidance from different federal agencies during COVID-19 and shared
these resources with awardees, which helped the provider save time by
not having to track changing federal guidance during the COVID-19
pandemic.
SAMHSA provided a range of flexibilities to assist awardees in grant
administration and program implementation during the COVID-19
pandemic, according to SAMHSA documentation and agency officials.
Some flexibilities—including those authorized in statute and those
permitted by the Office of Management and Budget—helped awardees
Grant Administration and
Program Flexibilities
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GAO-26-107748 Behavioral Health During COVID-19
meet grant administration requirements, including managing grant
funding, during the COVID-19 pandemic. Additionally, SAMHSA and
other federal agencies provided some flexibilities to help awardees carry
out program functions, such as delivering behavioral health services,
during the COVID-19 pandemic. Selected awardees used grant
administration and program flexibilities to varying degrees and cited some
flexibilities, such as project period extensions and budget revisions, as
particularly useful in adjusting their programs to address COVID-19-
related needs. (See app. III for selected grant administration flexibilities
allowed by SAMHSA during the COVID-19 pandemic.)
SAMHSA provided a variety of grant administration flexibilities, upon
request, to support awardees during the COVID-19 pandemic, including
several that helped awardees manage grant funding to meet COVID-19
needs.65 Specifically:
Project period extensions. SAMHSA provided a flexibility known as a
no-cost extension—which allows awardees to extend the project period
for an expiring grant without receiving additional grant funding from
SAMHSA—for COVID-19 supplemental funding awards to nearly all
SUBG and MHBG awardees, according to agency officials.66 (See fig. 6.)
65SAMHSA provided grant administration flexibilities to awardees on a case-by-case basis
upon awardee request. The Office of Management and Budget required awarding
agencies to document certain grant flexibilities provided to award recipients during the
COVID-19 pandemic, including project period extensions (i.e., no-cost extensions) and
financial reporting extensions. We reviewed documentation for selected state awardees
and interviewed SAMHSA officials to confirm that the agency tracked these flexibilities
during COVID-19.
66SAMHSA awarded $5.4 billion to SUBG and MHBG awardees in COVID-19
supplemental funding as authorized by the Consolidated Appropriations Act, 2021, and
the American Rescue Plan Act of 2021. Awardees initially had until March 14, 2023, to
expend supplemental block grant funds from the Consolidated Appropriations Act, 2021,
and were eligible to receive up to two project period extensions, known as no-cost
extensions, each for up to 12 months, from SAMHSA to extend this deadline. American
Rescue Plan Act of 2021 funds were not eligible for an extension, according to SAMHSA
officials. Pub. L. 116-260, div. M, tit.II, 134 Stat. 1182, 1913 (2020); Pub. L. No. 117-2, tit.
II, subtit. H, 135 Stat. 4, 45. Traditional (i.e., non-supplemental) block grant funds were
also not eligible for extensions, according to SAMHSA officials.
Grant Administration
Flexibilities
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GAO-26-107748 Behavioral Health During COVID-19
Figure 6: Number of SAMHSA Awardees That Received Project Period Extensions
for Block Grant COVID-19 Supplemental Funding
Notes: SAMHSA awarded $5.4 billion of COVID-19 supplemental funding to Substance Use
Prevention, Treatment, and Recovery Services Block Grant (SUBG) and Community Mental Health
Services Block Grant (MHBG) awardees as authorized by the Consolidated Appropriations Act, 2021,
and the American Rescue Plan Act of 2021. Awardees initially had until March 14, 2023, to expend
supplemental block grant funds from the Consolidated Appropriations Act, 2021, and were eligible to
receive up to two project period extensions, known as no-cost extensions, each for up to 12 months,
from SAMHSA to extend this deadline. American Rescue Plan Act of 2021 funds were not eligible for
an extension, according to SAMHSA officials.
Of the eight selected state awardees we interviewed, all requested and
received one or more no-cost extensions for SUBG COVID-19
supplemental funding, State Opioid Response, and Emergency COVID-
19 grant awards during the COVID-19 pandemic, according to SAMHSA
officials. Seven selected states received one or more no-cost extensions
for MHBG COVID-19 supplemental funding, according to officials.
Additionally, many selected providers we interviewed said they received
no-cost extensions for SAMHSA awards during the COVID-19 pandemic.
Officials from selected states and providers described using no-cost
extensions to spend remaining grant funding, serve additional clients, and
complete data collection and reporting, for example. Additionally, officials
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GAO-26-107748 Behavioral Health During COVID-19
from nearly all states and some providers said they used no-cost
extensions to make up for COVID-19-related delays in grant
implementation. For example, one state’s subawardees encountered
behavioral health staff workforce shortages, which delayed
implementation of grant projects, according to agency officials. One
provider said they had reached about 90 percent of their goal for number
of clients served at the end of their original grant project period, and
receiving a no-cost extension allowed them to meet and eventually
exceed this goal.
While SAMHSA provided these project period extensions, officials from
many selected states said they nonetheless experienced challenges
planning and implementing grant activities within the program project
periods allowed by some COVID-19 supplemental funding awards.67 For
example, officials from one state said its subawardees experienced
challenges with staff capacity, which made it difficult to implement grant
programs and spend all grant funding within the allotted timeframe.
