[Senate Hearing 117-775]
[From the U.S. Government Publishing Office]
S. Hrg. 117-775
PROTECTING YOUTH MENTAL HEALTH:
PART II_IDENTIFYING AND
ADDRESSING BARRIERS TO CARE
=======================================================================
HEARING
before the
COMMITTEE ON FINANCE
UNITED STATES SENATE
ONE HUNDRED SEVENTEENTH CONGRESS
SECOND SESSION
__________
FEBRUARY 15, 2022
__________
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Printed for the use of the Committee on Finance
_________
U.S. GOVERNMENT PUBLISHING OFFICE
54-176-PDF WASHINGTON : 2023
COMMITTEE ON FINANCE
RON WYDEN, Oregon, Chairman
DEBBIE STABENOW, Michigan MIKE CRAPO, Idaho
MARIA CANTWELL, Washington CHUCK GRASSLEY, Iowa
ROBERT MENENDEZ, New Jersey JOHN CORNYN, Texas
THOMAS R. CARPER, Delaware JOHN THUNE, South Dakota
BENJAMIN L. CARDIN, Maryland RICHARD BURR, North Carolina
SHERROD BROWN, Ohio ROB PORTMAN, Ohio
MICHAEL F. BENNET, Colorado PATRICK J. TOOMEY, Pennsylvania
ROBERT P. CASEY, Jr., Pennsylvania TIM SCOTT, South Carolina
MARK R. WARNER, Virginia BILL CASSIDY, Louisiana
SHELDON WHITEHOUSE, Rhode Island JAMES LANKFORD, Oklahoma
MAGGIE HASSAN, New Hampshire STEVE DAINES, Montana
CATHERINE CORTEZ MASTO, Nevada TODD YOUNG, Indiana
ELIZABETH WARREN, Massachusetts BEN SASSE, Nebraska
JOHN BARRASSO, Wyoming
Joshua Sheinkman, Staff Director
Gregg Richard, Republican Staff Director
(II)
C O N T E N T S
----------
OPENING STATEMENTS
Page
Wyden, Hon. Ron, a U.S. Senator from Oregon, chairman, Committee
on Finance..................................................... 1
Crapo, Hon. Mike, a U.S. Senator from Idaho...................... 3
Casey, Hon. Robert P., Jr., a U.S. Senator from Pennsylvania..... 5
Hassan, Hon. Maggie, a U.S. Senator from New Hampshire........... 5
Cardin, Hon. Benjamin L., a U.S. Senator from Maryland........... 6
WITNESSES
Terrell, Trace, lead intervention and outreach specialist,
YouthLine, La Pine, OR......................................... 7
Benton, Tami D., M.D., psychiatrist-in-chief, executive director,
and chair, Department of Child and Adolescent Psychiatry and
Behavioral Sciences, Children's Hospital of Philadelphia,
Philadelphia, PA............................................... 9
Lubarsky, Jodie L., M.A., LCMHC, vice president of clinical
operations, Youth and Family Services, Seacoast Mental Health
Center, Inc., Portsmouth, NH................................... 11
Hoover, Sharon, Ph.D., professor, child and adolescent
psychiatry; and co-director, National Center for School Mental
Health, University of Maryland School of Medicine, Baltimore,
MD............................................................. 13
ALPHABETICAL LISTING AND APPENDIX MATERIAL
Benton, Tami D., M.D.:
Testimony.................................................... 9
Prepared statement........................................... 51
Responses to questions from committee members................ 58
Brown, Hon. Sherrod:
Submission for the record.................................... 59
Cardin, Hon. Benjamin L.:
Opening statement............................................ 6
Casey, Hon. Robert P., Jr.:
Opening statement............................................ 5
Crapo, Hon. Mike:
Opening statement............................................ 3
Prepared statement........................................... 62
Hassan, Hon. Maggie:
Opening statement............................................ 5
Hoover, Sharon, Ph.D.:
Testimony.................................................... 13
Prepared statement........................................... 62
Responses to questions from committee members................ 66
Lubarsky, Jodie L., M.A., LCMHC:
Testimony.................................................... 11
Prepared statement........................................... 71
Responses to questions from committee members................ 73
Terrell, Trace:
Testimony.................................................... 7
Prepared statement........................................... 75
Wyden, Hon. Ron:
Opening statement............................................ 1
Prepared statement........................................... 77
Communications
American Hospital Association.................................... 79
American Psychological Association............................... 82
American Therapeutic Recreation Association...................... 89
Barrett, Stephanie............................................... 92
California Youth Connection et al................................ 93
Children Now (California) et al.................................. 100
Children's Health................................................ 102
Children's Hospital Association.................................. 105
Children's Trust Fund Alliance, Generations United, and
FosterClub..................................................... 108
Citizens Commission on Human Rights.............................. 112
Driscoll Health System........................................... 116
First Focus on Children.......................................... 118
FosterClub
Healthy Schools Campaign......................................... 126
Juvenile Law Center.............................................. 128
Mending Minds Village............................................ 133
Mental Health Liaison Group...................................... 135
National Advocacy on Serious Neurobehavioral Illness and National
Shattering Silence Coalition................................... 139
National Association for Children's Behavioral Health............ 141
Nationwide Children's Hospital................................... 143
Nemours Children's Health........................................ 146
Partnership to End Addiction..................................... 150
Primary Care Collaborative....................................... 152
Reed, Ethan J.S.H................................................ 156
The Trevor Project............................................... 157
Voice for Adoption............................................... 162
Youth Villages................................................... 167
PROTECTING YOUTH MENTAL HEALTH:
PART II--IDENTIFYING AND
ADDRESSING BARRIERS TO CARE
----------
TUESDAY, FEBRUARY 15, 2022
U.S. Senate,
Committee on Finance,
Washington, DC.
The hearing was convened, pursuant to notice, at 10:03
a.m., via Webex, in the Dirksen Senate Office Building, Hon.
Ron Wyden (chairman of the committee) presiding.
Present: Senators Stabenow, Cantwell, Menendez, Carper,
Cardin, Brown, Bennet, Casey, Whitehouse, Hassan, Cortez Masto,
Crapo, Grassley, Thune, Portman, Cassidy, Lankford, Young, and
Barrasso.
Also present: Democratic staff: Shawn Bishop, Chief Health
Advisor; Elizabeth Dervan, Health Counsel; and Michael Evans,
Deputy Staff Director and Chief Counsel. Republican staff:
Kellie McConnell, Health Policy Director; and Gregg Richard,
Staff Director.
OPENING STATEMENT OF HON. RON WYDEN, A U.S. SENATOR FROM
OREGON, CHAIRMAN, COMMITTEE ON FINANCE
The Chairman. The Senate Finance Committee will come to
order. And, during this morning's hearing on the youth mental
health epidemic, we are going to have an opportunity to build
on last week's superb discussion with the Surgeon General, Dr.
Murthy.
Last Tuesday, Dr. Murthy told us that mental health
problems often show up first when we have people who are very
young, but the average delay between the onset of mental health
symptoms and the beginning of treatment is actually 11 years.
Those are, in the Surgeon General's words, ``11 long,
confusing, isolating, and painful years.''
This obviously is a number worth a thousand words, and more
than anything it says that America's approach to mental health
care is way out of whack, and it starts failing America's young
people early on. So, there are several priorities for today.
Let's focus on how mental health care for young people
starts much earlier--earlier screenings, earlier interventions,
earlier discussions with primary care doctors. There is also a
need to step up mental health efforts in schools and in our
communities.
Those are also places where trained professionals can get
the symptoms right from the outset and refer young people to
skilled practitioners when necessary. At present, we get told
again and again that school counselors are overwhelmed,
community-based programs are too few, and referrals are
inconsistent. Mental health care simply does not start early
enough, and it's not reaching young people where they are,
especially kids in rural areas.
Second, our country must have better crisis care. The 11-
year treatment gap is a sign that young people are struggling,
going without the treatment they need, and heading on a path to
crisis. In addition, America's mental health system too often
fails the young when they are in crisis as well.
The evidence shows that the pandemic has driven a shocking
increase in self-harm among young people. Suicide attempts
among young teen girls resulting in hospitalizations recently
jumped more than 50 percent. Far too many of these young people
in distress are spending days or even weeks boarded in
emergency departments. For the bulk of the time, they are
probably alone. Imagine, colleagues, feeling a sense of extreme
isolation clashing with the chaos and commotion of the
emergency department buzzing outside your door.
Just yesterday I spoke with a group of Oregon health-care
practitioners and physicians who told me they were concerned
that in many of these crisis situations, young people who end
up in the hospital emergency rooms are not even seeing
practitioners who have training in mental health. The emergency
room is no place for a child in crisis to spend day after day,
but it is all too common. Young people simply deserve better.
Third and finally, solving these problems is going to
require creativity from the public and the private sector. The
Children's Health Insurance Program and Medicaid, which is the
largest single payer of mental health care for young people,
can play a key role in sparking new solutions. These efforts
will be essential to make sure mental health is treated with
the same consistency and focus given to physical health.
The bottom line is, no more mental health business as
usual, because business as usual is failing too many young
people at every single point, from the first sign of symptoms
to the most critical moments of crisis.
There is a lot for the committee to discuss today on these
key issues. We are going to have a great panel whom I am going
to introduce shortly. I want to thank Senators Carper and
Cassidy for heading up our efforts on youth mental health care.
And I also want to commend Senator Stabenow for her years and
years of work on behavioral health issues that are so
important, and that we will build on.
[The prepared statement of Chairman Wyden appears in the
appendix.]
The Chairman. Now we will turn to Senator Crapo for his
opening remarks. And then we will have introductions--and where
is my friend, Senator Crapo?
There he is. Senator Crapo?
OPENING STATEMENT OF HON. MIKE CRAPO,
A U.S. SENATOR FROM IDAHO
Senator Crapo. Thank you, Mr. Chairman, and thank you to
our witnesses for joining us today as we discuss ways to
respond to mental health challenges impacting children and
adolescents across the country.
According to recent reports from the CDC, the number of
young people dealing with depression, anxiety, and suicidal
thoughts has unfortunately risen during the pandemic, as social
isolation has taken its toll on far too many children and
adolescents. Although it appears the pandemic is subsiding and
our return to normalcy may be imminent, we cannot ignore the
lasting effects of the past 2 years on the social and emotional
well-being of children.
We should do all that we can, within our jurisdiction, to
increase access to high-quality mental health services and
reduce the causes of delayed and forgone treatment. While
mental health issues affect people of all ages, children's
needs are often different from those of adults, necessitating
carefully tailored solutions.
As this committee works in a bipartisan way to advance the
conversation on mental health, we must not only identify the
complexity and scope of the problems at hand, but also explore
innovative, sustainable, and concrete policy solutions. I look
forward to working with my colleagues on both sides of the
aisle to develop meaningful measures to meet some of the
Nation's mental health challenges, including by expanding
access to telehealth services, supporting our mental health
workforce, and better integrating physical and mental health-
care services.
Children can and often do benefit from services delivered
via telehealth. While we often focus our telehealth discussions
on Medicare, where key access gaps and barriers remain, this
committee should also prioritize clarifying and expanding care
delivery options for children covered by Medicaid, regardless
of geographic location.
Additionally, we should work to maintain a strong mental
health workforce with the capacity to care for all who need
services. These efforts will prove particularly crucial as
health-care professionals burn out, steep regulatory demands
continue, and other strains jeopardize long-term provider
retention and capacity.
We have clear opportunities for improvement at every level.
I regularly hear from front-line providers, as well as State
policymakers, seeking the flexibility to innovate and craft
targeted, local solutions to the challenges facing their
communities.
Their ideas and input will play a critical role in this
process, especially as we look to bridge gaps in care, better
integrate physical and behavioral health services, and promote
value-based payment models that put patients first. If
structured effectively, these reforms could prove game-changing
for populations of all ages, including young people.
Finally, no conversation on mental health-care reforms for
children and young adults would be complete without input from
those whom the policies intend to empower and support. To that
end, Trace, thank you for your willingness to join us today to
share your perspective.
We have the opportunity to better support children, their
families, and their providers, by enhancing mental health
outcomes across the United States. Moreover, we can and must do
so while honoring this committee's strong tradition of member-
driven, bipartisan, and fiscally responsible legislative
solutions.
Thank you to our witnesses for agreeing to share their
expertise from across the continuum of care. They have provided
invaluable service during these unprecedented times, and I look
forward to hearing their testimony.
Thank you.
[The prepared statement of Senator Crapo appears in the
appendix.]
The Chairman. Senator Crapo, thank you for a very helpful
opening statement. As you noted, we are going to do this in a
bipartisan way. There is an awful lot of common ground here,
and I am especially appreciative that you zeroed in on
telehealth, because the Finance Committee is especially proud
of the telehealth contribution we made at the beginning of the
pandemic, during those early days when the Centers for Medicare
and Medicaid Services, headed by Seema Verma, were trying to
figure out how to proceed. And to a great extent, they took the
telehealth provisions of the CHRONIC Care law that was written
in a bipartisan way in our committee.
So I appreciate your zeroing in on telehealth issues, and
we are certainly going to build on them in our work this year.
And also, thank you for giving a little bit of a send-off, as
we move to introductions, to Trace Terrell, because he is one
of our own, a student from La Pine, OR, a mental health leader,
and an advocate in his community. He has volunteered with
YouthLine, a peer-to-peer youth crisis service based in our
State that receives 27,000 contacts each year from young people
across the country. YouthLine is provided by Lines for Life, a
nonprofit dedicated to suicide prevention and mental health
support, and Oregon's home for the National Suicide Prevention
Lifeline.
Beyond YouthLine, Mr. Terrell has advocated for youth
mental health through a number of other organizations,
including the National Mental Health Advisory Board supported
by Well Being Trust, Young Invincibles, and Active Minds.
A high school senior--because I am on the Intelligence
Committee, people sometimes tell me important little items
about our guests, and I recently learned that Mr. Terrell has
been accepted to Johns Hopkins University, and we all want to
extend congratulations for that great achievement.
With that, I am going to turn it over now to my colleagues
to introduce witnesses that they have worked with and are very
proud of. Senator Casey will introduce Dr. Tami Benton from the
Children's Hospital of Philadelphia. Senator Hassan will then
introduce Jodie Lubarsky from Seacoast Mental Health Center in
New Hampshire. And then Senator Cardin will introduce Dr.
Sharon Hoover from the University of Maryland School of
Medicine's National Center for School Mental Health. And then
we will hear their testimony.
Senator Casey?
OPENING STATEMENT OF HON. ROBERT P. CASEY, JR.,
A U.S. SENATOR FROM PENNSYLVANIA
Senator Casey. Mr. Chairman, thanks very much for this
opportunity. I am pleased to introduce Dr. Tami Benton. And I
appreciate Dr. Benton's expertise at this hearing today, in
addition to her lifelong commitment to serving both children
and families.
Dr. Benton is psychiatrist-in-chief, executive director,
and chair of the Department of Child and Adolescent Psychiatry
and Behavioral Sciences. She is clinical director of child and
adolescent psychiatry, and a psychiatrist in the 22q and You
Center at the Children's Hospital of Philadelphia, which we
often refer to by the acronym CHOP. She also serves as
president of the American Academy of Child and Adolescent
Psychiatry and as an associate professor of psychiatry at the
Perelman School of Medicine at the University of Pennsylvania.
Dr. Benton also serves on the board of the Juvenile Law Center,
which advocates for children and child welfare in the juvenile
justice system.
Her expertise spans pediatric depression, suicide, and
anxiety, particularly for minority youth and those with chronic
diseases, as well as our mental health workforce shortage.
So, Dr. Benton, thank you for being with us today. And
thank you for all you have done to support families long before
and throughout this pandemic. I look forward to your insights
today.
The Chairman. Thank you, Senator Casey, and we look forward
to hearing from Dr. Benton.
Senator Hassan is here to introduce Ms. Lubarsky.
OPENING STATEMENT OF HON. MAGGIE HASSAN,
A U.S. SENATOR FROM NEW HAMPSHIRE
Senator Hassan. Well, thank you so much, Chairman Wyden and
Ranking Member Crapo, for holding today's hearing on protecting
youth mental health. It is essential that we get our children
the mental health support and resources that they need. And I
would like to welcome a Granite Stater who is with us today to
serve as an expert for today's hearing.
Jodi Lubarsky is the vice president for clinical
operations, Youth and Family Services, at the Seacoast Mental
Health Center in Portsmouth, NH. She has a master of arts in
mental health counseling and is a licensed clinical mental
health counselor.
At the community mental health center where Ms. Lubarsky
works, she oversees the evaluation and treatment services for
children, adolescents, and their families. These services
include psychotherapy, psychiatry, community-based behavioral
supports, targeted case management, substance use disorder
treatment, 24/7 crisis intervention, and post-intervention
services to schools and communities affected by suicide and
loss.
To say she is at the front lines of some of the toughest
battles our children face would be an understatement. In her
role as vice president and as mental health counselor, Ms.
Lubarsky provides support to young people who are experiencing
mental health challenges, and she has seen firsthand how the
pandemic and the shortage of mental health services has
increased the number of patients in her center.
In fiscal year 2020, the Youth and Family Services team at
Seacoast Mental Health Center provided more than 33,000
services. In fiscal year 2021 alone, it provided more than
41,000 services to children and families, a 25-percent
increase. The number of patients seen in fiscal year 2021 was
almost 13 percent higher than in the previous year.
In response to the wave of children and young adults
requiring services, Ms. Lubarsky has worked on innovative
programs in New Hampshire that have been integrated into places
like our schools and our summer camps.
Given her extensive experience and expertise, she will be
able to speak today about the challenges facing our children,
the critical programs that she has helped to develop, and the
persistent barriers that limit access to mental health care.
Jodi, thank you for being here and for your work on behalf
of New Hampshire's children and families. I look forward to
hearing from you today.
Thank you, Mr. Chairman.
The Chairman. And thank you for all your help for this
hearing, and for making sure we could have Ms. Lubarsky. And we
are looking forward to working closely with you every step of
the way as we tackle this issue.
Senator Cardin is here to introduce Dr. Sharon Hoover.