Budget revisions. SAMHSA allowed awardees to request re-budgeting
of award funds due to COVID-19 circumstances.68 For example,
SAMHSA approved budget revisions for five selected states’ State Opioid
Response grants during the COVID-19 pandemic, according to agency
officials. In addition, some selected providers said SAMHSA approved
budget revisions for their certified community behavioral health clinic and
community mental health center awards. Awardees described revising
budgets for various reasons, such as purchasing technology, increasing
staff salaries, or limiting COVID-19 spread. For example, one provider
said that because they were unable to hire staff for all of the positions
originally included in their award budget, they worked with SAMHSA
67These challenges are similar to challenges identified in our prior work examining federal
relief funding for behavioral health during the COVID-19 pandemic. See GAO-22-104437
for more information on behavioral health grantee challenges implementing programs
within short project periods during the COVID-19 pandemic.
68Awardees submit a budget as part of their SAMHSA grant applications, which SAMHSA
approves when it selects grant applications for funding, according to the agency.
Awardees must submit a revised budget for SAMHSA approval to reallocate funds to
address unexpected program changes. Revisions to the budget involve transferring funds
that were not previously approved in the application. According to SAMHSA
documentation, awardees had the flexibility to re-budget up to 25 percent of their budget
(or up to $250,000, whichever was less) without submitting a formal budget modification
request to the agency. If the awardee intended to re-budget more than this amount due to
COVID-19 circumstances, SAMHSA required them to submit a COVID-19 post-award
amendment for SAMHSA approval. This flexibility only applied to non-block grant
awardees.
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officials to reallocate funds from unfilled staff positions to other activities,
such as training staff, purchasing medical equipment, and leasing a
vehicle to conduct home visits or transport clients to services. Another
provider said SAMHSA approved their revised budget to increase salaries
to help recruit staff, and to renovate clinic space to facilitate social
distancing.
Financial reporting extensions. SAMHSA allowed awardees to take up
to 3 months beyond the original due date to reconcile financial
expenditures and submit final financial reports as needed, according to
agency officials.69 Four selected states received an extension for SUBG
financial reporting and five selected states received an extension for
MHBG financial reporting, according to SAMHSA officials. Officials from
one state said these extensions helped staff manage their workloads,
particularly as staff were heavily involved in COVID-19 response. One
provider also said they received a financial reporting extension.
Waivers of maintenance of effort requirements. During COVID-19,
SAMHSA allowed some waivers of block grant “maintenance of effort”
requirements, which required recipients to maintain a certain level of state
expenditures for activities.70 SAMHSA allowed for a waiver of this
requirement if states provided documentation of the effects of COVID-19
on mental health or substance use disorder services expenditures, such
as decreased service delivery due to challenges with in-person treatment,
according to agency documentation. SAMHSA waived maintenance of
effort requirements for three selected states’ MHBG awards and for four
selected states’ SUBG awards from 2020 through 2023, according to
SAMHSA officials. For example, SAMHSA waived these requirements for
one state that cited reduced state spending due to its increase in
telehealth and reduced staffing, according to SAMHSA officials.
69SAMHSA requires awardees to submit federal financial reports detailing expenditures
and other financial information annually and at the end of the program project period,
according to agency documentation. Awardees must generally submit the final federal
financial report 120 days after the project period end date.
70Under the maintenance of effort requirement, a state must maintain its expenditures for
relevant activities at a level that is not less than the average maintained by the state in the
2-year period before the fiscal year for which it is applying for the MHBG or SUBG grant.
See 42 U.S.C. § 300x-4(b); 42 U.S.C. § 300x-30(a). SAMHSA may waive the
maintenance of effort requirement for a state if it determines that “extraordinary economic
conditions” justify such a waiver or in the case of a public health emergency such as
COVID-19. See 42 U.S.C. § 300x-4(b)(3); 42 U.S.C. § 300x-30(c); 42 U.S.C. § 300x-67.
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Expansion of allowable costs. SAMHSA allowed awardees to spend
grant funds on some activities that were normally not allowed under the
grant, according to agency officials. Three selected states used this
flexibility to continue providing behavioral health services through their
State Opioid Response grants during the COVID-19 pandemic, according
to SAMHSA officials. For example, states used this flexibility to support
COVID-19 testing at mobile care units or to purchase personal protective
equipment so behavioral health staff could safely continue to provide
grant-funded services, according to agency officials.
SAMHSA and other federal agencies such as the Drug Enforcement
Agency made certain program flexibilities and modifications available to
help states and behavioral health providers, including our selected
awardees, deliver services during the COVID-19 pandemic. (See table 1
for an overview of selected program flexibilities available to SAMHSA
awardees.)
Program Flexibilities
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Table 1: Selected Flexibilities Related to SAMHSA Awardees’ Program Implementation During and After the COVID-19
Pandemic
Flexibility
Description
Status
Take-home
methadone
doses
Prior to the COVID-19 pandemic, federal regulations required frequent
patient visits to Opioid Treatment Programs to receive doses of
methadone, a medication used to treat opioid use disorder.a
During the COVID-19 pandemic, the Substance Abuse and Mental
Health Services Administration (SAMHSA) issued guidance allowing
states to request blanket exceptions for all stable patients in Opioid
Treatment Programs to receive 28 days of take-home doses of the
patient’s medication for opioid use disorder, such as methadone, and up
to 14 days for patients who are less stable but who the program believes
can safely handle this level of take-home medication.
SAMHSA issued a final rule revising
the Opioid Treatment Program
regulations to allow patients to receive
take-home doses of methadone under
certain conditions, effective April
2024.b
Telehealth
initiation of
buprenorphine
Prior to the COVID-19 pandemic, prescribers—including Opioid
Treatment Programs—were generally required to perform an in-person
medical evaluation before prescribing buprenorphine via telehealth.
During the COVID-19 pandemic, this requirement was waived, allowing
prescription of buprenorphine via phone or video telehealth without a
prior in-person visit in certain situations. SAMHSA issued similar
telehealth buprenorphine prescribing guidelines specific to Opioid
Treatment Programs.
SAMHSA issued a final rule revising
the Opioid Treatment Program
regulations to allow initial prescribing
of buprenorphine via phone or video
telehealth, and initial prescribing of
methadone via audiovisual telehealth
in certain situations, which went into
effect in April 2024.b
The Drug Enforcement Administration
and SAMHSA issued a joint final rule
codifying the buprenorphine
telehealth prescribing allowance in
certain situations, effective December
31, 2025.c
Virtual client data
collection
Prior to the COVID-19 pandemic, SAMHSA required certain awardees to
collect some client data through in-person interviews.
During the COVID-19 pandemic, SAMHSA allowed certain awardees to
collect the required client data over the phone or electronically.d
According to SAMHSA officials,
awardees may continue to collect
these data virtually, as of September
2025.
Telehealth
platforms
The Department of Health and Human Services (HHS) Office for Civil
Rights is responsible for enforcing the Health Insurance Portability and
Accountability Act of 1996 and its implementing regulations, the Privacy
and Security Rules, which set out privacy and security requirements for
protected health information. The Office for Civil Rights can issue
penalties for noncompliance with these rules.e
During the COVID-19 pandemic, SAMHSA worked with the Office for
Civil Rights to implement the office’s Notice of Enforcement Discretion,
which announced it would not impose penalties against health care
providers for the good faith provision of telehealth using certain non-
public facing audio or video communication platforms, such as Apple
FaceTime, for noncompliance with Health Insurance Portability and
Accountability Act of 1996 rules.f
Expired in May 2023, according to an
HHS Office for Civil Rights Notice of
Expiration issued in April 2023.g
Source: GAO analysis of federal legislation and documentation from SAMHSA and HHS Office for Civil Rights, and interviews with SAMHSA officials. | GAO-26-107748
Notes: The Secretary of Health and Human Services declared a public health emergency in response
to COVID-19 on January 31, 2020, under section 319 of the Public Health Service Act; it expired on
May 11, 2023. This information pertains to flexibilities SAMHSA provided to awardees during the
COVID-19 public health emergency. We refer to the COVID-19 public health emergency as the
COVID-19 pandemic for the purposes of this table.
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aOpioid Treatment Programs are certified by SAMHSA to prescribe medications for the treatment of
opioid use disorder, such as methadone and buprenorphine.
bMedications for the Treatment of Opioid Use Disorder, 89 Fed. Reg. 7528 (Feb. 2, 2024) (to be
codified at 42 C.F.R. pt. 8).
cExpansion of Buprenorphine Treatment via Telemedicine Encounter, 90 Fed. Reg. 6504 (Jan. 17,
2025); see also Expansion of Buprenorphine Treatment via Telemedicine Encounter and Continuity of
Care via Telemedicine for Veterans Affairs Patients, 90 Fed. Reg. 13410 (Mar. 24, 2025).
dThis flexibility also waived consequences for awardees that were delayed in submitting their data or
unable to collect these data during the COVID-19 pandemic.
eSee 45 C.F.R. pts. 160 and 164.
f85 Fed. Reg. 22,024 (Apr. 21, 2020).
g88 Fed. Reg. 22,380 (Apr. 13, 2023).
Selected SAMHSA awardees described their experiences using these
program flexibilities during COVID-19, including how each flexibility
benefitted their programs and services.
Take-home doses of methadone to treat opioid use disorder. In
March 2020, SAMHSA allowed states to request blanket exceptions for
patients in Opioid Treatment Programs to receive up to 28 days of take-
home methadone doses, rather than the daily in-person dose
administration generally required prior to the exception.71 This flexibility
allowed clinicians to continue to treat opioid use disorder during the
COVID-19 pandemic while reducing direct patient contact, according to
SAMHSA. Clients, treatment programs, and states generally supported
the methadone take-home flexibility, and research has shown that this
flexibility eliminated requirements that promoted stigma and discouraged
people from accessing treatment, according to SAMHSA.
71Methadone is a medication used to treat opioid use disorder that generally can only be
dispensed through a SAMHSA-certified Opioid Treatment Program. According to
SAMHSA, practitioners should consider whether therapeutic benefits of take-home doses
outweigh the risks for each patient, such as the potential for overdose.
Opioid Treatment Programs
Opioid Treatment Programs provide evidence-
based medications to treat opioid use
disorder, in combination with counseling and
related services to support remission and
recovery. All Opioid Treatment Programs
dispense and administer methadone—which
may generally only be administered or
dispensed by an Opioid Treatment Program—
and many also offer buprenorphine and
naltrexone, the three types of medication
approved by the Food and Drug
Administration to treat opioid use disorder.