OPENING STATEMENT OF HON. BENJAMIN L. CARDIN,
A U.S. SENATOR FROM MARYLAND
Senator Cardin. Well, thank you, Mr. Chairman. Let me thank
Senator Wyden and Senator Crapo for their leadership on this
issue, and on so many others, bringing us together to deal with
the critical problems.
I first want to acknowledge Trace, and congratulations on
your acceptance to Johns Hopkins, located in Baltimore, MD. We
are proud to have you in our State.
I am proud to introduce a fellow Marylander, Dr. Sharon
Hoover. She is a licensed clinical psychologist and professor
at the University of Maryland School of Medicine, Division of
Child and Adolescent Psychiatry. She is also co-director of the
National Center for School Mental Health, and director of the
National Center for Safe Supportive Schools within the National
Child Traumatic Stress Network.
Dr. Hoover has led and collaborated on multiple Federal-
State grants, and is currently co-leading two large randomized
trials of school mental health efforts. Since 2004 she has
worked with the National Child Traumatic Stress Network's
Treatment Services Adaptation Center for Resiliency, Hope, and
Wellness in Schools to train school districts and school
leaders, educators, and support staff in a multiple-tiered
system of support for psychological trauma.
Dr. Hoover is a certified national trainer for the
Cognitive Behavioral Intervention for Trauma in Schools
program, and the Support for Students Exposed to Trauma
program.
Last year she was kind enough to join the constituent event
I hosted concerning youth and COVID-19, and I know that Dr.
Hoover's input was extremely helpful to my constituents, and I
know she will add greatly to our discussion today.
Welcome, Dr. Hoover. It is a pleasure to see you.
The Chairman. Thank you, Senator Cardin, and for your years
of advocacy in the health-care area for vulnerable folks in
Maryland and our country.
So thank you all, colleagues.
And, Mr. Terrell, we are glad to have your voice coming
from La Pine, and please proceed.
STATEMENT OF TRACE TERRELL, LEAD INTERVENTION AND OUTREACH
SPECIALIST, YOUTHLINE, LA PINE, OR
Mr. Terrell. Thank you. Thank you Chairman Wyden, Ranking
Member Crapo, and the other members of the committee, for the
opportunity to represent the youth perspective as it pertains
to mental health.
My name is Trace Terrell, I use he/him pronouns, and I am a
17-year-old from La Pine, OR. Before I share more about myself,
I would first like to tell you some things I have heard from
teens across the country.
4:07 p.m.: I just need someone to talk to; 4:37 p.m.: my
dad hit me, but you can't call the cops; 5:23 p.m.: I need
therapy, but my family can't afford it; 8:07 p.m.: I just lost
my dad, and I can't stop crying; 6:42 p.m.: I want to kill
myself.
These are just some examples of the many conversations that
I respond to as a volunteer with YouthLine, a free,
confidential, teen-to-teen crisis help support hotline located
in Oregon. Whether helping someone navigate complicated
feelings about their sexuality or working with others to
develop comprehensive safety plans, I spend 3\1/2\ hours every
week responding to a variety of mental health challenges
experienced by teens across the country, with an emphasis on
the fact that no problem is ever too big or too small.
I became involved with YouthLine during my freshman year of
high school. As someone who struggled with depression, suicidal
ideation, eating disorder behavior, and anxiety throughout
middle and early high school, I, for the longest time, believed
that no one could relate to my experiences.
However, as I became more involved, I realized that my
challenges were a microcosm of public health issues that
affected hundreds of thousands of teens across the country.
As more and more teens start to have conversations about
mental health and engage in help-seeking behaviors, the need
for expansive and intersectional mental health efforts has
never been so great.
So, what can we do to address the youth mental health
crisis?
One, we must centralize our efforts in schools. From my
experience and many of my peers, mental health efforts in
schools are lacking. Day after day, I hear my friends and those
on the line talk about how inaccessible school counselors are
due to being overworked and overloaded. This has been an
especially difficult challenge for the many teens who rely on
school mental health professionals for crisis care. We have to
address this staffing crisis.
We must also create a streamlined approach to free mental
health screenings and referrals. At my school, four of every
five referrals to external resources are not carried out. Let
that sink in: 80 percent of referrals go nowhere. Someone who
needs help, should receive help.
Last, we need a comprehensive and standardized mental
health curriculum. All students should learn about engaging in
real-world help-seeking behavior, developing systems of self-
care, and supporting our friends with mental health struggles,
because statistics show that we turn to each other before
anyone else.
Two, we need to address the pressing challenges that young
people continue to face in accessing mental health care. While
I am no expert in policy solutions, I am someone with lived
experience. I know what it is like to be a teen today
struggling with mental health. And I know what it is like to
offer support to teens in crisis.
On and off the lines, the most common struggles I see
expressed by my peers in regard to accessing mental health care
are financial, transportation, and broadband barriers; the
urban/rural divide in mental health care; the lack of mental
health professionals and adequate follow-through care; and the
stigma around mental health.
These issues are incredibly real. My friends have struggled
to receive professional mental health services because it is
too expensive for their families, too far away, or inaccessible
because of unreliable Internet access. We need to bring care to
where people are. And for teens, that is in schools or at home.
In addition, we know that the lack of mental health
professionals in the United States prevents teens from
receiving the help they need. One of the ways we can approach
this issue is by funding a national YouthLine. We know that
peer-to-peer support works, and that there is a substantial
need for it.
What youth need is to be able to call on the new 988 and
have the opportunity to be connected with another trained teen.
Three, we must invite youth to the table and value their
insights as natural partners in this work. I am just one of 165
YouthLine volunteers. What does that tell you? Youth are not
afraid to talk about mental health. If anything, adults are.
Across the country, young people are mobilizing and advocating
for mental health like never before.
Beyond YouthLine, I have been involved with organizations
like Active Minds, for whom I and millions of my peers helped
to change the narrative for how we talk about value and seek
care for our mental health.
My peers and I believe that we deserve a seat at the table.
While there are many ways we can do this, it starts by ensuring
that young people can meaningfully contribute to and be
involved with legislative work on the local, State, and Federal
levels.
If there is anything I want to leave you with today, it is
this. Teens are talking, and we need you to listen. At
YouthLine, we know that the work we do makes a difference in
the lives of young people across the country, and we know that
because of what we hear from teens after we have connected them
to help, after we have talked about self-care, and after we
have helped them find a path forward.
6:26 p.m.: I feel so much better talking; 8:34 p.m.: if it
weren't for this conversation, I would not be here today.
Thank you.
The Chairman. Trace, thank you for getting us off to such a
powerful start, and what I want you to know--you said that
young people were mobilizing. Those are very welcome words, and
I think you are going to see today the Democrats and
Republicans in the U.S. Senate, the Finance Committee, are
going to start mobilizing to move real reform. And make no
mistake about it, you and young people are going to have a seat
at that table when we are working on these reforms.
So, thanks for getting us off to such a strong and powerful
start.
[The prepared statement of Mr. Terrell appears in the
appendix.]
Dr. Benton, let's see where you are. Dr. Benton from
Children's Hospital of Philadelphia, you have the honor of
trying to keep up with Trace. It is a big challenge, and you do
wonderful work, as Senator Casey said.
STATEMENT OF TAMI D. BENTON, M.D., PSYCHIATRIST-IN-CHIEF,
EXECUTIVE DIRECTOR, AND CHAIR, DEPARTMENT OF CHILD AND
ADOLESCENT PSYCHIATRY AND BEHAVIORAL SCIENCES, CHILDREN'S
HOSPITAL OF PHILADELPHIA, PHILADELPHIA, PA
Dr. Benton. Chairman Wyden, Ranking Member Crapo, and
members of the committee, thank you for this opportunity to
testify.
I wish there were no need for me to appear today, but
children and adolescents are experiencing mental distress at
higher rates and with more dire consequences than ever before.
In the first half of 2021 alone, we reported cases of self-
injurious behavior and suicide in children ages 5 to 17 at a
45-percent higher rate than during the same period in 2019. And
for children under 13, the suicide rates for Black children
have increased at twice the rate for White children.
The pandemic has both highlighted and worsened disparities
in pediatric mental health care. There are barriers to access,
under-recognition, and under-treatment of mental health
disorders. The burden of illness is worsened for children of
color, who often have greater exposure to environmental
traumas.
It is also true that children with mental health challenges
are overrepresented in the juvenile justice and child welfare
systems, where higher rates of mental health disorders are
often unrecognized and untreated.
You have heard many of these statistics before, but I would
like to share with you how these situations show up in my day-
to-day life as a physician.
A 5-year-old in the emergency department who discloses
suicidal feelings and plans to run into traffic in reaction to
her parents' job loss, financial stresses, and her mother's
depression.
A 6-year-old boy suspended from first grade for kicking a
desk after witnessing a shooting 20 feet away from him while
walking home from school, too terrified to disclose the
experience for fear that he would be the next victim.
A 16-year-old honor student becoming depressed after a
romantic breakup, eventually making a serious suicide attempt
while waiting 6 weeks for treatment, and then hospitalized for
2 weeks in a medical facility where he waited for in-patient
psychiatric care. And then when it was available, financial
barriers interfered with the smooth transition.
It is situations like these that led the American Academy
of Child and Adolescent Psychiatry, the American Academy of
Pediatrics, and the Children's Hospital Association to sound
the alarm for kids, and to declare a national emergency in
children's mental health. But there are things that we know.
Children and adolescents recover best when care is targeted
to their needs, evidence-based, no more restrictive than it
must be for safety, and close to home. And, while I can speak
more directly to the shortage of child and adolescent
psychiatrists, there are also severe shortages of other
pediatric mental health providers, which all must be addressed.
These shortages lead to increased emergency visits for
things that are preventable. In my home institution at
Children's Hospital Philadelphia, we have 20 to 30 patients
boarding, awaiting acute psychiatric care. And this is true on
any given day.
We typically operate at full capacity, so occupied beds
prevent children with complex medical needs from receiving
care. But despite the things I have just shared, I remain
optimistic. Effective strategies exist for preventing and
treating pediatric mental and behavioral conditions while
supporting the natural resilience of children and families.
But success requires responses to two urgent tasks before
us: first, addressing the immediate crisis that we are facing
right now; and second, reframing our pediatric mental health
system with the goal of preventing disrupted development and
facilitating a successful transition to adulthood. Expansion of
the workforce will take time, even if we start today. So I will
focus more on immediate options to address the crisis.
One of the best things that we can do is to support those
on the front lines now by providing them with effective
training. This should also extend beyond primary care
pediatricians. Caregivers and educators can be empowered
through training to better manage the situations they face. And
we must act now to pivot mental health services from crisis-
driven care to prevention, and make sure that needed treatments
are available where families are likely to be, such as
pediatricians' offices, daycare, after-school programs, and
schools.
The pandemic has also taught us important lessons.
Telehealth has been an important tool for providing care across
State lines, in underserved areas, rural areas, local and
distant communities, and for working families. It has had
surprising therapeutic advantages such as seeing the whole
family, and seeing them in their natural environment.
This tool must continue as an adjunct to our current
continuum of treatment. And I cannot conclude my remarks
without noting that both coverage of the range of services kids
need, and the appropriate reimbursement for these services are
essential. The continuum of services needed for children for
mental health are absent at every level. Children need to get
the right treatment at the right time at the right place.
And finally, I want to end by sharing an experience that
reflects my hope for the future.
Just last week I interviewed two fifth graders, Daniel and
Kaitlin. They asked me, ``When can normal feelings like
depression, anxiety, become bad for you?'' These are questions
that all Americans should be asking at this time--and should be
able to answer.
I want to thank you again for allowing me to provide this
testimony. I am confident that you will take this opportunity
to secure our Nation's future by supporting our children
through the crisis.
Thank you.
[The prepared statement of Dr. Benton appears in the
appendix.]
The Chairman. Dr. Benton, thank you very much for your
helpful testimony. And I noted you talked about access to
coverage and reimbursement. We think that is very much
intertwined with some of these big insurance companies not
following through on parity, which is so essential for mental
health patients. So you gave us a lot of very valuable input,
and we look forward to working with you.
Now we will go to Ms. Jodie Lubarsky.
STATEMENT OF JODIE L. LUBARSKY, M.A., LCMHC, VICE PRESIDENT OF
CLINICAL OPERATIONS, YOUTH AND FAMILY SERVICES, SEACOAST MENTAL
HEALTH CENTER, INC., PORTSMOUTH, NH
Ms. Lubarsky. Good morning, Chairman Wyden, Ranking Member
Crapo, Senator Hassan, and members of the U.S. Senate Committee
on Finance. I want to thank you for the opportunity to testify
today as a witness regarding pediatric mental health. I am both
humbled and grateful for this opportunity.
I currently serve as the vice president of clinical
operations for Youth and Family Services at Seacoast Mental
Health Center. We are one of 10 community mental health centers
in the State of New Hampshire. I am also a Licensed Clinical
Mental Health Counselor still actively seeing pediatric
patients, a youth swim coach, and a parent.
In March of 2020, life as we once knew it changed for all
of us. As adults, we made many quick pivots to respond and
adapt to the COVID-19 pandemic. As we made many adaptations in
both our personal and professional lives, we had our past
experiences to reflect upon. When faced with the new and often
unpredictable challenges the pandemic created, we pulled from
our toolbox of coping strategies. We knew who we could turn to
for the extra support we might have needed as we navigated
those challenges.
But for most of the youth in our country, they were left
feeling paralyzed, stymied, hopeless, and scared. For many
youth, this was their first experience with grief, trauma,
depression, or anxiety. Life for them had completely changed,
and their worlds were turned upside down. The uncertainty,
social isolation, and stressors related to the pandemic have
left many kids unable to cope or understand the breadth and
depth of this experience. And for some, there was no trusted
adult to support them during this critical developmental period
and their only means of symptom relief was contemplating death.
We are learning that teenage girls have begun to
demonstrate an increase in the acuity of their symptom
presentation. Data from the Centers for Disease Control and
Prevention indicates a 51-
percent increase in suicide attempts by teenage girls ages 12
to 17. LGBTQ+ youth continue to have higher rates of suicide
than their heterosexual peers. Data from 2020 demonstrated that
the percentage of emergency department visits for mental health
emergencies rose by 24 percent for children between the ages of
5 and 11 and 31 percent for those ages 12 to 17, compared with
2019.
Youth mental health has become the secondary pandemic to
COVID. As mental health needs rise for pediatric patients, the
availability of services continues to become more scarce. Youth
are presenting to hospital emergency rooms in a state of
psychiatric crisis. Many who are assessed and meet the criteria
for psychiatric inpatient level of care will be faced with
boarding in an emergency room for days, weeks, and sometimes
months before a bed becomes available.
Emergency room boarding often creates more distress,
decompensation in psychiatric symptoms, and increased traumatic
exposure, while receiving no mental health care until the
inpatient bed becomes available. Staffing shortages in both
outpatient and inpatient settings due to an exhausted,
depleted, and underpaid mental health workforce have only
prolonged access to care for pediatric patients.
Without adequate funding and reimbursement structures from
both Medicaid and private payers, mental health providers are
left with the difficult decision to leave the nonprofit world
and enter a for-profit world in order to make a livable wage.
During the pandemic, there were two 3-percent increases to
Medicaid rates. And while that is appreciated, prior to those
two increases there had not been meaningful increases in
Medicaid rates in over 20 years. Without a realistic
reimbursement structure based on the current cost of living,
centers are losing staff who can no longer afford to work in
mental health settings.
Some mental health centers are reporting a 40-percent
rolling 12-month turnover rate in staffing during the pandemic,
leaving no workforce available to attend to the critical and
fragile needs of pediatric patients. And for the mental health
workforce that remains, they are often left supporting higher
caseloads than their private-practice peers, with limited time
while attending to significant administrative tasks that
private mental health providers are not expected to complete.
The community mental health workforce treats some of the
most complex cases. The complexity of cases, the severity of
need, and demand placed upon this workforce during the pandemic
have left many professionals questioning their longevity in the
mental health field. I feel many mental health professionals
entered with an altruistic spirit and are now left feeling
broken and tired.
While we can discuss an ideal service array, evidence-based
practices, and the ideal care setting, none of this can be
provided without a robust, well-trained, adequately
compensated, and sustainable mental health workforce from all
professional disciplines and degree levels. Simply put, we need
to be able to adequately reimburse mental health providers in
order to compensate the mental health workforce. Adequate
reimbursement will help to sustain a robust mental health
workforce to provide high-quality, timely, adequate care to our
pediatric population.
I thank you for your time today.
[The prepared statement of Ms. Lubarsky appears in the
appendix.]
The Chairman. Thank you very much, Ms. Lubarsky. You
finished so powerfully with the workforce, I just wanted to
come back for a moment and say ``thank you'' for mentioning at
the outset, that in those first days of the pandemic, you
reached for your mental health toolbox, because that is really
what this is all about: making sure that practitioners, not
somebody micro-managing in Washington, DC, can have an adequate
array of tools.
And as you know so well from your outstanding work, too
often the toolbox is pretty barren in much of the country. And
that is what Dr. Murthy told us last week. So, thank you. I
know you are going to get some questions in a moment.
Dr. Sharon Hoover is next, please.
STATEMENT OF SHARON HOOVER, Ph.D., PROFESSOR, CHILD AND
ADOLESCENT PSYCHIATRY; AND CO-DIRECTOR, NATIONAL CENTER FOR
SCHOOL MENTAL HEALTH, UNIVERSITY OF MARYLAND SCHOOL OF
MEDICINE, BALTIMORE, MD
Dr. Hoover. Thank you. I want to express my thanks to you,
Chairman Wyden, for the invitation to speak with the committee
today, and for your leadership on the issue of mental health in
our Nation, including the impacts on youth. I thank also
Ranking Member Senator Crapo, and all of the committee members
for your vision to improve the mental health and well-being of
our young people, and for the opportunity to be here with you
today to talk about these important issues.
I am speaking to you from my perspective as co-director of
the National Center for School Mental Health, which is funded
by the U.S. Department of Health and Human Services, and as a
professor of child and adolescent psychiatry. But I also speak
to you through my lens as a parent to three teenagers, all of
whom had their learning landscape significantly altered during
COVID, with almost a year of virtual education.