Opioid Treatment Programs must be
accredited, certified by the Substance Abuse
and Mental Health Services Administration
(SAMHSA), registered with the Drug
Enforcement Administration, and licensed by
the state in which they operate. As of May
2024, SAMHSA has certified over 2,100
Opioid Treatment Programs across most
states and territories, and several operated by
Tribal Nations.
Source: SAMHSA documentation. | GAO-26-107748
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Of the 52 states, territories, and the District of Columbia with SAMHSA-
certified Opioid Treatment Programs, 43 states and the District of
Columbia—including four of our selected states—opted into this flexibility
to allow the Opioid Treatment Programs in their state to use this flexibility
starting in March 2020, according to SAMHSA officials.72 One selected
provider said they used this flexibility to allow patients to take home
methadone doses. Officials from one state said this flexibility was
beneficial as it prevented interruptions in patients’ treatment and helped
address transportation barriers to receiving care. Officials from another
state said this flexibility reduced the number of clients who visited Opioid
Treatment Programs in person, and as a result, the state’s Opioid
Treatment Programs did not experience COVID-19 outbreaks.
Telehealth initiation of buprenorphine to treat opioid use disorder.
SAMHSA worked with the Drug Enforcement Administration to allow
clinicians to prescribe buprenorphine via telehealth starting in 2020,
including audio-only telephone calls, to new clients who had not
previously been evaluated in person.73 Nearly all selected states and
some provider awardees said they used this flexibility, although one of
these providers said they preferred to complete initial medical evaluations
in person before prescribing buprenorphine whenever possible. Awardees
said that this flexibility was beneficial for a variety of reasons. For
example, officials from one state said this flexibility helped them increase
access to medication and expand the number of clinicians who could
72SAMHSA initially provided this flexibility in March 2020 to simplify the process for Opioid
Treatment Programs to request approval for providing take-home methadone doses,
according to officials. According to SAMHSA officials, some states with few Opioid
Treatment Programs opted to have the programs submit requests to use this flexibility
directly to SAMHSA rather than through the state. SAMHSA issued additional guidance
regarding this flexibility in November 2021 that extended the take-home flexibility to one
year after the end of the COVID-19 public health emergency or until publication of revised
Opioid Treatment Program regulations. At that time, 42 states and the District of
Columbia—including five of our selected states—requested and received approval to use
this flexibility, according to agency officials. SAMHSA revised its Opioid Treatment
Program regulations in February 2024 to codify this flexibility. Medications for the
Treatment of Opioid Use Disorder, 89 Fed. Reg. 7528 (Feb. 2, 2024) (to be codified at 42
C.F.R. pt. 8).
73Buprenorphine is a medication to treat opioid use disorder that can be prescribed or
dispensed in physician offices, according to SAMHSA. SAMHSA made a similar flexibility
available to Opioid Treatment Programs in April 2020 and issued additional guidance in
November 2021, according to agency officials. At that time, 36 states—including five of
our selected states—allowed Opioid Treatment Programs in their state to use this
flexibility. According to SAMHSA officials, the agency did not allow telehealth initiation of
methadone to treat opioid use disorder because differences in the medications required
in-person assessment.
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GAO-26-107748 Behavioral Health During COVID-19
prescribe medication for opioid use disorder during the COVID-19
pandemic. One provider said this flexibility helped clients overcome
barriers to treatment, such as finding childcare or coordinating in-person
services with work schedules to attend in-person clinic visits.74
Virtual client data collection. SAMHSA allowed awardees to collect
required grant data on clients served over the phone or electronically
during the COVID-19 pandemic, rather than in person as required prior to
the pandemic, according to agency documentation and officials. Officials
from nearly all selected states and all providers said they used this
flexibility. Officials from one state said this flexibility was useful because
collecting data in person was not always possible during the COVID-19
pandemic. In addition, one provider said staff were able to collect these
data much faster over the phone.
Nearly all awardees said they used the virtual client data collection
flexibility; however, officials from some selected states and many selected
providers said they experienced challenges meeting data collection and
reporting requirements during the COVID-19 pandemic.75 For example,
officials from one state said that behavioral health staff struggled to
collect required client data before the pandemic, but this challenge was
exacerbated during the COVID-19 pandemic due to the increased
number of clients. SAMHSA officials said they provided technical
assistance and increased flexibility to awardees that reported data
collection challenges, and the agency did not penalize awardees for
unavoidable challenges with data collection.
Telehealth platforms. SAMHSA worked with the HHS Office for Civil
Rights to allow health care providers to use telehealth platforms during
the COVID-19 pandemic that were not compliant with the Health
74In addition, in March 2020, the Drug Enforcement Administration announced that
prescribers who were registered with the agency in one state and were authorized by
another state’s laws to prescribe controlled substances for clients in that state, including
via telehealth, did not have to obtain an additional registration from the Drug Enforcement
Administration for that state. See Drug Enforcement Administration, Letter to Registrants
(DEA067), (Springfield, Va.: Mar. 25, 2020). SAMHSA communicated with Opioid
Treatment Programs and treatment providers about this flexibility and worked with the
Drug Enforcement Administration to provide clarification as questions arose, according to
SAMHSA officials.
75These challenges are similar to challenges identified in our prior work examining federal
relief funding for behavioral health during the COVID-19 pandemic. See GAO-22-104437
for more information on behavioral health grantee challenges meeting client data reporting
requirements during the COVID-19 pandemic.
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Insurance Portability and Accountability Act of 1996 rules for privacy and
security of protected health information, according to agency officials.76
Officials from many selected states and some providers said they used
noncompliant telehealth platforms at some point during the COVID-19
pandemic. For example, one provider said they used platforms that were
not compliant early in the COVID-19 pandemic to quickly deliver
telehealth services before eventually transitioning to a compliant platform.
Another provider said that this flexibility was particularly useful for the
rural community they serve, because clients did not always have
consistent internet connection and were more easily reached by Apple
FaceTime or other communication tools that were not compliant with
Health Insurance Portability and Accountability Act of 1996 rules.
We provided a copy of this draft report to HHS. HHS provided technical
comments, which we incorporated as appropriate.
We are sending copies of this report to the appropriate congressional
committees, the Secretary of Health and Human Services, and other
interested parties. In addition, the report is available at no charge on the
GAO website at https://www.gao.gov.
If you or your staff have any questions about this report, please contact
me at HundrupA@gao.gov. Contact points for our Offices of
Congressional Relations and Media Relations may be found on the last
page of this report. GAO staff who made key contributions to this report
are listed in appendix IV.
Alyssa M. Hundrup
Director, Health Care
76The Health Insurance Portability and Accountability Act of 1996 and its implementing
regulations, the Privacy and Security Rules, establish standards to safeguard patients’
protected health information. To comply with these rules, health care providers must use
certain technology platforms, including video and other remote communication
technologies, that meet privacy and security requirements. See 45 C.F.R. pts. 160 and
164. During the COVID-19 pandemic, the Office for Civil Rights announced that it would
not impose penalties against health care providers who used certain noncompliant
telehealth platforms in good faith. See 85 Fed. Reg. 22,024 (Apr. 21, 2020).
Agency Comments
Appendix I: Objectives, Scope and
Methodology
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GAO-26-107748 Behavioral Health During COVID-19
The Consolidated Appropriations Act, 2023, includes a provision for us to
review Substance Abuse and Mental Health Services Administration
(SAMHSA) programs and activities to support the continued provision of
mental health and substance use disorder services and related activities
during the COVID-19 pandemic.1 In this report, we describe
1. how SAMHSA’s advisory councils and National Mental Health and
Substance Use Policy Laboratory (Policy Lab) supported the agency’s
COVID-19 response;
2. how selected SAMHSA awardees provided services during the
COVID-19 pandemic and what challenges they experienced; and
3. how SAMHSA provided assistance to awardees to support their
response to the COVID-19 pandemic.
To address our first objective, we reviewed documentation and
interviewed SAMHSA officials about the agency’s advisory councils and
committees—which we refer to as advisory councils for the purposes of
this report—and the Policy Lab. We reviewed documentation and
interviewed officials about activities from January 2020 through May
2023—the beginning and end of the public health emergency declaration
for COVID-19, which we refer to as the COVID-19 pandemic for the
purposes of this report. We reviewed documents from the advisory
councils and the Policy Lab, such as reports, meeting minutes, and
information from the General Services Administration’s Federal Advisory
Committee Act database.2 We also interviewed officials from SAMHSA
and its Policy Lab to identify additional ways that these groups supported
SAMHSA’s COVID-19 response, such as through discussions or informal
advice.
To address our second and third objectives, we reviewed documentation
from and interviewed a nongeneralizable sample of SAMHSA awardees.
Awardees included seven states and one territory—which we refer to
collectively as selected states—and 16 behavioral health providers in the
selected states. The selected states are Michigan, Mississippi, Montana,
Oregon, Pennsylvania, Puerto Rico, Texas, and Vermont. Puerto Rico
1Pub. L. No. 117-328, § 2112(e), 136 Stat. 4459, 5722 (2022).
2Eight of SAMHSA’s nine advisory committees are subject to Federal Advisory Committee
Act requirements. These committees are required to make committee records, such as
meeting minutes, agendas, and reports, available to the public. See 5 U.S.C. § 1009.
SAMHSA’s Tribal Technical Advisory Committee is not subject to Federal Advisory
Committee Act requirements, according to SAMHSA officials.
Appendix I: Objectives, Scope and
Methodology
Appendix I: Objectives, Scope and
Methodology
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GAO-26-107748 Behavioral Health During COVID-19
also operated a behavioral health provider organization, and state officials
spoke to us about their experiences both as a state agency and as a
behavioral health provider receiving SAMHSA grants during the COVID-
19 pandemic. Therefore, Puerto Rico is counted both as a state awardee
and a behavioral health provider awardee, and we interviewed a total of
23 selected awardees. We use the following modifiers to quantify
awardees’ responses: “nearly all” represents seven states when we are
referring to just the states we interviewed; 12 to 15 providers when we are
referring to just the providers we interviewed; or 18 to 22 awardees (i.e.,
the total across states and providers we interviewed). Likewise, “many”
represents five to six states, eight to 11 providers, or eight to 17
awardees; and “some” represents two to four states, three to seven
providers, or three to seven awardees.