They, along with most children across the globe, had
significant disruption to their learning and to their well-
being, though I am fortunate that my kids are now going to
school, and they are doing well. But we know that many are
suffering. Even before the pandemic, youth mental health
challenges were rising, with suicide being the second leading
cause of death for young people ages 10 to 24.
As noted by Surgeon General Murthy during last week's
hearing, one of the most central tenets in creating accessible
and equitable systems of care is to meet people where they are.
And for most young people, this is in schools.
I often think back to a story that my dad, who is now 85
years old, told me about his first day of school. He grew up in
a small town in rural West Texas called Spur. They didn't have
pre-K or Kindergarten, so it was first grade, and on that first
day he recalled that his peers and he received toothbrushes
from his first grade teacher. It was the first toothbrush that
he had ever owned. And I remember asking him, ``You didn't have
toothbrushes?'', to which he replied, ``No; my family wouldn't
have spent the money on toothbrushes back then.'' Mind you, my
dad went on to a long career in computer science, and he helped
create coding to put our astronauts on the moon. But he often
credits those teachers in his early years who cared about him
with setting him on that path.
And when I consider that moment when he received his
toothbrush on the first day of school, I think of it really as
a classic example of how our schools are a vital place to
promote our children's health and well-being. We simply cannot
rely on our health-care system alone to support the mental
health and well-being of our young people.
We know on average, as Senator Wyden noted in the
beginning, that people do not get into care for over a decade
after the initial onset of symptoms, and half of mental
illnesses begin in the school-age years.
Our traditional approach to mental health care has not
leveraged the natural venues where our young people access
support. It is really akin to waiting for toothaches, cavities,
and abscesses until a child gets proper dental care. Instead,
we should do the equivalent of passing out toothbrushes and
providing preventive and early dental care, by offering every
child in every school the social, emotional, behavioral, and
mental health supports that they need to be successful.
Increasingly, schools have comprehensive school mental
health systems, which reflect partnerships between the
education and behavioral health sectors to support a full
continuum of mental health and substance use services and
supports, from promotion to treatment. And when treatment is
delivered in a school setting, youth are far more likely to be
identified early and to initiate and complete care.
Schools that have these systems in place recognize that
poor mental health leads to poor learning, and positive mental
health promotes academic and life success.
There are many policy and funding opportunities, including
strengthening full Medicaid programs that can help advance a
continuum of mental health supports and services in schools.
And Congress has the opportunity to support investment and
technical assistance to ensure that young people can get the
mental health support that they need.
In my written testimony, I do provide detail on several
steps that Federal and State leaders can take to advance
comprehensive school mental health systems. And we have
witnessed many States adopt new policies to advance school
mental health.
Tomorrow, the Hopeful Futures Campaign, a coalition of
national organizations committed to ensuring that every student
has access to effective and supportive school mental health
care, is releasing the first ever ``America's School Mental
Health Report Card and Action Center,'' with individual report
cards for all 50 States and DC. And these school mental health
report cards highlight accomplishments and provide important
action steps to help address the children's mental health
crisis in every State. They can serve as a great starting point
for policymakers who want to strengthen school mental health
supports and policies in their communities. You can find the
report cards at hopefulfutures.us starting tomorrow morning.
Today, Americans across the country are united in our
concern about the mental health of our young people and the
impact it has throughout their lives. I want to express my
gratitude to you all for opening up this important discussion
on youth mental health, for recognizing schools as an essential
place to strengthen our children's well-being, and for
committing to investing now to create hopeful futures for our
Nation's youth.
[The prepared statement of Dr. Hoover appears in the
appendix.]
The Chairman. Thank you very much, Dr. Hoover, and we are
going to get you into this discussion in just a minute.
Trace, you really make all of us in Oregon so proud, and
you said it so well. And I want to get into an area that I
really had not heard about from you. And that is, how serious
this problem is with young people getting lost in the system,
where they just do not get connected. And the figure you used
is 80 percent of referrals from schools for mental health
support just go nowhere--just get lost.
How does this make students and young people feel when they
just get lost in all of this red tape and bureaucracy?
Mr. Terrell. That is a great question, Senator Wyden. And I
want to clarify that that statistic was for my school. So, I do
not actually know the national figure, but I imagine there are
similar trends across the country.
The Chairman. That was for your school, right, Trace?
Mr. Terrell. Yes.
The Chairman. Good. Please, go ahead.
Mr. Terrell. But I think, when we talk about access to
care, there has to be a conversation about what happens next,
right? What happens next? Who is going to provide the follow-
through care? And I think for a lot of teens who get to this
point and initially have that first conversation, not being
able to get those accesses afterwards is incredibly isolating
and incredibly defeating. And I think it really highlights some
of the failures of our mental health-care system and things
that need to be addressed. Because teens who need help should
receive help, and that help should be meaningful and
sustainable for as long as they may need it.
The Chairman. Okay. Sit tight, Trace.
Dr. Hoover, that 80-percent figure is really show-stopping.
And my sense is, whether it is 80, or 60, or something, we are
just losing a lot of young people at a really crucial time.
What ought to be done about that?
Dr. Hoover. I totally agree, and I would agree with Trace
that it is probably not just in his school. We are seeing these
figures across the Nation.
So, the bottom line is that getting care to kids in some of
our traditional outpatient settings really is a challenge. So,
as you heard earlier, one of the first lines of action really
is to bring services to where young people are in their
schools. We know that every State, and many districts within
each State, have examples of really effective school-based
mental health care, right? So this includes expanding our
school-employed workforce, including our school psychologists,
school social workers, and counselors, but also helping
facilitate partnerships with community behavioral health
provider organizations to bring their services into schools.
School-based health centers are also an ideal model of
providing this type of onsite care. So, increasing support for
school-based health centers is one avenue.
We mentioned telehealth already. We know the expansion of
telehealth offers incredible opportunity to expand the reach of
specialists, not just in rural settings, although that is
critical, but also into our urban settings. We have been
providing telehealth from our hospitals into Baltimore City
schools for a number of years now.
We heard from Ms. Lubarsky about reasonable reimbursements.
That is a critical way of getting services to schools and into
outpatient care, and having providers there to receive students
when they are referred.
So those are some of the avenues.
The Chairman. Well, thank you both.
And, Trace, if ever there was an area, as you said, for the
committee to work with young people, it is mobilizing, in your
words, to make sure that we do not see as many of these
referrals get lost in the system. It is just too important,
because those are young people who are getting lost.
I want to ask you one other question, Trace. And that is,
you and I talked about barriers to care. And clearly, stigma
associated with mental health challenges is a big part of this.
I saw this with my brother who struggled with schizophrenia for
years--and as I went off and played basketball and all kinds of
things like that. And my concern is, I keep hearing from people
in the schools, and students like yourself, that the stigma has
clearly gotten worse as a result of the pandemic, causing more
young people to be isolated from each other; that there is not
enough peer-to-peer contact and the like.
Can you give us your thoughts on that?
Mr. Terrell. Of course; yes. I mean, I think we definitely
saw how the pandemic increased rates of loneliness, isolation,
and other high-acuity mental health struggles. But I think
really the most important takeaway from the pandemic, and our
response to the mental health-care crisis, is the fact that
COVID-19 exacerbated disparities that were already there,
right? We know that access to care was limited before COVID-19,
and the pandemic only amplified those barriers.
So, if a teen's only way of receiving mental health support
was with a school counselor, that relationship was no longer
there and they could no longer have that conversation about
mental health. And that in and of itself is destigmatizing the
stigma around mental health. And I just want to bring up, if a
teen feels like the only way they can express their emotions is
through the barrel of a gun, what have we become as a society
in our perception of mental health for young people?
And we really need to talk about mental health, and I think
that first starts with having this conversation and recognizing
how COVID exacerbated already existing disparities.
The Chairman. Trace, we had high expectations for you this
morning, and you went way over the bar. So, thank you so much.
And you are going to have a seat at the table as we go forward
on these big issues, and thank you.
Senator Crapo is next.
Senator Crapo. Thank you very much, Senator Wyden.
And I agree, Trace, with Senator Wyden's comments. I am
going to let you off the hot seat for a minute, though, and go
back to Dr. Hoover, and then to some of our other witnesses.
Dr. Hoover, for Idaho and other States with large rural
communities, the mental health-care delivery system looks
substantially different from other urban or suburban
populations. Even though the need for mental health services is
similar between rural and urban areas, it is harder for
children in rural areas to access those same mental health
services.
In your work with the States, can you elaborate on some of
the specific risks and challenges that younger Americans living
in rural areas might confront with regard to mental health?
And I ask this question in the context of, already you have
indicated that our schools, many of them, have good programs in
place, and that they are working well and need to be
strengthened and enhanced and given more tools.
But focus a little bit on rural areas. How are we doing
there? And what role do schools play in providing mental health
services to our youth?
Dr. Hoover. Thank you, Senator Crapo, for the question. And
frankly, school mental health is perhaps even more relevant and
important in our more rural communities, just because of the
workforce shortage, and also some of the stigma issues that
Trace just spoke to.
We know that, in rural communities, our young people and
families often have a harder time accessing services, as you
mentioned. And there often is more of a stigma associated with
seeking out mental health supports. We hear often--I was just
working with some rural counties in Maryland, and we often hear
``everybody knows each other,'' right? So seeking mental health
supports can be even more risky from a student perspective, or
even from a family perspective.
That being said, we know that schools can be a place where
mental health can be destigmatized. So it is one step, I would
say, that is critical in rural communities, and in all
communities, to really make mental health part of the education
that our young people experience.
So, we can establish mental health as part of the K through
12 curricula, and a number of States are doing that. I know New
York, Florida, Virginia, have led the way to infuse mental
health as part of what young people learn about. They learn
about how to achieve positive mental health, how to recognize
if there are some problems, and how to seek support when they
actually need support for themselves or for a family member or
a peer. So part of it, again, is reducing stigma, and that is
particularly critical in our rural settings.
I would say, in terms of the workforce, we know we have to
get workforce into our rural communities. And some of that will
require kind of reaching down into our high school, and
certainly our undergraduate training environments. I worked
with some groups in Nebraska that have done an excellent job of
really fostering the high school interest in mental health
specialties as they come into undergraduate and then graduate
training, but also really working with other providers in
schools, including our school nurses and other health
providers, and even our front-line educators, to do some task
shifting, to adopt some of the skills that they can equip young
people with.
We do not have to--we really simply cannot rely exclusively
on our specialty mental health providers, especially when we do
not have enough.
So those are some of the solutions that I look forward to
working with you on.
Senator Crapo. Well, thank you very much.
Let me move next to Ms. Lubarsky. I am not going to have
time to get to all the witnesses. I apologize. But we have lots
of questions, and we will give you some even after the hearing.
Ms. Lubarsky, your experiences can provide a deeper
understanding of the range of services provided across the
continuum of mental health care. One of the most common
concepts discussed in the stakeholder responses we have
received is the need for increased coordination and case
management to lead to better outcomes.
In your role as a community mental health leader, can you
explain exactly what ``targeted case management'' means in
practice when you are caring for the kids and their families?
Ms. Lubarsky. Yes. Thank you, Senator Crapo, for your
question. Targeted case management I really view as a
fundamental important service for every youth who is receiving
clinical services at a mental health center.
When we think about Maslow's hierarchy of needs and that
ability to meet your most basic needs in life, that is why we
utilize case management with our pediatric patients and their
families. If you cannot feel food secure, housing stable, able
to access your education in a meaningful way, and really be
able to be socially connected to your community in a manner so
that, when you are done with your mental health care, you are
moving to your supports in your community, then you are not
going to be able to reach that final goal, which may be your
therapeutic goal when you are coming in for mental health care.
So providers here at the center--for every youth who is
eligible for mental health services, they have the ability to
receive targeted case management as well. So we are doing that
very nice balance between providing the clinical mental health
care, while also looking at their needs outside of mental
health to make sure we are bringing those worlds together.
Senator Crapo. Well, thank you. And I will submit my
questions for the record to the other witnesses I did not get
to. Thank you to all of you for your testimonies.
[The questions appear in the appendix.]
The Chairman. Thank you, Senator Crapo. And as we said at
the outset, we are going to make this a bipartisan effort. This
is one of the most important undertakings the Finance Committee
has been part of, and we thank you for your leadership.
And also, to focus on bipartisanship, Senator Stabenow--who
for years has worked relentlessly to improve behavioral health
with our colleague, Senator Blunt of Missouri--is with us.
Senator Stabenow, your questions.
Senator Stabenow. Well, thank you, Mr. Chairman. I just
want to say ``thank you'' to you and ``thank you'' to Senator
Crapo. This is so important. Spending not one hearing but
multiple hearings on mental health is absolutely critical and
has not been done since I have been in the Senate, and I am
very grateful for all of your leadership.
And yes, this is an area of bipartisanship where we have
begun a process of changing to address health care above the
neck the same way we address health care below the neck--in the
funding and so on. We have models that work now, and we've just
got to move forward and get it done. And there is a lot more to
do.
And I want to also just give a shout-out to Trace. Thank
you so much. Thank you for coming forward and sharing your
experience, and for now being a part of really making a
difference in young people's lives. And part of overcoming the
stigma is all of us just telling our own story, the story of
someone in our own family, so that we are treating anxiety, or
mental illness, the same way we would if somebody was a
diabetic, or had a broken leg, a broken arm, that it is just
part of health care. And I hope we are going to work together
and we are all going to get there.
So let me--and by the way, I also wanted to say, Trace, in
your written testimony, I appreciate your mentioning both our
school-based health clinics, which I think are the model for us
in the school setting, and our Certified Community Behavioral
Health Clinics, which really are the model for quality,
comprehensive care in the community now that are fully funded,
where professionals are fully funded, so that we can move
forward.
So, Dr. Benton, I wanted to ask you particularly about that
point, because I appreciate all of our witnesses and their
wonderful testimony, but our Certified Community Behavioral
Health Clinics, which we now have demonstrated in 10 States,
are fully funded. What can happen--if we are funding behavioral
health like our FQHCs, our community health centers, with high
standards, full funding--is health care where we are seeing now
the difference that that can make. And we are working hard to
have this be the structure across the country really, which I
believe can really transform the services we are talking about.
But the CCBHCs, as we call them, really make help available
where children are. And we nearly have about 25 percent so far
of the community services being given to children. And there is
a lot more that we can do.
So I wonder if you might speak a little bit more--I know
you discussed this in your testimony, but highlight the
importance of these comprehensive community clinics,
particularly on under-served communities.
Dr. Benton. Thank you so much, Senator Stabenow, for that
question. The Certified Community Behavioral Health Clinics are
key components of the mental health continuum. And a
significant component of the problems we faced this year
related to those services being overwhelmed by the number of
patients and limited numbers of providers.
It is vitally important to address equity for all children
to have care in their communities where they are everyday that
is accessible to their families, that is culturally competent,
and integrates principles of cultural humility. And in academic
centers like the children's hospitals, we partner very strongly
with the community centers to expand access. And so we should
be able to provide and fill in the gaps where they exist in
those clinics.
So, for example, because the reimbursement is not always
what it should be, they tend to run with a lower number of
providers. And it is our responsibility in centers where there
are more resources to be able to provide that support to the
communities.
But without a strong partnership, we will never be able to
successfully address the concerns of young people in our
country.
Senator Stabenow. Absolutely. I totally agree. And we can
do this. We have done this on physical health, and so we
absolutely can do this.
I know my time is running out. The time is too short. I
have many questions I will submit. I did want to also just
indicate that I am excited to be leading the committee's
working group on workforce issues, which each of you have
raised and are so critically important. And I am working with
Senator Daines, my colleague, on this, and we will be reaching
out to each of you to ask for your further input.
So, thank you, Mr. Chairman.
[The questions appear in the appendix.]
The Chairman. Thank you, Senator Stabenow. I was about to
mention the good work that we know you are already beginning
with Senator Daines.
So our guests have an understanding of how we are going to
work, we have a Democrat and a Republican serving on each of
the key areas that we have to tackle. And because Senator
Stabenow's expertise in this area and her advocacy is so
important, I think we are especially lucky to have her handling
the workforce issue, which I think we have all heard people
mention repeatedly.
So, Senator Stabenow and Senator Daines are going to be
playing a key role, and we thank her for all of her leadership.
Senator Grassley is next. And we welcome him.
Senator Grassley. Thank you, Mr. Chairman.
I am going to lead into a question for Dr. Benton. In
September, the DEA issued its first Public Safety Alert since
2015. It warned of a significant nationwide surge in
counterfeit pills that are mass-produced by criminals in labs,
deceptively marketed as legitimate prescription drugs. These
counterfeit pills are killing unsuspecting Americans,
particularly young people, and at an unprecedented rate. Many
youth are getting illicit pills knowingly or unknowingly
through Snapchat or TikTok. This use of illicit drugs is driven
by mental health challenges, anxiety, suicidal thoughts, and is
resulting in accidental overdose deaths.
So, do you believe that kids dying of suicide or accidental
drug overdose is driven by mental health challenges?
Dr. Benton. Well, thank you for that question, Senator
Grassley. It is a complicated one. And so, definitely there are
increases in rates of mental health conditions that contribute
to suicide. But mental health conditions are not the only
factors that contribute to completed suicide, which is one of
the reasons it has been so difficult to prevent.
So, environmental factors, other things that you just
identified, exposure on the Internet, all kinds of unregulated
advertisements for young people, all contribute to those
challenges.
I also want to call out something else that you were
highlighting with your question, which is that the focus on
medications and the focus on pill treatments for young people
with mental health conditions discounts the fact that most
young people actually need psychosocial intervention.
So there are multiple environmental factors, psychosocial
factors, and other treatment factors that we need to consider
when thinking about treatment--not just emphasizing
pharmacologic treatments that are available, which I think
would diminish some of the focus on young people obtaining
medications.
Senator Grassley. I am going to go on to another subject,
Dr. Benton. In your written testimony you mentioned the
importance of patient-centered medical homes for kids to
improve access. In 2019 we passed the bipartisan ACE Kids Act
establishing pediatric home health for kids with complex
medical conditions.