The experiences of selected awardees are not generalizable across all
SAMHSA state or provider awardees. However, the information we
obtained from them illustrates a variety of experiences with SAMHSA
grants and assistance during the COVID-19 pandemic. We selected
states
1. that received funding through four SAMHSA grants: Community
Mental Health Services Block Grant (MHBG); Substance Use
Prevention, Treatment, and Recovery Services Block Grant (SUBG);
State Opioid Response; and Emergency Grants to Address Mental
and Substance Use Disorders During COVID-19 grant programs
(Emergency COVID-19 grants);
2. with two or more providers that participated in SAMHSA’s Certified
Community Behavioral Health Clinic Expansion grant program or
Community Mental Health Centers grant program during the COVID-
19 pandemic; and
3. to obtain variation in rurality, health department governance structure
(i.e., the relationship between state and local health agencies), and
geographic region, among other factors.
To select behavioral health providers, we selected two providers in each
selected state to achieve variation in rurality, SAMHSA awards received
(i.e., Certified Community Behavioral Health Clinic Expansion grant,
Community Mental Health Centers grant, or both), and the timing of
awardees’ first Certified Community Behavioral Health Clinic Expansion
grant award relative to the COVID-19 pandemic (see below for more
details about these grant programs).
Appendix I: Objectives, Scope and
Methodology
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GAO-26-107748 Behavioral Health During COVID-19
We focused our review on six SAMHSA grant programs: MHBG, SUBG,
State Opioid Response, Emergency COVID-19 grants, Certified
Community Behavioral Health Clinic Expansion, and Community Mental
Health Centers grant programs. We selected these six grant programs
based on several criteria, including provision of direct behavioral health
services to clients, total funding amount awarded from fiscal years 2019
through 2023, and a grant purpose to fund COVID-19 behavioral health
response. Together, these selected grant programs represented over
three-quarters (approximately 78 percent) of SAMHSA’s total funding
awarded to support behavioral health services in fiscal years 2020
through 2023. The selected SAMHSA grant programs also provided
variation in awardee type (i.e., inclusion of states, territories, and
behavioral health providers), grant type (i.e., block grants—
noncompetitive, formula grants mandated by Congress—and non-block
grants), type of behavioral health services funded (i.e., mental health,
substance use, or both), and grant program start date in relation to the
COVID-19 pandemic. Two of these six grant programs—Emergency
COVID-19 grants and Community Mental Health Centers grants—were
created specifically to respond to the COVID-19 pandemic, while the
other four grant programs predated the pandemic. (See app. II for
summary information on selected SAMHSA grant programs that
supported the direct provision of behavioral health services during the
COVID-19 pandemic.)
To describe selected state and provider awardees’ provision of behavioral
health services and challenges they experienced, we reviewed
documentation and interviewed selected awardees on these topics
regarding their experiences from January 2020 through May 2023. We
reviewed progress reports state awardees submitted to SAMHSA that
summarized awardees’ changes in services and challenges during the
COVID-19 pandemic. We also interviewed selected awardees about how
they provided services and any challenges they experienced during the
COVID-19 pandemic. Additionally, we interviewed representatives from
four national associations to gain a broader perspective on SAMSHA
awardees’ experiences and challenges during the COVID-19 pandemic.
Specifically, we interviewed representatives from the following four
national associations: (1) National Association of State Mental Health
Program Directors; (2) National Association of State Alcohol and Drug
Agency Directors; (3) National Indian Health Board; and (4) National
Council for Mental Wellbeing. SAMHSA contracts with the National
Council for Mental Wellbeing to operate the Certified Community
Behavioral Health Clinic Expansion Grantee National Training and
Technical Assistance Center. These associations have expertise in areas
Appendix I: Objectives, Scope and
Methodology
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GAO-26-107748 Behavioral Health During COVID-19
relevant to our review, including mental health services and wellbeing,
substance use disorders, and SAMHSA awardees’ experiences providing
behavioral health services during the COVID-19 pandemic.
To describe the assistance SAMHSA offered to awardees during the
COVID-19 pandemic, including any flexibilities the agency provided to
awardees for grant administration and program implementation, we
reviewed documentation and interviewed agency officials, selected state
and behavioral health provider awardees, and national association
representatives. For example, we reviewed progress reports and budget
modification requests that state awardees submitted to SAMHSA,
relevant federal statutes and regulations, and documentation from
SAMHSA and other federal agencies to summarize the assistance and
flexibilities that SAMHSA provided during the COVID-19 pandemic.
Appendix II: Summary of Selected SAMHSA
Grant Programs During COVID-19
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GAO-26-107748 Behavioral Health During COVID-19
The Substance Abuse and Mental Health Services Administration
(SAMHSA) awarded over $32 billion during the COVID-19 pandemic—
fiscal years 2020 through 2023—to support programs that provided direct
behavioral health services, according to agency data. This included
approximately $8.3 billion in COVID-19 supplemental funding. Together,
these selected grant programs represent over three-quarters
(approximately 78 percent) of SAMHSA’s total funding awarded to
support behavioral health services in fiscal years 2020 through 2023.
Our selection of grant programs was informed by several criteria,
including provision of direct behavioral health services to clients, total
funding amount awarded in fiscal years 2020 through 2023, and a
purpose to fund the COVID-19 behavioral health response. We selected
grant programs to provide variation in grant type (i.e., block grants—
noncompetitive, formula grants mandated by Congress—and non-block
grants), awardee type (i.e., inclusion of states, territories, and behavioral
health providers), type of behavioral health services funded (i.e., mental
health, substance use, or both), and program start date in relation to the
COVID-19 pandemic. Two of these six programs—the Community Mental
Health Centers grant program and the Emergency Grants to Address
Mental and Substance Use Disorders During COVID-19—were created
specifically to respond to the pandemic, while the other four programs
predated the pandemic. (Table 2 provides information on the six grant
programs included in the scope of this review, including the amount of
funding SAMHSA awarded through each program during the COVID-19
pandemic.)