Last fall, the Centers for Medicare and Medicaid Services
issued guidance for ACE kids and is working with Medicaid
programs in the same way.
For you, Dr. Benton: is access to out-of-State providers a
challenge for kids with complex medical needs? And let me
follow it up with what might be my last question. For kids with
these needs, what does coordinated mental and physical health
care look like? And describe medical home.
Dr. Benton. Thank you, Senator Grassley, for your
leadership in this area. So for patients, the medical home has
provided significant support for young people with complex
medical conditions. But we still have work to do in the area of
integrating the medical and mental health benefits and
treatments.
And so, for the patients in our medical home, we do better
at providing mental health support for young people, but we
still face challenges around parity for mental health and
medical services.
So, within our own institutions, when young people come to
us locally or from out of State, frequently the medical benefit
is accepted and easily accessible, but when those same
youngsters need mental health treatment, they frequently find
themselves in a situation where they are being billed for a
service that is out of network, or they are not paid at all.
And it poses significant challenges for families who deserve
the care that their child needs, but the parity issues remain
barriers.
We have made significant progress, and I look forward to
your continued work in this area in leading us through these
complex co-morbid conditions. We have made progress, but we
still have more work to do.
Senator Grassley. For Mr. Terrell, you will have to give a
short answer to this because my time is up, but what efforts
should be taken to address unique rural mental health needs?
Mr. Terrell. Like I said, access to care is super
important. And I really appreciate this question, just because
I think that you have had so much stewardship and insight about
this issue. So I think if we can really bring--personally, I
live in a rural community, and what I think would be really
helpful would be to bring care to where people are. And that
means funding school-based health centers, CCBHCs, and other
community-based mental health supports that really help teens
to just get the support that they need.
It is easier to be on a school campus and get medical
services than it is to be at home, have to coordinate
transportation, and get there, which is a barrier that so many
teens in rural communities face.
Senator Grassley. Thank you.
Thank you, Mr. Chairman. I will submit questions in
writing.
[The questions appear in the appendix.]
The Chairman. Very good.
Senator Cantwell is next, our Northwest partner.
[No response.]
The Chairman. Senator Cantwell, are you on line?
[No response.]
The Chairman. I will give this just a quick moment, because
I think she is.
[Pause.]
The Chairman. Senator Thune would be after Senator
Cantwell.
[No response.]
The Chairman. Senator Menendez?
[No response.]
The Chairman. Senator Portman?
[No response.]
The Chairman. Senator Carper?
[No response.]
The Chairman. And for our guests, you should know that this
is a particularly hectic day in the Senate, so members are
going to be coming in and out.
Senator Carper?
[No response.]
The Chairman. Senator Cassidy is here. Senator Cassidy is a
very valued member, with his expertise on health care as a
physician. Senator Cassidy?
Senator Cassidy. Thank you very much for that. By the way,
I thought I had 15 or 20 more minutes to listen, and everybody
else is out. So, anyway, thanks for doing that.
Dr. Hoover, I used to work with a school-based clinic to do
hepatitis B immunization, and I am very aware of how well they
can function bringing care.
Now first, I think we have to acknowledge that if the child
is not in school, it is difficult for the child to be
evaluated. But that said, now kids are back in school, so there
is some progress there. But let me ask--and you may have
covered this while I was in another committee hearing.
Now my understanding is that the schools and the school
systems would benefit when CMS gives them updated guidance as
to the possibility of providing these services in that venue.
Any comments on that, Dr. Hoover?
Dr. Hoover. That is exactly right, Senator Cassidy. And I
appreciate the question. And you are correct that it is easier
to get the school-based care to young people when they are
actually in schools.
And one of the things that we are hoping Congress can
support is really urging CMS to modernize the existing school
guidance for Medicaid in schools. This guidance has not been
updated since 2003, and it is critical for State education and
State Medicaid agencies to work together to actually be able to
support and resource mental health providers.
Senator Cassidy. Let me ask you--I have limited time--what
is the problem with the current guidance, or lack thereof, that
limits the ability to expand mental health services through the
school-based clinics?
Dr. Hoover. So just quickly, a lot of States do not want to
move forward with implementing the current Medicaid-supported
mental health services in schools. They are worried. They are
hesitant that expanding their programs may put them at audit
risk. The guidance really is not updated to reflect
improvements in telehealth. It is not updated to reflect the
free care policy reversal in 2014. So there are a number of
updates to Medicaid that would need to be reflected in this
guidance for States to feel comfortable moving forward.
Senator Cassidy. And specifically, you mentioned tele-
mental health. I am really struck. If you look at adolescent
psychiatrists in my State, they are in the cities. They are not
in the rural areas.
So one, the infrastructure bill expands Internet services
throughout the State. That will be huge. But secondly, you have
to get the adolescent psych who is in Shreveport to be able to
communicate to the child who might be in Winn Parish. You do
not know the geography of my State, but it is urban to rural.
What impediments right now does the rule give as regards the
utilization of that tele-mental health?
Dr. Hoover. So as you know, during COVID we saw a huge
expansion of telehealth. And we know that providers and
families need guidance and technical support to actually use
the telehealth equipment. But more important than that, we need
to see the continued expansion of reimbursement and policies
that support teleproviders to be able to not only provide
services within their communities, but even across State lines
as necessary, to address some of the workforce shortages.
Senator Cassidy. Now, if you gave advice to this
committee--because we have jurisdiction over Medicare,
Medicaid, CMS--one thing is to urge CMS to update this
guidance. And again, is there any single point--you are talking
to Senators Wyden and Crapo right now [laughter]. They are the
straws that stir the drinks of Medicaid, Medicare, and CMS. So,
if you had to kind of just sit down and pound your hand on the
table, what would you say to our chair and ranking member that
we have to get done before we move on?
Dr. Hoover. Absolutely I would say that Congress should
encourage all States to cover all medically necessary mental
health services, including prevention services for all
Medicaid-enrolled students, and simultaneously ensure that
school Medicaid programs have the updated guidance, best
practices, and technical assistance that they need.
Senator Cassidy. Mr. Terrell, can you just put the dot on
the ``I'' as regards the importance of school-based clinics
with regard to the provision of mental health?
Mr. Terrell. Of course; yes. Like I said, this is a great
question, because I think it is so relevant. And when the teens
are able to get care where they are, it just encourages health-
seeking behaviors. It promotes developing systems of self-care.
And it really promotes general health and well-being outcomes.
I think the fact that teens are sometimes able to just walk
over to a medical clinic and get the help that they need is so
essential, especially if they are not able to at home and they
do not have reliable Internet access. So when we concentrate
our efforts on schools, it is really important to make sure
that we build these natural partnerships and kind of leverage
the power within those.
Senator Cassidy. I would just add to that, from my
experience working with school-based clinics, sometimes there
are issues which should not be--for example, abuse by a parent,
which can be discussed in the safe setting of a school-based
clinic with a licensed health-care provider. And so it also,
frankly, helps the business model of the school-based clinic.
In some States they have a very difficult time keeping their
doors open, so that they cannot provide a needed service that
actually benefits.
With that, I yield back, Mr. Chair.
The Chairman. Thank you, Senator Cassidy.
And for our guests, Senator Cassidy and Senator Carper are
going to be leading the task force on young people, so they are
going to be invaluable on the issue we are dealing with.
We now have an order of Senator Cantwell, Senator Thune,
and Senator Menendez. And members have been coming in and out.
Senator Cantwell is next in the order.
Senator Cantwell. Thank you, Mr. Chairman.
And continuing on that same theme of young people, Ms.
Lubarsky, the Surgeon General's December advisory on mental
health stated that one in three high school students and half
of the female students reported persistent feelings of sadness
and hopelessness during the COVID pandemic.
So we already know what our challenges are. The Washington
Hospital Association reported that, during the past 2 years,
major depression disorders are leading youth inpatient
diagnoses in my State. So, when it comes to seeking treatment,
not everybody gets a fair shot at that. The number on
individuals with lower incomes is that they are nearly 20
percent higher than the rate for those people with higher
incomes. So affordability is a factor.
I know my colleague, Senator Stabenow, had a chance to ask
questions earlier, but I am very supportive of her Certified
Community Behavioral Health Clinics. These have been great
programs.
There are five community clinics in my State that serve
low-
income populations. And this grant over the past 2 years has
been used to enhance the care of those experiencing mental
illness. So we really are building capacity. Clinics like
Comprehensive Health Care in Yakima were used for innovative
purposes, creating a program to offer mental health first aid
training, critical incident stress debriefings, and helping to
receive support.
So do you think that these programs such as the Certified
Community Behavioral Health Clinics and their grants have been
helpful in reducing the barriers for treatment of youth and
families, particularly in some of our less accessible areas in
more rural parts of the United States? And should Congress
consider expanding these programs to address disparity in
access? And what would you prioritize within that system?
Ms. Lubarsky. Senator, thank you very much for your
question. I am so pleased that you mentioned mental health
first aid. As a youth mental health first aid instructor, I
think it is also a vital component of our prevention efforts in
youth mental health.
In regards to the CCBHCs and other health-care facilities,
I think they are one of many ways that we reduce the barriers
to accessing mental health care for our pediatric population.
There really is no one-size-fits-all for the right delivery
model. And so, where some youth and their families are
comfortable coming into an outpatient clinic, because of the
stigma that is often attached with mental health services, I
think having the ability to access your mental health care at a
community health center, at a pediatric office, at your school
setting, or through a telehealth device, is crucial to make
sure that we have mental health care accessible to everybody.
In our community, it may be hard for some of our families
who lack adequate transportation to get to our offices. Yet one
of our federally funded health-care facilities is on the bus
line. And so, we worked in partnership with the health-care
facility to have mental health staff there so if that is the
only means of using public transportation to get to the
appointment, families can still access their health care. So I
think it is critical.
Senator Cantwell. And what about this issue that you bring
up of integrated health care--so, you know, treating mental
health and other physical health in the same location? Because
most times people come with both issues, or things that
exacerbate one or the other, like you said. So there is less
stigmatization in treating the whole person.
Ms. Lubarsky. Absolutely. It is critical, because I really
do think physical health and mental health occur together. And
when our mental health is not doing well, we will see a
decompensation in our physical health system, whether that is
poor sleep, poor diet, isolating from others, not engaging in
physical activities that can promote good mental wellness. So
we really do have to bring the physical and mental health
worlds together for the whole self.
Senator Cantwell. Well, thank you. Is there anything you
would prioritize in the improvement of that program if we had
more dollars for the certified program?
Ms. Lubarsky. I think, as I spoke to in my verbal
statement, it is really around those reimbursement rates, and
making sure that we are reimbursing centers, individuals,
organizations in a meaningful way to sustain the workforce in
order to deliver the crucial care.
Senator Cantwell. Okay; great.
Thank you, Mr. Chairman.
The Chairman. Thank you, Senator Cantwell. The Northwest is
going to be very united in this effort, and I look forward to
working with you.
I believe Senator Menendez will be next. Senator Menendez,
are you out there online?
[No response.]
The Chairman. We may have lost Senator Menendez. Senator
Menendez?
[No response.]
The Chairman. Senator Portman is next then.
Senator Portman. Thank you, Mr. Chairman.
I appreciate the testimony and the fact that you all are in
the trenches every day doing great work with our young people.
Dr. Hoover, you talked about telehealth, and I just want to
be sure that we are also focused on the broader behavioral
health, and specifically substance abuse. It seems to me that
telehealth is one of the few silver linings in an otherwise
dark cloud of COVID, and with regard to substance abuse
treatment, that there has been some real improvements. Would
you agree with that?
Dr. Hoover. I would agree with that. I mean, certainly the
opioid crisis has brought attention to that, and it has been
exacerbated during COVID. So the funding provided by the
Federal Government to States and communities to support the
opioid crisis has been tremendous, and certainly there has been
an improvement in care. Tele-mental health has improved that as
well.
Senator Portman. This is why we have to continue the
reimbursement under Medicare and Medicaid--and Medicaid
particularly--for substance abuse, at a time when we had
100,000 drug overdose deaths in the period from April of last
year to April of this year; so, during 1 year, a record level.
That was a 28\1/2\-percent increase in overdose deaths. That is
really heartbreaking, because we had made great progress in
2018 and 2019.
Now we are, unfortunately, seeing more and more people
dying of overdose deaths. The report we have about young
people--because that is the topic today--shows that we have
seen an increase of anywhere from three times higher number of
overdose deaths to thirteen times higher in 2021 compared to
the numbers we had from 2019--and by the way, dramatic
increases among Black youth in terms of overdoses that are
particularly concerning.
Our State has done a report. It recently looked at it from
a different perspective. They said how many years have been
lost. So their analysis is that, beyond the numbers we already
know, the loss of years lived for more than 21,000 young people
who died from overdoses show that adolescents and teenagers 10
to 19 lost, cumulatively, 200,000 years of life. And when they
expanded the study to include 10- to 24-year-olds, it grew to
more than 1 million years lost.
So it is a shocking way to look at it, but think of all
that lost potential, and all that God-given potential being
ruined. So this is a huge reason why we need to figure out, as
a Congress, how to get back on this issue. And deadly fentanyl
is killing, we think, about two-thirds of these kids. So this
is synthetic opioids streaming across the border.
We have done a lot more in terms of the prevention side and
the treatment and recovery side, but obviously not enough. And
what we see in Ohio is that this deadly fentanyl is often
masked as other substances. So it looks like a pain medication,
or an anti-anxiety medication, or an ADHD medication, and we
have had parents approach me in Ohio and talk to me about this
issue because they believe that their son or daughter died of
an unintentional overdose by being deceived about what was in a
pill.
So, Dr. Hoover, talk to us a little about that. And anybody
else can jump in. What do you think the reasons are for this
big jump in overdose deaths? And how much of it do you think is
attributable to these cartels putting fentanyl into other
medications?
Dr. Hoover. Well, to jump in quickly and defer to Dr.
Benton on the impact of drugs and the medical side of that,
certainly in terms of the co-morbid mental health issues, we
know that the substance abuse issues we are seeing increasing
in young people are likely very related to their increase in
depression, anxiety, and post-
traumatic stress.
Not only were we seeing increases in that pre-pandemic, but
we are seeing real exponential growth in that in the context of
COVID. So we know when that happens, we see increases in
substance use, and so it is not surprising when you get those
really tragic numbers.
I will defer my time over to Dr. Benton with respect----
Senator Portman. You are talking about self-medication
because of other behavioral health and mental health
challenges?
Dr. Hoover. That is a piece of it, absolutely, that self-
medication to address anxiety, depression, trauma, and just to
really cope with the isolation and loneliness that our children
have experienced over the last couple of years.
Senator Portman. Dr. Benton, can you talk a little about
the synthetic opioid issue of the fentanyl getting into other
medications?
Dr. Benton. So what I can say is that we are seeing
increases in utilization across the country. And unfortunately,
I have to say that in many mental health programs, there is not
the robust substance use and addiction treatments that we would
like to see. And a major focus of expansion of resources in
treatment for young people needs to focus on increasing the
integration of substance use and mental health treatment
services.
We know that for young people with any mental health
condition, the co-morbid use of substances only makes the
outcomes worse. And the substance use is associated with worse
outcomes, including suicide and other impulsive behaviors that
land young people in bad situations.
And so, that has to be a focus. Right now, they run almost
as two separate systems in some ways. And that really needs to
be a focus of our efforts going forward if we are going to
address the substance-related morbidities that we are seeing
right now.
Senator Portman. Okay.
I think my time has expired, but, Trace, I would love to
hear from you on this, if we can have a minute, Mr. Chairman,
if Trace has any thoughts.
Mr. Terrell. Yes, I would love to. Thank you, Senator. I
think when we talk about all these statistics, it is really
alarming. But I also think that there is a beacon of hope.
Since YouthLine's inception, we have experienced an annual
increase in contact volume of about 15 percent annually, with
an additional increase of 3 to 5 percent since the COVID-19
pandemic.
And obviously, while that proves that there is a need for
mental health care, there are also so many teens reaching out
for help. And I think that that is really inspiring, and I
think it shows the resilience of teens in regard to mental
health challenges and substance use challenges. And so I think,
if we can really ensure that the people reaching out for help
are able to receive help, we will get really far on this issue.
Senator Portman. Thank you, Mr. Chairman.
The Chairman. Thank you, Trace.
Next is Senator Menendez.
Senator Menendez. Well, thank you, Mr. Chairman.
Across the Congress, we all talk about the provider
shortages the Nation is facing, especially mental health
providers who are available for Black and Latino communities.
And the pandemic has taken a disproportionate toll on minority
communities, and the provider shortage has only grown more
dire.
More dedicated support for a larger and more diverse
pediatric workforce is critical, I believe, to address
children's mental health needs now and into the future.
So, Dr. Benton, what are three things this committee can do
to address the recruitment, training, retention, and
professional development of a diverse clinical and nonclinical
pediatric mental health workforce?
Dr. Benton. Thank you for that question, Senator.
It is one of the issues that I struggle with every day as a
training director and as a physician. One of the things that we
could do now is developing pipelines at a much younger age.
So, in my testimony I mention the 5th graders interviewing
me. They were interviewing me about why did I become a child
psychiatrist? And I was really pleased that they were asking
these kind of questions in 5th grade. So starting a pipeline
where we are present and we are reaching out to communities of
color is really important.
Education and destigmatizing mental health conditions in
the Black community, and the Latino community, by partnering
with trusted community organizations--loan repayment is an
incredible issue. Many of my physicians say, ``I cannot afford
to work for you because I have loans to repay, and you don't
pay enough.''
And so loan repayment for all the mental health
professionals, I think is important. And incentives for people
to choose mental health could be part of loan repayment--or
some other payment measure would be really helpful. And then
reaching into the communities where minority populations are
would be extremely important.
So we tend to recruit from communities that are affiliated
with academic centers, and we do not reach into the communities
where patients are actually receiving services.
Those are some of the things that we could do now to
support diversification of our workforce.
Senator Menendez. Well, I appreciate those insights. And we
may reach out to you to build upon them as we explore the
initiatives here.