Appendix II: Summary of Selected SAMHSA
Grant Programs During COVID-19
Appendix II: Summary of Selected SAMHSA
Grant Programs During COVID-19
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Table 2: Summary of Selected SAMHSA Grant Programs That Supported Behavioral Health Services During the COVID-19
Pandemic, Fiscal Years 2020–2023
Grant program
Purpose
Number and type
of awardees
Total funding awarded
(COVID-19 supplemental
funding awarded)a
Substance Use
Prevention,
Treatment and
Recovery Services
Block Grant
(SUBG)
Plan, implement, and evaluate activities that prevent and
treat substance use. Specifically targets pregnant women
and women with dependent children; injection drug
users; tuberculosis services; early intervention services
for HIV/AIDS; and primary prevention services.
60 states, territories,
Pacific jurisdictions,
District of Columbia,
and tribal entity
$10.4 billion
($3.1 billion)
Community Mental
Health Services
Block Grant
(MHBG)
Provide comprehensive, community-based mental health
services to adults with serious mental illness and to
children with serious emotional disturbance and to
monitor progress in implementing a comprehensive,
community-based mental health system.
59 states, territories,
Pacific jurisdictions,
and District of
Columbia
$5.5 billion
($2.3 billion)b
State Opioid
Response
Increase access to medication-assisted treatment for
opioid use disorder, reduce unmet treatment need, and
reduce opioid overdose deaths.
58 states, territories,
Pacific jurisdictions,
and District of
Columbia
$5.8 billion
($0)
Certified
Community
Behavioral Health
Clinic Expansion
Help community behavioral health systems and clinics
meet the certification criteria and establish certified clinic
programs, improve and enhance existing certified
community behavioral health clinic programs, and
provide support for uncompensated care. The certified
community behavioral health clinic model includes 24
hours a day, 7 days a week crisis services,
comprehensive behavioral health services, and care
coordination.c
525 certified
community behavioral
health clinics and
clinics seeking
certificationd
$2.4 billion
($1.3 billion)
Community Mental
Health Centers
Support and restore the delivery of clinical services that
were impacted by the COVID-19 pandemic and
effectively address the needs of individuals with serious
emotional disturbance, serious mental illness, and co-
occurring disorders.
This grant program was created specifically to respond to
the COVID-19 pandemic.
230 community
mental health
centers, including
centers operated by
state and local
government agencies
$823 million
Emergency Grants
to Address Mental
and Substance Use
Disorders During
COVID-19
Provide crisis intervention services, mental and
substance use disorder treatment, and other related
recovery supports for children and adults impacted by
the COVID-19 pandemic.
This grant program was created specifically to respond to
the COVID-19 pandemic.
125 states, territories,
District of Columbia,
Tribes, and tribal
organizations
$345 million
Notes: In fiscal years 2020 and 2021, SAMHSA received $8.5 billion in supplemental funding to help
address behavioral health needs that resulted from the COVID-19 pandemic through appropriations
in the CARES Act, the Consolidated Appropriations Act, 2021, and the American Rescue Plan Act of
2021, and through interdepartmental funding, according to agency officials. SAMHSA awarded
approximately $8.3 billion of this supplemental funding in grants to recipients that included states,
territories, the District of Columbia, Tribes, and nongovernmental organizations.
Source: Substance Abuse and Mental Health Services Administration (SAMHSA) documentation and statements from officials. | GAO-26-107748
Appendix II: Summary of Selected SAMHSA
Grant Programs During COVID-19
Page 54
GAO-26-107748 Behavioral Health During COVID-19
aCOVID-19 supplemental funding awarded reflects the total amount of grant funding awarded to
SAMHSA awardees as of July 28, 2025, and it excludes funds that have been relinquished by
awardees, according to SAMHSA officials. For existing grant programs that predated the COVID-19
pandemic, the amount of COVID-19 supplemental funding awarded is displayed in this table as a
subset of the total funding awarded. For new grant programs created during the COVID-19 pandemic
using COVID-19 supplemental funding—including the Community Mental Health Centers grant
program and the Emergency Grants to Address Mental and Substance Use Disorders During COVID-
19 program—only one funding amount is displayed.
bAlthough the COVID-19 supplemental funding appropriated $3.1 billion to SAMHSA for the MHBG,
the Consolidated Appropriations Act, 2021, required some of this funding to be used to support
community mental health centers. See Pub. L. No. 116-260, div. M, tit. III, 134 Stat. 1182, 1913
(2020). As a result, SAMHSA awarded approximately $823 million to the Community Mental Health
Centers grant program, according to officials.
cThis includes Certified Community Behavioral Health Clinic Planning, Development, and
Implementation Grants to help establish new certified community behavioral health clinics, as well as
Improvement and Advancement Grants to help existing certified community behavioral health clinics
to expand.
dThis reflects the number of certified community behavioral health clinic awardees with active
SAMHSA awards during the COVID-19 public health emergency (January 2020 through May 2023),
according to SAMHSA data. Therefore, this does not include certified community behavioral health
clinic awardees that received funds through SAMHSA’s 2023 Certified Community Behavioral Health
Clinic Expansion Grants, which the agency awarded in September 2023, after the end of the COVID-
19 public health emergency.