And part of the reason I raise this--I look at the first
half of 2021 alone. Children's hospitals reported cases of
self-injury and suicide in ages 5 to 17 at a 45-percent higher
rate than during the same time frame in 2019. And for children
under 13, the suicide rate is twice that for Black children
than for White children.
So what can we do to reduce the likelihood of suicide in
children and adolescents, particularly minorities? And how do
we better target our resources?
Dr. Benton. Senator Menendez, this is one of my areas of
passion. So among minoritized youths across ethnic groups, the
rates of suicide attempts are higher than they are among non-
minority groups. And one of the challenges has been
identification among minoritized youth and access to services
that are culturally competent and/or a demonstration of
cultural humility.
The data demonstrates pretty strongly that culturally
concordant therapists and patients have better retention and
treatment, and better outcomes in treatment over time. And
certainly it will never be the case that we will have one-to-
one matching for patients by ethnic group, nor am I sure that
is the goal, but the goal is, for groups where there is not
concordance between the patient and the therapist, that there
be cultural humility, that we train individuals to learn to
inquire and understand the cultural experiences of others when
we are engaged in treatment.
And so the training opportunity is there. But it is
essential because we are seeing, for youth across each ethnic
group, increasing rates of suicide, while they are declining
for non-minoritized populations. So it is vitally important.
Senator Menendez. And finally, about roughly 17,000 3- and
4-year-olds are expelled from their preschools each year. And
despite Black children making up only about 18 percent of the
school population, they make up 40 percent of all expelled
children. And even more troubling is that, within the high rate
of expulsion for Black toddlers, how often Black boys are
expelled.
So how can we better support training for pre-K teachers
and child-care providers in basic behavioral health techniques
to combat bias and give these important social and emotional
regulation tools to children from their earliest ages? And I am
happy to entertain anybody who can answer that.
Dr. Benton. Well, thank you. Thank you, Senator Menendez. I
would hope that Dr. Hoover would respond as well.
Prevention and education are key. Addressing bias among
school personnel is essential to address this--and providing
more resource supports in centers where children appear every
day in day care, and in primary care, with some preventive
education around what is normal and abnormal development.
I am sorry, Dr. Hoover; I wanted to give you an opportunity
to comment.
Dr. Hoover. Not at all. I know the time is short, and I
will just quickly add that investment in early childhood mental
health consultation programs across States is critical--and as
you alluded to, culturally responsive teaching practices. There
is a lot of evidence to suggest that those can help in reducing
discipline referrals and expulsions.
Senator Menendez. Thank you all.
The Chairman. Thank you, Senator Menendez.
Senator Cardin is next.
Senator Cardin. Thank you, Mr. Chairman. And let me thank
all of our witnesses. I think this panel has been extremely
helpful. This is an area, as you can tell by the questions,
where you do not know who the Democrats or the Republicans are
on the committee. We have a mutual desire to try to get this
right, and we recognize we have a real challenge in mental
health in this country, but particularly with our youth with
the experiences of COVID-19. We know that we have a greater
challenge than ever before.
So I want to talk about the school setting for one moment,
what we can do. I am responsible--as one of the co-chairs of
the groups that Senator Wyden has been talking about--to deal
with telehealth, and I am curious.
You have all talked about the importance of expanding
telehealth, but what are the challenges within the school
setting of expanding telehealth services? Where do we need to
try to put our attention, either change in policy or resources,
in order to expand the productive use of telehealth in the
school setting?
Either Dr. Hoover, or whoever would like to respond to
that. Perhaps start with Dr. Hoover.
Dr. Hoover. I am happy to jump in. Thank you, Senator
Cardin, for your leadership on this issue of mental health
across the Nation, and specifically in the area of parity and
tele-mental health.
We know tele-mental health has actually been in the schools
for years. Our child psychiatrists were delivering tele-mental
health across schools in Maryland and in Baltimore City back
when I was delivering services in the early 2000s.
We know that there are continued infrastructure
improvements that are necessary to improve tele-mental health
services in schools, and that would include enhanced broadband
systems, up-to-date telehealth delivery equipment, Internet
connectivity services, especially to some of our rural
communities. We know that policy expansion is important,
including reimbursement parity for tele-mental health and
expanded access to Medicaid and children's health insurance
telehealth programs.
So there are a number of areas that we have seen
improvements in during COVID that we need to continue and to
expand. And that applies to physical health as well.
Senator Cardin. If I could get either your view or Dr.
Benton's view, we have made a lot of resources available to our
school systems in response to COVID. Have they been used to
expand the connectivity that you are talking about for mental
health services?
Dr. Hoover. Some have, and again I am happy to defer to Dr.
Benton here as well, but some have. One of the things we know,
though, is that some of the COVID-related funding, for example,
is creating kind of a one-and-done, or some hiring--you know,
short-term hiring fixes. But we know that it is critical to
make some of these Medicaid policy adjustments so that we can
allow for sustainable funding for telehealth and other mental
health services.
Dr. Benton?
Dr. Benton. Yes, I would concur with Dr. Hoover. I think
many of the systems have used the resources well, but many of
them were under-staffed before the pandemic and did not have
access to adequate resources.
They have reached out for telehealth, but there are a
variety of factors that impact their ability to optimize its
use. One of them is the privacy standard. So communications
between mental health providers and schools, through HIPAA and
FERPA, are issues that really need to be addressed in
communicating about mental health concerns.
Some schools may have one or two school counselors, but not
necessarily access to a provider team of psychiatrists that can
partner with the schools, as Dr. Hoover described, to provide
that additional level of care that is not necessarily available
in the schools.
And then in addition to that, you know, we do need to think
about our care models very differently. So, for example, there
are services that are cheaper to set up that are available
right now, such as school-based crisis services, so when a
school is under-resourced and there is a crisis, it is very
possible to send someone to that school to see that youngster
on site with the family, or urgent cares that are on-site at
schools.
So there are some other things that we could do to support
our schools. So I thank you for your leadership in supporting
the schools through the pandemic. We should retain those
things, and there are other things that we could do to expand
them.
Senator Cardin. So, Dr. Benton, you talked about the need
to have improved screening in regards to mental health for our
students. Can telehealth be helpful in dealing with screening,
recognizing that you need personnel in the school itself? But
can that be better utilized than we are using it today for
screening?
Dr. Benton. Yes, Senator. That is an excellent
recommendation. And yes, it would be very helpful. One of the
challenges for schools is they screen, and then they cannot
respond. And so, having telehealth allows them to screen
youngsters for problems or challenges before they become major
problems. And telehealth can be used to address some of the
more acute things on site.
Currently, screening is not viewed enthusiastically
because, if you find something, you cannot do anything about
it. The utilization of telehealth to connect with a crisis
provider would allow the school to be able to respond in a safe
and effective way.
Senator Cardin. Thank you, Mr. Chairman. I appreciate it.
The Chairman. Thank you, Senator Cardin, and we appreciate
your leadership on these issues as well.
Next I believe--Senator Lankford, are you out there?
[No response.]
The Chairman. Senator Brown?
[No response.]
The Chairman. Senator Barrasso, and then Senator Bennet.
Senator Barrasso. Well, thanks, Mr. Chairman.
First I want to congratulate and compliment you on your
opening statement. I thought you really hit the point on the
head in terms of how long this is often brewing before we know
of the problems. I am an orthopedic surgeon, and I have worked
with many people as president of the Wyoming State Medical
Society. I think you were absolutely right in the comments that
you made.
But being from Wyoming, rural health is a big issue for us.
And Senator Crapo started by talking about that. And then
telehealth is something we have used from a mental health
standpoint long before the pandemic. I think the pandemic has
brought mental health, as well as other kinds of health care,
to the fore in terms of the ability to try to use telehealth
much more productively. I think we are, hopefully, fast-
forwarding, as Senator Cardin was just saying, the acceptance
of telehealth.
My question is about trying to just get enough providers on
site in rural America, which is what Senator Crapo talked
about. So, for Dr. Benton and Dr. Hoover and Ms. Lubarsky--you
know, when I was in the State Senate in Wyoming, we were very
blessed with additional revenue that we were not expecting, but
we had it. And the commitment we made was to mental health.
So we put in a lot of financial resources and made a
deliberate effort to train, to recruit, and to attract more
mental health providers to Wyoming. But in spite of our best
efforts, Wyoming and other rural States that have tried to make
those similar commitments continue to face huge shortages of
all types of mental health providers.
So the money was there, and we still had the challenge. So,
can you discuss some solutions related specifically to
workforce development that you believe may help improve our
ability to attract and maintain staff into rural and sometimes
remote areas?
Ms. Lubarsky. If I may--and I think it is a great question,
Senator. I think one of the challenges that occurs within our
State of New Hampshire is some of the licensure requirements
for professionals.
We have a lot of silos with our Board of Mental Health
Practice about who is allowed to provide licensure supervision
for an individual who comes from their master's degree program.
And that at times creates the barriers to who we are able to
hire. Because, if we have to have a specific credentialed
professional to provide supervision to that same category of
professionals, and we do not have them employed at our center,
then that candidate no longer looks at us as a place that they
want to be employed at.
I have talked to colleagues across our State who have lost
employees who went to other States because, not only could they
make a higher income, but they needed to get the licensure
supervision from a particular person. So I think we need to
make licensure requirements create more flexibility on who can
provide that supervision in order to attract the staff that are
needed to provide the care.
Senator Barrasso. Anyone else?
Dr. Benton. I was----
Senator Barrasso. Yes, go right ahead. No, please.
Dr. Benton. I was going to say, I would echo your comments.
Telehealth also adds another opportunity, and it is for
training remotely. And so, for areas where there is a shortage
of providers, we have been able to partner using telehealth to
expand skills and to train people.
You know, thinking about Ms. Lubarsky's comments about task
shifting, it is an excellent opportunity for us to provide
skills for master's-level clinicians, clinicians who need
supervision and may be in another State, for backup
consultation across counties. But also, by allowing us to
continue with licensure across State lines, we can actually
also provide support for clinicians in those areas.
I also just want to mention, a quick win is really
educating the people that we already have. So the
pediatricians, the nurse practitioners, other mental health
clinicians, master's-level people, peer navigators like Trace--
all of those resources in communities can be utilized to
support individuals.
We have programs where we are teaching grandmothers to do
cognitive behavioral therapy for their anxious grandchildren.
And so I think, thinking about how we provide care differently
could provide us more opportunities for mental health support.
Senator Barrasso. Well, thank you, Dr. Benton.
And to Ms. Lubarsky, to your point of the--actually, I am
working with Senator Smith; it is a bipartisan bill on marriage
counselors who do some mental health work as well. And they are
not able to be reimbursed through Medicare, and different
Federal issues too where they provide health care but--so it is
the siloing by State, but also the Federal Government sometimes
gets in the way as well.
And then--I know I am running out of time. You know, we
have a commitment in my family to working with families who
have lost someone to suicide, what we can do along those lines.
We are continuing to look, not just to raise awareness, but for
best practices.
And, Dr. Benton, I see you are shaking your head ``yes'' on
this. It is a big issue for all of us. So I do not know if you
have some final thoughts on that.
Dr. Benton. Yes, thank you, Senator, for that question. So,
in addition to the suicides, you know that over 160,000 young
people have lost parents to COVID. And of course, the threat is
always not just grief, but traumatic grief. And we are not
ready for it.
Fortunately, there are quite a few support services
available to families who have lost family members to suicide,
and for those who are suicide survivors. So the American
Foundation for Suicide Prevention is a resource for all
families that provides a lot of support and information
nationally for families who have experienced that loss.
But we have to pay particular attention to those
populations who have experienced traumatic grief, because
traumatic grief is more closely associated with the onset of
depression. And in order to be preventive, we need to develop
early interventions and support for youngsters who have lost
their parents during COVID, and for individuals who have lost
their families to events like suicide and homicide.
So, thank you for that.
Senator Barrasso. Thank you for that.
Thank you, Mr. Chairman.
The Chairman. Thank you, Senator Barrasso. And we are very
much going to focus on the best practices that you mentioned.
It is a very solid way forward.
We are having colleagues come and go. So we are going to
have Senator Thune, Senator Bennet, and Senator Lankford, and
we are going to lock in those three, okay?
Senator Thune?
Senator Thune. Thank you, Mr. Chairman and Senator Crapo,
and I appreciate your continued focus on youth mental health,
and I appreciate the panel for joining us today.
As I discussed last week, when I talk to parents, teachers,
and school administrators across South Dakota, addressing the
behavioral health needs of students is a big priority.
Dr. Hoover, in your testimony you mentioned that we need to
be looking for more formal partnerships with community
behavioral health providers. We have multiple cooperatives in
place in my State where schools are in close enough proximity
to share a provider, but in some circumstances distance is a
barrier.
Do you know of instances where the partnerships you
referred to have been formed using telehealth, or a combination
of in-person and telehealth services? And what are the biggest
barriers that schools or school boards encounter in forming
these types of partnerships?
Dr. Hoover. Thank you for the question, Senator Thune.
Absolutely. We have seen, actually, tremendous partnerships
that rely almost exclusively on telehealth, especially for some
of our rural communities. Some of the best examples started in
South Carolina several years back, where they have the Medical
University of South Carolina providing telehealth services to
schools across some of their most rural districts in South
Carolina.
So we have seen these community behavioral health
partnerships with schools through kind of the standard
memorandum of understanding with schools and community
behavioral health, where sometimes they will do some onsite
supports, but really much of the service that is provided is
through telehealth.
As we mentioned earlier, some of the real barriers to that
are reimbursement. Sometimes schools are not allowable as sites
of service, and certain provider types are not allowable, which
really does require taking a look at State Medicaid plans and
thinking about how to expand school health programs under
school Medicaid--and certainly just a lack of awareness of some
of the guidelines for how you can set up these partnerships and
get reimbursed and supported.
Senator Thune. Thank you.
Doctors Benton and Hoover--and Dr. Benton, if you want to
take this first--youth mental health in Indian Country has been
a significant challenge for some time now. Some of the stories
are heartbreaking. There was a 2017 Department of Education
report that confirmed that kids in public schools on the
reservations have a greater risk of behavioral health
challenges, including increased risks of suicide.
Do you have suggestions for how this committee can help
improve access to culturally appropriate care on the
reservations, especially how we could grow the workforce there,
which is a challenge? Finding providers, recruiting, and then
being able to retain providers in Tribal communities has really
been a challenge.
Dr. Benton. Well, thank you, Senator, for that question.
And we too struggle with the challenges that you identified.
The Certified Community Behavioral Health Clinics are an
excellent way to attract clinicians of diverse backgrounds.
Clinicians like myself of diverse background tend to focus on
supporting populations that are similar. And so, the chances of
working in your community are greater if you are a member of
the community.
How do we increase providers in those communities? By
targeting the communities who need the treatment, identifying
individuals in those areas, and providing the support needed.
So many of the challenges for minority populations relate
to finances: high student loan burdens, low support for strong
academics in the community. Those are all areas where we would
be able to support education, increase interest, and support
individuals who would go on to get education in those areas.
And some of our focus could be on supporting them in their
communities. So many times in academia, we are all familiar
with the idea that we recruit people away from their
communities, as opposed to providing resources in that
community to educate young people through their high schools,
the community colleges, training programs, and then
diversifying opportunities for support.
So, in line with Dr. Hoover's comments about task shifting,
it is teaching people to provide services at the bachelor's
level, or other levels that would allow them to expand support
for care in their communities.
Senator Thune. Thanks.
Dr. Hoover. To piggyback on that, in addition to recruiting
members within communities and retaining them in their
communities to support their communities, also investing in
technical assistance and training centers and resources within
their communities. A great example of that is the National
American Indian and Alaska Native Mental Health Technology
Transfer Center, which is funded as part of the Substance Abuse
and Mental Health Services Administration.
And then I will just also add, really expanding the Federal
workforce development programs that we have already mentioned,
including loan repayments, but also things like the Minority
Fellowship Program, the National Health Service Corps, can
really help in this regard.
Dr. Benton. And I would add to that some of our national
organizations that support children's mental health, like the
American Academy of Child and Adolescent Psychiatry. All those
programs actually have minority-focused fellowships to support
the development of other mental health professionals. And
partnering with the HBCUs for Black families, for programs and
educational systems that primarily serve Hispanic and Native
American youth, would be places that we would be able to
support development of professionals who remain in those
communities.
Senator Thune. Thank you, both.
Mr. Chairman, my time has expired. Thank you.
The Chairman. Thank you.
Senator Bennet is next.
Senator Bennet. Thank you very much, Mr. Chairman. Can you
hear me?
The Chairman. We can.
Senator Bennet. Great. I really appreciate you and the
ranking member for continuing this series of hearings on mental
and behavioral health for youth. We are having a crisis in
Colorado. In fact, Colorado's Children's Hospital was the first
hospital in the country, I think, to declare a state of
emergency in mental health for youth.
So I want to thank the witnesses for being here to testify,
and I am particularly grateful for having Mr. Terrell here
advocating on behalf of his peers and his generation.
I have a second question for him, but let me start first
with this on reimbursement and prevention. Last week the
Surgeon General was here, and I raised the importance of
reimbursement for mental and behavioral health services,
something our committee has jurisdiction over, through CMS. And
while I was going through your testimony, the common theme was
that we need improved reimbursement for services across the
continuum of care, and meeting youth where they are. And I
wholeheartedly agree with this.
So I would ask Dr. Benton, first maybe, what kind of
services should be reimbursed by Medicare or Medicaid or
private payers that are not usually covered? And what services
need increased reimbursement? Can you highlight where you
believe reimbursement parity is failing the American people?
Dr. Benton, let's start with you and anybody else who would
like to add after that.
Dr. Benton. Well, thank you. Thank you, Senator, for that
question. So currently, most of the early childhood services
are not reimbursed. So there are services that are required in
the medical and mental health setting that are comprehensive
services that should start from birth through adulthood. But
services that do not necessarily have a psychiatric diagnosis
attached are frequently not reimbursed.
So, for example, if a mother who was having difficulties
attaching or parenting her newborn, those services are not
necessarily reimbursed by traditional mental health providers.