Appendix III: Selected Grant Administration
Flexibilities Allowed by SAMHSA During the
COVID-19 Pandemic
Page 55
GAO-26-107748 Behavioral Health During COVID-19
The Substance Abuse and Mental Health Services Administration
(SAMHSA) allowed awardees to use a range of flexibilities related to
grant administration during the COVID-19 pandemic from January 2020
through May 2023, according to agency documentation and officials.
Although SAMHSA extended COVID-19 flexibilities to all grant recipients,
there was variability in which programs allowed the use of certain
flexibilities because some have different regulatory and statutory
requirements, according to SAMHSA officials. Table 3 includes an
overview of selected grant administration flexibilities generally available to
SAMHSA awardees.
Table 3: Overview of Selected Grant Administration Flexibilities Allowed by SAMHSA During the COVID-19 Pandemic
Grant flexibility
Description
No-cost extensions on
expiring awards
Allowed awardees to extend project period of performance for expiring grants by up to 1 year.
Extension of financial and
other reporting
Allowed awardees to delay submitting financial and other reporting up to 3 months beyond original due
date.
Extension of closeout
Allowed awardees to delay submission of reporting required for grant closeout for up to 1 year after
award expires.
Waiver of maintenance of
effort requirementa
Allowed awardees to request waived maintenance of effort requirements for state expenditures for block
grants. May be granted through a Public Health Emergency waiver or an economic circumstances
waiver.
Exceptions to compliance
with Synar requirementsb
Allowed Substance Use Prevention, Treatment, and Recovery Services Block Grant awardees to delay
submission of Synar report in 2020, submit incomplete report without penalty, or request 1-year coverage
study extension.
Flexibility with applicant
System for Award
Management registrationc
Relaxed requirements for active registration in the System for Award Management at the time of
application, or extended deadlines for recertifications.
Abbreviated non-
competitive continuation
requests
Allowed awardees to request continuation of grant projects by providing a brief statement verifying ability
to resume activities and accept further grant funding.
Expenditure of awards for
salaries and other project
activities
Allowed awardees to continue to charge salaries and benefits (consistent with awardee pay policies) and
other costs necessary to resume grant activities.
Expanded allowable costs
Allowed awardees to charge normally unallowable costs, such as cancelling events or travel, necessary
for pausing and restarting activities.
Waivers from prior
approval requirements
Waived requirements for prior approval of special or unusual costs as necessary to effectively address
the response.
Extension of currently
approved indirect cost
rates
Allowed awardees to use current indirect cost rates for 1 additional year without submitting a new
proposal.
Budget revisions or
modifications
Allowed awardees to re-budget funds to other activities because of COVID-19, as long as the activities
are allowable under the Funding Opportunity Announcement and in line with other requirements.
Source: GAO analysis of Substance Abuse and Mental Health Services Administration (SAMHSA) documents, information from the Office of Management and Budget, and statements from SAMHSA
officials. | GAO-26-107748
Appendix III: Selected Grant Administration
Flexibilities Allowed by SAMHSA During the
COVID-19 Pandemic
Appendix III: Selected Grant Administration
Flexibilities Allowed by SAMHSA During the
COVID-19 Pandemic
Page 56
GAO-26-107748 Behavioral Health During COVID-19
Notes: This information pertains to flexibilities SAMHSA provided to awardees during the COVID-19
public health emergency (January 2020 through May 2023). Flexibilities available to SAMHSA
awardees varied across grant programs.
aUnder the maintenance of effort requirement, a state must maintain its expenditures for relevant
activities at a level that is not less than the average maintained by the state in the 2-year period
before the fiscal year for which it is applying for the block grant. See 42 U.S.C. § 300x-4(b); 42 U.S.C.
§ 300x-30(a). SAMHSA may waive the maintenance of effort requirement for a state if it determines
that “extraordinary economic conditions” justify such a waiver or in the case of a public health
emergency such as COVID-19. See 42 U.S.C. § 300x-4(b)(3); 42 U.S.C. § 300x-30(c). Under the
public health emergency waiver, SAMHSA can grant extensions and waive application deadlines or
compliance with any other requirement for awardees of non-discretionary grants. 42 U.S.C.§ 300x-67.
bThe Synar program monitors the sale and distribution of tobacco products to minors. Synar
inspections are carried out each year by youth inspectors, who visit retail establishments and attempt
to purchase tobacco products. The coverage study inventories retail outlets in each state that sells
tobacco products.
cThe System for Award Management is an online system that facilitates federal awards processes,
including registering to do business with the federal government and viewing contract data.
Appendix IV: GAO Contact and Staff
Acknowledgments
Page 57
GAO-26-107748 Behavioral Health During COVID-19
Alyssa M. Hundrup, HundrupA@gao.gov
In addition to the contact named above, Karen Doran (Assistant Director),
Rachel Weingart (Analyst-in-Charge), Matthew Curtis, Mal Kennedy, Jeff
Mayhew, and Cynthia Turner made key contributions to this report. Also
contributing were Sonia Chakrabarty, Laura Elsberg, David Jones, Ariel
Landa-Seiersen, and Eric Peterson.
Appendix IV: GAO Contact and Staff
Acknowledgments
GAO Contact
Staff
Acknowledgments
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