Furthermore, for pediatricians--who are typically the best
people to identify early childhood problems, because children
have frequent visits in the first year of life--they are not
reimbursed for the time it takes to provide the level of
counseling that is needed for new parents who have new infants.
And so, if we target it, the reimbursement for those
services, the pediatricians would be allowed to do their jobs.
The nurse practitioners could do their jobs. People who are
working with young children could do their jobs. And for young
children who are not yet impaired by a mental health condition,
preventive services would allow families to seek that care in
appropriate facilities, and reimbursement could occur at the
same time.
So I think that early childhood services currently are
under-
reimbursed for the ones that are available. And for children
who do not necessarily have a mental health condition already,
they are not able to seek the services they need and get the
payment that is required.
Senator Bennet. Thank you for that answer. I very much
appreciate it.
Let me ask my second question, because I know time is
short. As I mentioned, it is so important to have a young
person here, Mr. Chairman--and thank you for doing that--to
give their perspective on the crisis. We should think about
things, including young people, here more often. As you know,
the National Suicide Prevention Lifeline will be transitioned
to 988 by July 16, 2022. In Colorado, we are having, I am sad
to say, an epidemic of teenage suicide. The numbers are just
staggering. And Senator Cornyn and I have introduced
legislation to increase funding to make sure that this
transition to the prevention lifeline is successful. And we are
thinking about how to incorporate texting to connect
individuals with services. They call or text in to make it more
effective.
And I just wonder, Mr. Terrell--could you share your
thoughts on all of this, and what types of resources and
improvements we should be thinking about that would be most
meaningful, in your mind?
Mr. Terrell. Yes, thank you, Mr. Bennet. That is a great
question, and I think one that takes a lot of conversation to
actually get to a good policy solution. But statistics show
that teens talk to their friends more than anything. So the
more that we can empower and equip youth with the skills needed
to support their friends in crisis, I think the more we will
see kind of general health and well-being trends for youth
increase.
All YouthLine volunteers get the opportunity to go through
pretty extensive training. So I personally went through 63
hours of training, where I got suicide alert training, applied
suicide intervention skills training, youth mental health first
aid, and CPR. And those are all master's kind of clinician-
level training.
And so we know that youth have the capacity to take on this
role if supported in their communities. And so, like I
mentioned in my testimony, I think the idea of a national
YouthLine where we expand across the country, and we really
invite youth from all different communities to be involved in
this process and help destigmatize the conversation around
mental health, would be really helpful. And I think I would be
really happy to connect with you later on that.
Senator Bennet. Very good. I will take you up on that. I
know the chairman has your contact information, so I will track
you down. And I very much appreciate it.
Thanks, Mr. Chairman; I know I am out of time.
The Chairman. Thank you for all your leadership, Senator
Bennet.
The next two are Senator Lankford and Senator Brown.
Senator Lankford. Mr. Chairman, thank you. And to all our
witnesses, thanks for being here as well, and talking through
this important conversation.
Dr. Benton, I do want to be able to start with you. For
individuals within the school, whether it be a school counselor
or a teacher who may discover some mental health challenges the
child would have, are there any barriers to communicating right
now in the system, whether it be HIPAA issues, or legal issues,
or just process issues, with that individual communicating with
parents, other school counselors, or engagement with law
enforcement or outside medical entities? Are there barriers
that are there that we need to be aware of?
Dr. Benton. Yes; thank you, Senator Lankford, for that
question. And I will start my comments then defer to Dr.
Hoover, who has more expertise. But yes, there are barriers
currently. So you are not able to have a conversation between a
mental health clinician, who actually may be caring for a
youngster, and his teacher or school counselors without
permission, either through FERPA for the school, and for HIPAA
for the provider. And those two groups do not often communicate
with each other, posing barriers for care.
It creates a situation where, for teachers and for
counselors, addressing mental health concerns may require
sending that young person off to an emergency department in
order to get the care that they need. So yes, there are
definitely barriers in communication related to privacy laws.
Dr. Hoover, I don't' know if you have further----
Dr. Hoover. I agree. The good news is that many school
systems, in partnership with behavioral health systems, have
really navigated those HIPAA-FERPA privacy issues, for example,
by initially sending paperwork home to families, even at the
start of school years, to inquire about whether they are
willing to give consent for communication to occur when in the
best interests of the child's health and well-being and
academic success, allowing for some of that communication to
occur--again, with privacy in mind, but also supporting
academics.
The other area that I would say is critical is really
expanding data systems that allow for the seamless sharing of
data between health and education sectors. And that has been
done well in several districts and States. So there are good
examples. It is just not widespread enough yet.
Senator Lankford. So are there needs that we have as far as
a change in statute to allow more of that communication to
occur at this point? Or do you think the statute is
appropriate, we just need additional permissions and access
points?
Dr. Hoover. Good question. I mean, frankly I think that
technical assistance and training, and just raising awareness
that HIPAA and FERPA do not have to be barriers to
communication as long as you have family engagement and
consent, that may be enough. It has been enough in several
communities to actually bridge the divide here.
Dr. Benton. I will say, there are also State laws that
govern who actually can release information. And so that also
becomes a barrier, because sometimes the young person actually
has control over that information, and the parents don't. And
so, I think in some places it works, but I think greater
guidance and standardization of these processes would help all
of the communities.
Ms. Lubarsky, I know that this must come up for you, often.
Ms. Lubarsky. So, it does come up for us quite a bit, but I
think the training involved, I think making sure that schools
and the mental health providers--I think about our examples of
where we are integrated in over 25 schools in our region,
providing mental health care, where we are delivering that for
our staff and working collaboratively with the school, with the
family system, parent, guardian, and caregiver, to make sure
everybody is involved. I think honestly, where we see this as a
barrier, where it comes up as a challenge is when there is
failure to communicate with the family system about the youth's
needs, and making sure in advance of providing care or
suggesting care, that those conversations are happening as
well.
So I think that is where training is a big component.
Senator Lankford. I would agree. In Oklahoma, we just had a
law passed within our State that has allowed for training for
everyone with the school on suicide prevention. We have 13,000
people in schools who have been trained just in the last couple
of years, just to be able to help with suicide prevention and
to be able to know how to engage, and then the next steps on
that.
So in our State, we have been very forward-leaning to be
able to do what we can to be able to help.
Mr. Chairman, a conversation that we could have at some
point, to be able to have on this whole issue as well, is the
``whys'' and the prevention behind the scenes. We always, on
the Finance Committee, we look at it and say, ``What can we do
with more Medicare or Medicaid, and the tools that we have?''
The next big question behind it is--as we watch suicide rates
rise 57 percent among teenagers and young adults over just the
last 15 years, as we watch all these other things occur--to ask
the practical question of ``why?''
Our Nation has been through difficult challenges in the
past: World War II, the Great Depression, all these other
things. Why are we watching some of the rise now? What is
happening in technology? What is happening in engagement? And
for myself personally, I worked with students for 22 years
before I came to Congress, working with middle school and high
school students. This is an area I worked with extensively, and
I think there are a lot of questions that we have not asked,
the ones behind the issue--not just how do we fix it, but why
are we seeing the rapid rise? And what do we need to be able to
do it? The issue of technology and telehealth is really
important, but there is another angle with technology as well
that is driving comparisons among individuals that is pretty
toxic.
So we have to be able to help resolve some of these issues
in the days ahead as well.
The Chairman. Thank you, Senator Lankford. A very important
point with respect to suicide. And Senator Barrasso took note
of how important it was as well. This is an area he is going to
focus on. So I think this will be another opportunity for both
sides to work together, and I appreciate both you and Senator
Barrasso bringing it up.
Senator Brown is next.
Senator Brown. Thank you, Chairman Wyden. Mr. Chairman, I
ask that written testimony offered by the director of pediatric
psychiatry and psychology at the Akron Children's Hospital be
included in the record for today's hearing.
The Chairman. Without objection, so ordered.
[The statement appears in the appendix beginning on p. 59.]
Senator Brown. Thank you, Mr. Chairman.
Dr. Benton, as you probably recall from your time, some
time ago, spent in my State for medical school, Ohio has
excellent children's hospitals in almost every part of the
State: Cincinnati Children's, Nationwide Children's in
Columbus, Akron Children's, and Rainbow Babies and Children's
in northeast Ohio, home to several outstanding centers of
excellence.
Despite the resources our State has, Ohio's children and
health workers are still struggling during this pediatric
mental health crisis. Ohio is just like counterparts across the
country: our children's hospitals need our support to rise to
meet the needs of children and adolescents in addressing this
serious, serious public health crisis.
Experts tell me that one of the biggest challenges is
meeting the needs of a multi-system youth. Could you talk about
actions, Dr. Benton, actions Congress can take to better
support children's hospitals and their work to support youth
served by multiple systems? For example, those who are in
foster care or justice-involved, or have a developmental
disability in addition to a mental health diagnosis--how can we
ensure effective communications between and among juvenile
justice and child welfare systems to best support these
children, who so often just get left out?
Dr. Benton. Thank you, Senator Brown, for that question.
And just so you know, Cincinnati is my home town. So I am an
Ohioan. So I just wanted to say that that is an excellent
question, and one of the greatest challenges that we face in
mental health care now.
So the systems in which children exist, as you have
highlighted--child care education, juvenile justice, foster
care, and others--have little or no collaboration. And systems
are actually not in place to facilitate that collaboration. The
attempts to coordinate it are either stifled by bureaucratic
challenges or unwillingness to acknowledge that the systems are
actually connected.
And so what would be required is a focus on requirements
among those organizations that there is better coordination.
You know, we talk often about case management as a broad term,
but those individuals are often the ones who are facilitating
communication between organizations that do parallel work
caring for the same kids, but do not necessarily have an
effective means for coordination.
You know, some of the data shows us pretty clearly that
about 50 to 75 percent of the over 2 million children who are
adolescents in juvenile detention actually have had limited
mental health treatment, or limited mental health support.
So essentially, communicating expectations that those
agencies collaborate around the care of the same kids by
establishing systems that facilitate that, could go a long way.
For children's hospitals, we struggle at times with children
who are admitted to the children's hospital with a medical
condition and a mental health condition. The medical condition
is resolved. The mental health issues are resolving, yet they
are waiting for placement in foster care, sometimes remaining
in the hospitals for up to a year.
And at that juncture, payers are not accountable. The
agency who acts as the parent is not accountable. And then the
hospital is accountable for providing all of those services
that require multi-agency collaboration. Expectations of
accountability for those agencies that are often managed by the
Federal Government and States would be essential for being
responsible for coordinating care of young people.
Senator Brown. Thanks, Dr. Benton.
I have a question that I would like all of you to answer,
but very briefly, because my time is short--and the chair is
always tolerant, but his patience probably wears thin.
I asked the Surgeon General last week how we better
integrate mental health resources within our schools. And my
question to each of you is, based on--actually, in Dr. Benton's
home town, there is a community school in Cincinnati, Oyler,
which has become a bit of a template for the whole State, and
the whole country.
Briefly describe, if you had a chance to offer a
suggestion, one thing schools can do to leverage relationships
with community partners, State or local health departments,
hospitals, service centers, whatever. Give one simple
recommendation of what we can do better, schools can do better
to leverage----
Dr. Hoover, do you want to start, and then Ms. Lubarsky and
then Trace, and then finish with Dr. Benton, briefly.
Thank you.
Dr. Hoover. Happy to. Thank you, Senator Brown, and I am
familiar with the school in the Cincinnati area that does this
well. And as you said, it serves as a model for the Nation.
So one simple thing that can be done is, there are good
templates for memoranda of understanding and requests for
proposals that can go out to districts to solicit community
behavioral health partners to come in and engage in school
behavioral health provider services in the schools. Instead of
it just being kind of a hodgepodge of services, it can be
organized through a request for proposals process with
standardized memoranda of understanding with community
behavioral health.
Senator Brown. Thank you.
Ms. Lubarsky next, and then Trace.
Ms. Lubarsky. Sure. First of all, I say, ``Go Bearcats,''
as a graduate of the University of Cincinnati. This is
something we have done really well in our community. It is
really establishing, not only those agreements of
understanding, but it is really finding a standardized
assessment tool that schools will feel comfortable utilizing in
order to be able to do that screening, to pass it on to the
behavioral health-care providers, whether it is utilizing our
mobile crisis team at the Center for youth who are going into
crisis in the school setting, or being accepting of the
behavioral and mental health supports that our staff can
provide. Frankly, using some standardized screens that school
districts feel comfortable with is one step in that direction
as well.
Senator Brown. Thank you.
Trace?
Mr. Terrell. I also think a part of the big reason is we
need to invite youth and kind of see what they actually need
and what resources would be helpful for them. Because it is one
thing to offer resources, and it is another for teens to
actually access them.
So, when we conduct needs assessments and really see what
works for youth, I think we will experience better outcomes in
that regard.
Senator Brown. Well said.
Dr. Benton, we will close with you. Thank you, Mr.
Chairman.
Dr. Benton. Thank you. I just want to say that I support
all of those things that were just mentioned--and putting a
system in place to make sure those things can happen easily and
accessibly.
Senator Brown. Thanks, Mr. Chairman.
The Chairman. Thank you, Senator Brown. And thank you for
having brought me to Ohio over the years to meet with a number
of your health-care providers. And we have seen his advocacy in
action.
Next is Senator Casey.
Senator Casey. Mr. Chairman, thanks very much. In light of
all the references to Ohio that Senator Brown made possible, I
want to make sure that we emphasize that Dr. Benton is now at
the Children's Hospital of Philadelphia. So we are honored that
she settled, at least most recently, in Pennsylvania.
But, Dr. Benton, I wanted to start with you, and start with
a critically important program that so many Americans know the
name of, and so many Americans have a sense of what it does,
but maybe none of us fully appreciate how important it is, and
that is Medicaid.
I have often said that Medicaid often tells us who we are
as a Nation, but maybe more importantly, it tells us whom we
value, whether it is children, or people with disabilities
including children, or older Americans who need skilled care in
nursing homes paid for by Medicaid. We also know that Medicaid
is the largest insurer for children, but it pays,
unfortunately, significantly lower Medicaid rates than
commercial rates, which has terrible consequences often for the
pediatric health workforce in equitable access to care.
I know in your testimony you highlighted low reimbursement
rates in mental health-care access, the concerns that you have
about that, particularly with regard to underserved
communities. On page 7 of your testimony you said, quote,
``Better reimbursement for mental health services in Medicaid
would make it possible to resource the full continuum of care
our children and youth need,'' unquote.
So the additional years to specialize in child psychiatry
are not financially rewarded in the current payment structure
with Medicaid, where a provider could earn more providing care
to adults. So this makes it hard for a child-focused provider,
and particularly challenging for families covered by Medicaid.
So how would aligning Medicaid reimbursement for children's
mental health services with Medicare levels impact kids' access
to care?
Dr. Benton. Well, thank you for that question, Senator
Casey. You know, aligning those incentives would increase the
reimbursement for Medicaid at a rate that would be more
acceptable to most institutions. And that is key. Community
mental health centers really struggle to meet the needs of
young people based on reimbursement. Children's hospitals
really struggle to meet the care for children with
reimbursement.
And in addition to that, lower pay for providers is
discouraging for subspecialists not only to serve the
populations of young people, but to even train to serve the
populations of young people. You know, general psychiatry
training takes 4 years. Child psychiatry training takes 6
years. Six years of accumulated debt, which has resulted in
mental health professionals opting out of payment structures
for reimbursement for mental health care.
And so, increasing the Medicaid reimbursement rates to be
on par with Medicare, and medical rates, would increase our
opportunity to address the gaps in the continuum. So there are
areas in the United States where there are no services on any
continuum available to young people.
Medicaid reimbursement would allow us to develop a full
continuum of care, not just emergency and inpatient crisis
services, but ambulatory services, home-based services, day
hospitals, intensive outpatient programs where young people
could be with their families and be at home getting the level
of services that they need.
And so, the current Medicaid reimbursement rates impact all
of those things. And increasing them to be better, which would
be consistent with the Medicare rates, would allow us to
provide the services that we need, and would allow us to
encourage young people to pursue careers where they provide
mental health care for young people.
Senator Casey. Doctor, thanks very much. I might submit an
additional question for the record for Dr. Benton.
[The question appears in the appendix.]
Senator Casey. And I will give back time, but I did want to
again thank the panel for their testimony today. In particular
I wanted to thank Mr. Terrell for coming forward on behalf of
his generation, and I hope there are other opportunities for us
to engage. But thanks very much, Mr. Chairman.
The Chairman. Thank you, Senator Casey.
Trace, you are now clearly the people's choice, because
both Democrats and Republicans are praising you to the skies,
and it is richly deserved.
Okay, Senator Hassan, we welcome you and all your good
work.
Senator Hassan. Well, thanks so much, Mr. Chairman. Thanks
to you and the ranking member, again, for this hearing. And I
will add my thanks to Trace as well, and also just note that
the good news for America is Trace is representative of his
generation, and there are lots of wonderful young people in my
State, and I know across the country, really advocating for the
mental health of their peers.
In New Hampshire, it is very true. I actually had a 9-year-
old look at me one day and say, ``What are you doing about
mental health, Senator?'' And so, thank you all for just being
the kind of advocates that make a difference.
I want to touch on a few topics that have been discussed,
but I want to drill down a little bit. Let me start with Ms.
Lubarsky.
In New Hampshire, a small pool of mental health providers
is working overtime to help the growing number of children with
mental health needs. And it is just not sustainable. And we
have all talked about that. Following up on the testimony you
have already given, what are the main causes for this mental
health workforce shortage in New Hampshire? And what can we do
to help alleviate the crisis?
Ms. Lubarsky. Thank you very much, Senator Hassan. I mean,
I think we have all spoken to this very well this morning, and
now going into the afternoon. It is really the ability for
centers to reimburse their staff at a rate that they can
survive on.
When we look at the cost of living--and we just spoke about
Medicaid rates being significantly low. So we have a workforce
that is burdened because of other providers in our community
and within our State and country who could accept Medicaid and
choose not to because reimbursement is so low, and we burden
those providers who are accepting of it. But the facilities
themselves cannot reimburse to sustain the staff long-term. We
hear that all the time in our exit interviews.
Senator Hassan. Thank you.
Dr. Hoover, you have also touched on this, but I want to
drill down on mental health in schools. Schools are often the
only place that children can receive mental health care, but
many schools lack the personnel and infrastructure to meet
demand. What are the barriers that schools face, particularly
when it comes to recruiting and retaining mental health
providers?
Dr. Hoover. Thank you, Senator Hassan, for your leadership
on this and for the question.
We know that we suffer from the same issues the general
workforce shortage reflects as well. So simply put, we do not
have enough providers. They are not trained well enough, and
they are not paid enough.
And what I mean by that, really, is that not only do we
have shortages in workforce coming into the field, but they do
not really represent the population being served in terms of
race, ethnicity, language spoken, so we have to do a better job
of recruiting and retaining diverse and representative
providers.
They are not trained well enough. And what I mean by that
is that we have many mental health providers--not enough but
many--but they are not trained to specialize in child and
adolescent mental health, nor to work in schools. And as we
have already said, they are not paid well enough. So
reimbursement rates are a large issue.
Again, I go back to that we also need to reenvision how we
think about our mental health workforce, and think about all of
the other professionals, and even nonprofessionals, who can do
this work well. I love the idea of a grandmother providing
cognitive behavioral therapy to grandchildren, as our child
psychiatrist, Dr. Benton, mentioned. But also our peer and
family navigators; we need to be doing more to invest in that
workforce as a way to support mental health.
Senator Hassan. Thank you. And I know in New Hampshire,
peer-to-peer training and student empowerment has been really,
really critical as well.
Ms. Lubarsky, mental health resources need to meet children
where they are. And during the school year, that is in the
classrooms, but mental health does not end when the school year
does.
So, you have led an innovative program based on that
insight, working with the Community Behavioral Health
Association and the State Government. Your clinic offered
mental health training for camp counselors and provided onsite
resources at summer camps throughout the State.
So kind of following up on where we were just going with
Dr. Hoover, what was the impact of this program? And how can we
scale up this model so that more children have support year-
round?
Ms. Lubarsky. So, I was so excited about this program. Our
Commissioner of Education labeled it ``rekindling curiosity.''
And it was really a means to tackle the mental health needs of
students, after being isolated from their peers.
So we began last summer by training summer camp staff in
recreation programs in camps across our State. And we are
allowed to carry that funding into the school year. So we have
continued to utilize it to provide professional development
days to educators, to do mental health youth training for
educators. I have staff right now who are planning for February
vacation week here in New Hampshire to go out and support young
people to be maintained in camp settings or recreation settings
that may otherwise not be able to be maintained because of
their behavioral health needs.
So, rather than excluding them or expelling them from these
programs, we have staff going onsite to support the counselors
and the youth to stay with their peers and really get a
meaningful camp or recreation experience.
Senator Hassan. Well, thank you so much. It is a great
program. Thank you for everything you are doing for New
Hampshire. We really, really appreciate you.
And the last thing is, I am going to follow up, Dr. Benton,
with a question for the record for you. I am particularly
concerned about the isolation of children who are
immunocompromised right now during the pandemic, and whether
there are specific ways we can help those kids. So I will
follow up with you on that.
[The question appears in the appendix.]
Senator Hassan. Thank you all. What an excellent panel.
The Chairman. Thank you, Senator Hassan. And that last
question is particularly important, and it has not gotten
enough attention, and thank you for asking.
Senator Cortez Masto is next, and then Senator Young, and
we will wrap up one of the best hearings I have certainly been
to.
Senator Cortez Masto?
Senator Cortez Masto. Mr. Chairman, I agree. I just have to
thank the witnesses for being here. It has been a long morning,
but a fruitful discussion. I thank you, Mr. Chairman, and the
Ranking Member of the committee so much for having this
hearing.
You know, let me just say, I hear every day that one of the
most critical ways we can protect kids' mental health is by
keeping our schools open. And that is one of the reasons why I
have been working to make sure that our schools stay open and
have what they need to keep and help our kids in the classroom
and provide the important services and support that we are
talking about today.
One of the areas though--and I am going to start, Ms.
Lubarsky, with you--is stigma. My goal has been to tear down
that barrier and do away with stigma. I think that anybody who
goes to a doctor and talks about their physical health, and has
a funding source for that, that should be on par with mental
health. It should be the same thing. You walk in, get help for
your mental health, and it should be funded, and there should
be no stigma associated with that.
But, Ms. Lubarsky, let me ask you. Can you talk about the
impact that telehealth has had there? Do you see patients more
inclined to follow through on the course of treatment through
telehealth? And does that knock down some of the stigma
associated with receiving services for mental health?
Ms. Lubarsky. Absolutely, Senator. Thank you for your
question. And when I hear your question, it makes me think of a
young lady I worked with years ago, and at the conclusion of
every one of our sessions, regardless of the weather, she would
pull over her hooded sweatshirt, sunglasses, and a hat, and
say, ``I don't want anybody to see me walking out of this
building, with a giant sign that says `Mental Health Center'
out front.''
So for a youth like her, having that option to sit in the
comfort of her home behind a screen, and nobody knowing that
she was accessing care with me, I think would be a complete
game changer for many of the youth in our world.
So yes, I think the addition of telehealth not only knocks
down barriers to giving care, but eliminates the stigma that
many youth and families see around mental health care.
Senator Cortez Masto. Thank you.
And one of the things that everybody has been talking
about, and I so agree, is access to the resources, the funding
to support your services when you seek those for mental health.
That is one of the reasons why I partnered with Senator Daines
on legislation that actually enabled families with high-
deductible health plans to access no-cost telehealth services
before they meet their deductible. What I find is, that is
often a barrier as well, just accessing the payment funds, the
resources to pay for these services. So, thank you.
Let me ask you this, Mr. Terrell, because I saw you nodding
your head. Based on your work with YouthLine, can you talk a
little bit about the value that peer-to-peer relationship has,
as well as how these kids feel less isolated and more willing
to seek services for their mental health?
Mr. Terrell. Absolutely. Thank you, Senator.
I think that is a really great question, because part of
the reason that YouthLine works so well is that it is peer-to-
peer. And we know from statistics that youth are more likely to
turn to their friends than anyone else.
So, when we foster that natural partnership, it really
helps to destigmatize mental health in that regard. But I also
think YouthLine works so well because it is a crisis support
service. And there is a difference in that, right?
So a lot of times when we talk about mental health, there
is this conception that you only have to be suicidal or
experiencing kind of acute high-stress situations, when that is
not true, right? We know that mental health encompasses a lot
of things. And so, when we talk about support, YouthLine is one
of the only crisis lines in the country that offers teens the
ability to talk about their mental health struggles without the
fear of the problem being too small or too big. We really
emphasize that there is no problem that is too big or too
small. And when we talk about mental health, we really need to
recognize that. And just something that my supervisor always
says is that we teach young people to call 911 when they are in
emergency settings. And unfortunately that permeates over to
how we view the national suicide prevention line, 988. So the
sooner we can teach children that it is okay to call a crisis
line, that it is okay to reach out for support for mental
health, I think the better we will see this issue become in the
future.
Senator Cortez Masto. Thank you, and I could not agree
more. I just so appreciate the comments today on the need for
more robust crisis services for kids.
The chairman and I have worked on this. I truly believe
that when they are in crisis mode, there should be a place to
call. And it is not law enforcement on the phone, it is a
mobile crisis intervention. That is why--the chairman knows
this--the bill that he and I worked on together is based on the
best practices in Oregon, in his State.
I think really, the focus for me is directing that crisis
mode and bringing those essential services at that time. You
know, Senator Cornyn and I have introduced legislation that
would actually set flexible standards for crisis services and,
again, provide insurance coverage, which we see as lacking as
well.
So I know my time is up. I cannot thank you enough for this
conversation, Mr. Chairman. I am hoping that, with telehealth
services and so many other areas that we have to focus on, we
are actually going to implement more work around bringing
essential mental health services to so many in our community.
Thank you again, everyone.
The Chairman. Well, I thank my colleague for her
leadership. And you made mention of the fact that, working
together, we were able to put together a model that brings
together mental health folks and law enforcement folks.
And so, if you go off and you talk to Senator Booker, he is
really interested in the program. If you go off and talk to
Senator Scott, which I have done repeatedly, I know my
colleague is very interested in the program. So the Finance
Committee is really trying, as you sugggest, to break some new
ground and fill in these gaps. I just thank my colleague for
all her leadership on these issues. She has just been
invaluable, and I thank her.
Senator Young, you are next.
Senator Young. Thank you, Mr. Chairman. And I want to thank
all of our panelists today. It is such an important hearing.
While we may not fully understand the pandemic's long-term
impact on America's youth, early data is alarming, especially
to this father of four teens. According to the Indiana Youth
Institute, teen suicide deaths in my State increased 73 percent
in 2020 compared to 2019, while teen deaths by overdoses
increased 66 percent from the previous year.
Dr. Hoover, what additional research do you believe is
needed to better understand these trends and identify effective
evidence-based interventions?
Dr. Hoover. Thank you, Senator Young, for that important
question, and for raising awareness again about the dire
statistics that we are seeing, both with respect to mental
health and suicide and also substance use. We cannot forget
substance use in this conversation on mental health, but I
appreciate you lifting that issue up.
With respect to research, we are fortunate that we are
seeing greater investments in research, in both mental health
prevention and intervention, and also in the substance use
arena. So we would certainly urge Congress to continue
supporting research in those areas.
Some of the areas that we think we need more investment in
would be novel treatments, specific to certain populations--
racial, ethnic populations, immigrant populations, different
student populations in rural versus suburban versus urban
settings--so really thinking about how we develop and implement
interventions that are specific and tailored to the community.
We also need to understand who is actually thriving or
succeeding in these environments of adversity, trauma, and
stress. So often, the research looks at those who are suffering
and how we can provide treatment, but it is really important
that we also look to research to understand what are the
protective factors, whether it is individual protective factors
or community factors, that actually promote thriving and
flourishing, and how we can bolster those through school-based
centers and other community interventions.
Senator Young. Well, thank you. That is quite helpful.
I would open this up to our panel, if you can keep your
response really brief, if you have one, panelists. What steps
can the Federal Government take right now--right now--to help
reach at-risk teens at their individual moment of crisis?
Dr. Benton. I have two brief suggestions. One would be
educating our front-line providers right now around addressing
mental health challenges. And the second is setting up more
crisis programs--mobile crisis services that can go into
families' homes and their environments and provide crisis
intervention.
Ms. Lubarsky. I would add to that, Senator, having worked
with school educators recently, they are feeling like mental
health is walking through their classroom doors every day. So I
think we need to afford educators the professional development
time, and give them that fundamental training in something like
youth mental health first aid so they can recognize the signs
and symptoms and know how to bring that young person over to
the next level of mental health care that they need.
Mr. Terrell. I think we should also make sure that this is
not the last conversation that we have about teen mental
health. As a teen, we need you to continue to have these
conversations, and to continue to involve us in this work. We
deserve a seat at the table, and I think that's it.
Senator Young. Trace, I think that is really important. I
mean, all our solutions need to be grounded in the realities of
individual human beings, folks on the front line of this
crisis, right, which is our teens.
Dr. Benton, in your testimony you discussed the web of
systems beyond health care that impact the well-being of
children and adolescents, such as foster care, education, food
programs, and how these systems rarely collaborate--or, when
they try, they are foiled by bureaucratic barriers or an
unwillingness to acknowledge their interconnected nature.
Research has indeed shown that addressing these types of
factors, which we often refer to as social determinants of
health, can positively impact the health and well-being of the
most vulnerable Americans, including our Nation's youth.
Doctor, how can we better leverage existing programs to
help children and their families address the barriers to
coordination between mental health and social services
programs?
Dr. Benton. Well, thank you for that question, Senator. One
of the things that we could do right now is demand a higher
level of accountability for agencies responsible for
coordinating these services. And I will just take child welfare
as an example.
So child welfare, as the parent, is acting in loco parentis
for any child in their custody, and is responsible for
coordinating schools, mental health, medical care, and all the
services. And I am assuming there are barriers to them doing
that, because it is challenging to make that happen. But I
think for those agencies, there needs to be clarity and
reinforcement around expectations that that coordination
happens.
And from where I sit, the greatest challenge that I am
facing in the care of young people at Children's Hospital right
now, is the child welfare system.
Senator Young. We need accountability metrics, and we need
to identify who is responsible for achieving these metrics. Is
that accurate?
Dr. Benton. You summed it up well. Thank you.
Senator Young. Thank you, much, Mr. Chairman.
The Chairman. I thank my colleague. And there is a vote on
the floor, so I am going to have to be very brief, but I just
want to say this has been one terrific panel. I mean, each of
you has really made the case that Trace started talking about
2\1/2\ hours ago. Trace Terrell of La Pine, OR, basically said,
``Look, what we've got to do in America, and we students are
starting it, is mobilize. Get active and mobilize for real
reforms of America's health care.''
And each of our witnesses, Trace, in their own way sort of
reaffirmed what you are saying. And so the first thing I want
to say is, Trace, we are going to dedicate our efforts for
mobilizing the Congress for these fundamental reforms the way
you have said you are mobilizing young people. So that is
number one.
Number two is, the message of so many young people getting
lost in the system is another extraordinary takeaway from
today's hearing. I noted in your testimony you said that at
your school, with respect to referrals to mental health
services, 80 percent of them went nowhere. And what was so
striking to me, Trace, is the number of experts from around the
country who said, ``Hey, Trace is speaking for his school but,
by the way, that is pretty much the pattern around the country.
It might not be 80 percent, but we are just losing too many
young people.'' And by the way, that is what Dr. Murthy said
last week: we are just losing too many young people.
So I am going to close with this, and we will dedicate this
to you, Trace, because this is a hearing on young people, and I
want to thank all our experts for being so helpful. Trace, I
want you to know, right at the heart of our work is our
judgment, Democrats' and Republicans', that our country is
better than this. We are better than this. And as we go
forward, you are going to have a seat at the table. You are
going to have a seat at the table. We are going to reach out to
young people across the country, and we are going to stay at
our work until we find some real solutions to the issues we
have talked about.
Big thanks to everybody. It was just a terrific hearing,
one of the best I have been part of, and I just want to thank
all of you, because you have really laid out the path that we
have to follow, and we are determined to do it.
Thank you all. The Finance Committee is adjourned.
[Whereupon, at 12:35 p.m., the hearing was concluded.]
A P P E N D I X
Additional Material Submitted for the Record
----------
Prepared Statement of Tami D. Benton, M.D., Psychiatrist-in-Chief,
Executive Director, and Chair, Department of Child and Adolescent
Psychiatry and Behavioral Sciences, Children's Hospital of Philadelphia
Chairman Wyden, Ranking Member Crapo, and members of the committee,
my name is Dr. Tami Benton. I am psychiatrist-in-chief and chair of the
Department of Child and Adolescent Psychiatry and Behavioral Sciences
(DCAPBS) at Children's Hospital of Philadelphia (CHOP) and the
Frederick Allen professor of psychiatry at the Perelman School of
Medicine at the University of Pennsylvania. I also serve as director of
the Child and Adolescent Mood Program and the Youth Suicide Center at
CHOP, a multidisciplinary clinical and research program focused on
depression and suicide among children and adolescents, with an emphasis
on minority youth. Finally, I am the president-elect of the American
Academy of Child and Adolescent Psychiatry (AACAP). Thank you for the
opportunity to testify today about the crisis in the mental, emotional,
and behavioral health \1\ of our children.
---------------------------------------------------------------------------
\1\ For brevity, I will refer simply to ``mental health'' in my
testimony, but the intention is to encompass mental, emotional, and
behavioral (MEB) health throughout.
CHOP was founded in 1855 as the Nation's first pediatric hospital.
Its longstanding commitment to exceptional patient care, training new
generations of pediatric health-care professionals, and pioneering
major research initiatives has resulted in many discoveries that have
benefited children worldwide. Its pediatric research program is among
the largest in the country, and we conduct research focusing on all
aspects of mental, emotional, and behavioral health, including
preventing a child with elevated symptoms from moving into crisis.
Based on this research and the work of others, we are greatly expanding
both the type and the reach of our pediatric mental health efforts.
However, this crisis cannot be addressed without your help.
overview
I wish there were no need for me to appear before you today, but
young children and adolescents in the U.S. are experiencing mental
health stress at higher rates and with more dire consequences than ever
before. Fifty-three percent of adults with children in their household
are concerned about their children's mental well-being, and they are
not wrong to have these concerns. In the first half of 2021 alone,
children's hospitals reported cases of self-injury and suicide in ages
5-17 at a 45-
percent higher rate than during the same time frame in 2019, and, for
children under 13, the suicide rate is twice that for Black children
than for White children.
I know you've heard many of these statistics before, but I see them
play out firsthand in my daily work. A few recent examples come to
mind: a 5-year-old with suicidal ideation and a plan to follow through,
an adolescent waiting months for a placement with appropriate services
while occupying a medical bed needed by others, a youth sent several
States away because finding a placement for children with both physical
and mental health concerns is nearly impossible, and other stories too
numerous to mention.
Clearly, our kids are falling through cracks in the system. While
these cracks predate the COVID-19 pandemic, the additional traumas and
challenges for children presented by the pandemic made them both worse
and more visible. This dire situation led the Children's Hospital
Association, the American Academy of Pediatrics, and the American
Academy of Child and Adolescent Psychiatry to declare a national
emergency in pediatric mental health, and they have joined together in
an awareness campaign called Sound the Alarm for Kids.\2\
---------------------------------------------------------------------------
\2\ See list of Sound the Alarm for Kids campaign partner
organizations in Appendix A, https://www.soundthealarmforkids.org/.
Already, more than 50 other national groups and 70 children's
hospitals have joined the campaign, a clear acknowledgement that it is,
indeed, time to sound the alarm. We have not one but two urgent tasks
---------------------------------------------------------------------------
before us:
1. Addressing the immediate and undeniable crisis facing kids
today; and
2. Reframing our pediatric mental health system to provide the
right care, at the right place, and at the right time.
This latter point may sound obvious; however, the reality is that
we commonly only address pediatric mental health after the onset of a
crisis. Delayed care is costly in many ways, including:
1. Emotional burden and social cost to the patient and their
family,
2. Strain on our child-care and educational systems,
3. Excess cost and poor outcomes associated with providing
inadequate care,
4. Delays in pediatric health care when medical hospital beds
are overutilized for boarding children in mental health crisis,
and
5. Wrongful placement of children in the juvenile justice
system.
The current state of care is unacceptable, and we must pivot to
proven models of prevention to reduce the number of our children
entering a period of crisis and assure access to appropriate pediatric
services both across the entire continuum of care and close to home.
shorter-term solutions
In the immediate-term, this means greater reliance on those on the
front lines--parents, teachers, general pediatricians, and other
caregivers. They need whatever proven tools we can give them, and they
need them as soon as possible. Examples include supplemental training,
ready access to phone consultations and referrals, pediatric mobile
crisis units to help children (and their caregivers) manage from home,
and school-based interventions, including telehealth. While a good
number of schools have a school psychologist, school counselor and/or
nurse on hand, they tend to have untenable student ratios. While these
providers may not have capacity at present, it makes sense to build on
these existing models of care through evidence-based training and
supplementing their efforts with telehealth.
Not only are these front-line workers lacking the support they
need, in some cases there are financial disincentives to providing
mental health services. For example, although up to half of all
pediatric primary care office visits involve a mental health
concern,\3\ primary care pediatricians who do additional training to
offer a mental health assessment necessary for appropriate referral, do
so without receiving compensation for the 1.3 to 2.8 times longer the
mental health assessment takes, compared to other primary care visits.
---------------------------------------------------------------------------
\3\ Martini, R., Hilt, R., Marx, L., Chenven, M., Naylor, M.,
Sarvet, B., and Ptakowski, K.K. (2012). Best principles for integration
of child psychiatry into the pediatric health home, American Academy of
Child and Adolescent Psychiatry.
We need more appropriately trained pediatric mobile behavioral
health crisis units. These provide mobile, short term, face-to-face,
therapeutic responses to youth experiencing a behavioral health crisis
and can help reduce psychiatric emergency department visits.\4\
Notably, there are effective models to build on in both urban and rural
settings, and these mobile crisis units can be stood up almost
immediately.
---------------------------------------------------------------------------
\4\ Fendrich, M., Ives, M., Kurz, B., Becker, J., Vanderploeg, J.,
Bory, C., Lin, H., and Plant, R. (2019). ``Impact of Mobile Crisis
Services on Emergency Department Use Among Youths With Behavioral
Health Service Needs.'' Psychiatric Services: 70 (10) 881-887.
Twenty-four-hour crisis hotlines, staffed with those trained in
child and adolescent mental health, can assist with de-escalation and
assessment. If linked with updated local resource and provider
information, these crisis lines can also refer to treatment facilities.
Depending on how they are configured, the crisis lines could be
utilized by providers, educators, families and even the kids
themselves. They would work best if connected to a frequently updated
collection of local resources. For this, it may be possible to build
out the existing 211 network or expand on the 988 network established
by the FCC last year to connect people to the National Suicide
Prevention Lifeline.
fixing a broken system
In the longer term, the whole continuum of care must be addressed
so that the right types and levels of care are available, e.g., the
emphasis should not be on inpatient mental health beds (although more
of those are also needed). If we are doing things right, children will
be treated more and more outside of a hospital inpatient setting, but
this will only be possible if intensive outpatient programs (IOPs),
partial hospitalization programs (PHPs), day programs, a full range of
additional step-down services, and preventive services are available.
Today, every one of these services is in short supply. As a result,
children often go without the services they need, or families find
themselves seeking services for their child far from home (including
out of State).
It is also important to acknowledge that there is a web of systems
beyond health care that impact the well-being of children and
adolescents. These include foster care, juvenile justice, childcare,
education, food programs and more, layering on additional complexities
to achieving the end goal of doing better by our kids. The many systems
that touch our kids rarely collaborate, and, when they try to, these
attempts are too often foiled by bureaucratic barriers or an
unwillingness to acknowledge the interconnected nature of the services
offered. Although a daunting prospect, we recommend a thorough
examination of how various agencies intersect in children's lives and
policy recommendations aimed at making those intersections synergistic
rather than counterproductive.
workforce shortages and pediatric behavioral health boarding
Not surprisingly, the shortage of pediatric mental health-care
providers and facilities means many children show up at emergency
departments (EDs), brought there by distraught caregivers, sent there
by overwhelmed schools, or taken there by police who see plainly in a
particular case, that care, not confinement, is what is needed. EDs are
not the ideal setting for these kids if they do not have medical needs.
EDs can be stressful environments and starting a mental health journey
that way often results in delayed care when children are ``boarded''
either in the ED itself or admitted to a medical patient bed. Neither
option satisfies the ``right care, right place, right time'' mantra,
and both can be detrimental.
At CHOP, we have up to 50 patients waiting for mental health beds
on any given day. As we typically operate at (or over) capacity, this
means that we cannot use that space for a child with more complex
medical needs. The kids who are boarding are kept physically safe, but
generally must wait for an appropriate treatment slot to open before
having their mental health crises fully addressed. Sometimes this wait
is only a few hours, but weeks of waiting is far too common, months is
not unheard of, and there are even instances of a child or adolescent
missing more than a year of their life, removed from school and family,
while waiting for the services they need to safely return to home and
school.
According to the American Psychiatric Association, there are an
estimated 15 million children nationwide in need of care from mental
health professionals. However, there are just 8,000 to 9,000
psychiatrists treating youth in the United States. Even when staffing
ratios are reasonable, resources are not distributed evenly across the
country, essentially resulting in pediatric mental health service
deserts.
While I can speak most directly to the shortage of child and
adolescent psychiatrists, there are also severe shortages of
psychologists, mental health therapists, nurse practitioners, case
managers, and community mental health workers to support children in
need.\5\ To increase the number of pediatric mental health providers
available to care for these children, incentives, including educational
funding and loan forgiveness programs should be directed at all
licensed pediatric mental health providers in all settings across the
continuum of care, including in schools. It is especially important to
include mental health professionals of all disciplines. While there is
a severe shortage of new pediatric psychiatrists coming into the
system, and that must be addressed, increasing the number of clinical
social workers with pediatric training, mental health therapists,
psychologists, nurse practitioners, case managers and community mental
health workers, who are all needed to expand access to mental health
care, could be done more quickly and in greater numbers.
---------------------------------------------------------------------------
\5\ National Projection of Supply and Demand for Selected
Behavioral Health Practitioners: 2013-2025. U.S. Department of Health
and Human Services. Health Resources and Services Administration.
Bureau of Health Workforce. Published November 2016, https://
bhw.hrsa.gov/sites/default/files/bureau-health-workforce/data-research/
behavioral-health-2013-2025.pdf.
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the unique needs of military families
Children in military and veteran families are experiencing mental
health challenges much like their civilian counterparts, but also face
some unique challenges due to the nature of their parents' service such
as frequent moves, prolonged separation resulting from parents'
deployments, and exposure to returning parents who themselves have been
affected by the trauma of combat deployment. How these children can be
connected to the full continuum of care described above must be
determined and then implemented.
improved access to integrated care and preventive services
For an overwhelmed system in which training enough providers will,
at best, take time, easing pressure on the system now is essential. The
best way to do this is support for both preventive services as well as
care that is integrated into settings where youth are likely to be,
such as the pediatrician's office, school, or other
community-based centers to help stem the tide of youth entering crisis.
When care isn't easily accessible (the ideal being true integrated
care, with a warm hand-off to someone in the same building), too often
a referral to mental health services ends in no services. When patients
are referred from primary care to free-standing mental health clinics,
only 25-50 percent of patients attend an appointment. When behavioral
health providers are on site, as part of the primary care team,
treatment initiation is dramatically improved.\6\ The pediatric
patient-
centered medical home model offers opportunities for family-centered,
team-based care, and pediatric mental health providers are increasingly
being recognized as key members of primary care teams.\7\ Insurance
carve outs for behavioral health care are among the barriers to
implementation, but targeted incentives related to integrated
behavioral health could further speed expansion and serve as a pathway
to mental health parity.
---------------------------------------------------------------------------
\6\ Blount, A. ``Integrated primary care: Organizing the
evidence.'' (2003). Families Systems and Health. 21:121-133.
\7\ Asarnow, J., Kolko, D.J., Miranda, J., and Kazak, A.E. (2017).
``The pediatric patient-
centered medical home: Innovative models for improving behavioral
health.'' American Psychologist, 72, 13-27. https://doi.org/10.1037/
a0040411.
Certified Community Behavioral Health Clinics (CCBHCs) are another
important access point to mental health care for children and youth,
particularly for those in underserved communities. In a recent survey,
79 percent of CCBHCs reported coordinating with hospitals to support
diversion from emergency departments and inpatient care,\8\ and a
similar proportion of CCBHCs directly employ child and adolescent
psychiatrists as part of their care teams. Providing these clinics with
additional resources could be another way to have more appropriate care
available closer to home, for kids in need.
---------------------------------------------------------------------------
\8\ According to a 2021 impact report (https://
www.thenationalcouncil.org/resources/2021-ccbhc-state-impact-report-
transforming-state-behavioral-health-systems/?daf=375atetbd56) that
surveyed 128 CCBHCs, 79 percent report coordinating with hospitals/
emergency departments to support diversion from emergency departments
and inpatient care. Additionally, according to a 2020 ASPE
implementation report (https://www.aspe.hhs.gov/sites/default/files/
migrated_
legacy_files/196051/
CCBHCImpFind.pdf?_ga=2.126261899.727227857.1643912188-731445304.
1625598149), 76 percent of CCBHCs employs child and adolescent
psychiatrists.
Ultimately, of course, prevention is the best approach as it both
serves are children better and it helps to alleviate an over-burdened
system. Preventive mental health interventions reduce the risk of a
child suffering a mental health crisis and are cost-
effective,\9\, \10\ but it is not well understood how early
these interventions can and should start. Remarkably, just by giving
parents and other caretakers tools to effectively address behaviors and
emotions as they come up, better trajectories are started as early as
infancy. Early intervention, services for young children that build
upon the natural learning opportunities that occur within the daily
routines of a child and their family, can effectively give children
tools to overcome delays and manage disabilities.\11\, \12\
For older kids, there are several effective depression prevention
programs, which, if more widely delivered, could prevent 22-38 percent
of depression episodes.\13\, \14\
---------------------------------------------------------------------------
\9\ Mihalopoulos, C., Vos, T., Pirkis, J., and Carter, R. (2012).
``The Population Cost-effectiveness of Interventions Designed to
Prevent Childhood Depression.'' Pediatrics 129 (3): e723-e730.
\10\ Bodden, D.H.M., van den Heuvel, M.W.H., Engels, R.C.M.E., and
Dirksen, C.D. (2021). ``Societal costs of subclinical depressive
symptoms in Dutch adolescents: A cost-of-illness study.'' Journal of
Child Psychology and Psychiatry, https://doi.org/10.1111/jcpp.13517.
\11\ Bailey, D.B., Hebbeler, K., Spiker, D., Scarborough, A.,
Mallik, S., and Nelson, L. (2005). ``36-month outcomes for families of
children with disabilities participating in early intervention.''
Pediatrics, 116, 1346-1352
\12\ Richard C. Adams, Carl Tapia, and The Council on Children With
Disabilities. ``Early Intervention, IDEA Part C Services, and the
Medical Home: Collaboration for Best Practice and Best Outcomes,''
Pediatrics, October 2013, 132 (4) e1073-e1088; DOI: https://doi.org/
10.1542/peds.2013-2305.
\13\ Cuijpers, P., van Straten, A., Smit, F., and Mihalopoulos, C.
``Preventing the Onset of Depressive Disorders: A Meta-Analytic Review
of Psychological Interventions.'' (2008). The American Journal of
Psychiatry; 165, 10; ProQuest Social Sciences Premium Collection pg.
1272.
\14\ Cuijpers, P., Munoz, R.F., Clarke, G.N., and Lewinsohn, P.M.
(2009). ``Psychoeducational treatment and prevention of depression: The
`coping with depression' course 30 years later.'' Clinical Psychology
Review 29 449-458.
Unfortunately, current mental health payment models do little to
support prevention services. Most billing codes required for use by
behavioral health clinicians usually necessitate the presence of a
diagnosed psychiatric condition. This means that a mental health
concern that could have been resolved relatively quickly can devolve
into crisis, which is far worse for the child and far more costly, both
literally and figuratively, for society. Even with early intervention,
which is inexpensive and effective, there are barriers that can
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significantly delay services.
Although we understand the challenges of fully realizing savings in
a 10-year legislative budget window, it is nonetheless essential to
increase funding for and access to preventive services for our
children. To this end, dedicated grant programs could further enable
community-based systems of care. Additionally, increasing health-care
payment flexibility with new billing codes that support preventive
services without a diagnosed psychiatric condition would better enable
these services to be embedded into pediatric primary care (where most
families already visit regularly) and other settings that children and
families frequent. Also, the Early and Periodic Screening, Diagnostic,
and Treatment (EPSDT) benefit for youth in Medicaid provides an
important opportunity to support early identification even before
diagnosis. The Department of Health and Human Services should be
instructed to working with States to test innovative strategies and
sustainable payment models within Medicaid's EPSDT services \15\ to
allow children at risk of mental health concerns, but without a
diagnosis to receive preventive services.\16\
---------------------------------------------------------------------------
\15\ ``Early and Periodic Screening, Diagnostic, and Treatment.''
Medicaid.gov (https://www.
medicaid.gov/medicaid/benefits/early-and-periodic-screening-diagnostic-
and-treatment/index.ht
ml#::text=PDF%2C%2068.09%20KB)-
,The%20Early%20and%20Periodic%20Screening%2C%20
Diagnostic%20and%20Treatment%20(EPSDT),who%20are%20enrolled%20in%20Medic
aid.&text=
Treatment%3A%20Control%2C%20correct%20or%20reduce%20health%20problems%20
found).
\16\ We can look to Massachusetts for innovation in this area.
Revisiting and realigning health insurer capitated payment rates to
reflect expanded preventive services would also facilitate earlier
interventions. Please refer to the relevant MassHealth Bulletin
(https://www.mass.gov/doc/managed-care-entity-bulletin-65-preventive-
behavioral-health-services-for-members-younger-than-21-0/download).
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setting children up for success from the earliest years
and addressing equity concerns
Early care and education programs, child care, and preschool
prevention programs have been overlooked and underfunded. As noted
above, these services have a key role in prevention. When using proven
techniques, they help young children build social-emotional life
skills, which can set the child on a pathway to greater resilience and
prevent mental health crises at later ages.
Within early education, there is another distinct crisis that
exists as the result of suspensions and/or expulsions of babies and
toddlers from childcare and Pre-K settings for behavioral concerns, and
this problem falls disproportionately on Black boys. If you take a
moment to imagine being told that nothing can be done for your 2-year-
old's behavior, and he is being expelled from child care--the message
to both the child and the parents is damaging in the moment
longitudinally. Promptly investing in basic behavioral health technique
training for child-care providers and Pre-K teachers will give our
educators the support they need to teach our youngest the social-
emotional life skills and regulation tools they need to participate in
these important developmental settings and enter kindergarten ready to
learn and thrive.
Care provided in communities offers the opportunity for early
identification and intervention for children and families with mental
health challenges at the right level and at the right time. It also
helps to address longstanding access disparities and overcome stigma.
Instead of this, our current system relies heavily on private
facilities which often pick and choose their patients. While they are
entitled to do so under current law, additional standards could be set
nationwide both to ensure kids get to open pediatric mental health
slots in facilities that accept Federal funding and to reduce bias in
these decisions.
Of course, inadequate Medicaid reimbursement for mental health
services disproportionately impacts communities that are already
medically underserved, in which those services are especially needed.
Better reimbursement for mental health services in Medicaid would make
it possible to resource the full continuum of care our children and
youth need, such as intensive outpatient, partial hospitalization, and
limited residential treatment facilities--and, importantly, bring that
care closer to home.
how telehealth can enhance care
Tele-mental health services have been described as an ideal
application of digital health services, and since the onset of the
COVID-19 pandemic, behavioral health providers at CHOP have completed
more appointments via telehealth than any other specialty; nearly
83,000 across the CHOP Care Network. This is an essential tool for
addressing the pediatric mental health crisis. To reach the
underserved, we recommend the inclusion of audio-only services as well
as coverage across sites of care including a child's home, school, or
childcare center. Increased reimbursement rates for telehealth services
supported the rapid expansion of telehealth and should be continued at
an appropriate level to maintain children's access to tele-behavioral
health services.
Telehealth across State lines is also an important way to improve
access to pediatric mental health services, particularly in States
where there is a shortage of providers. However, the process is both
complicated and expensive for providers to become licensed in multiple
States and/or obtain the credentials (like PsyPact) that allow care
provision across State lines. There is also no longer a State-by-State
standard of care, making State-based professional licensure a barrier
to care that is difficult to justify, especially in federally
recognized health professional shortage areas (HPSAs) and the dearth of
providers accepting Medicaid.\17\
---------------------------------------------------------------------------
\17\ Health Professional Shortage Areas (https://data.hrsa.gov/
topics/health-workforce/shortage-areas).
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improving reimbursement through both payment reform and higher rates
The behavioral health payment system is archaic and convoluted,
further restricting access to care. As it stands today, arranging for
care and payments can be confusing and administratively burdensome.
There is often disagreement as to which payer is responsible and where
the care can be provided. For boarded children, the result is something
close to nonpayment, where neither insurer assumes responsibility when
the services assigned to them are not being provided or not in what
they consider to be the approved setting. The disfunction is only
greater when a child or adolescent reports with both a medical and
mental health issue,\18\ and few settings are equipped to address these
complex cases.
---------------------------------------------------------------------------
\18\ We have been able to provide limited relief of this latter
problem by providing full-time medical staff to a facility that
otherwise only addresses MEB issues, but this only works when the
medical issue is relatively easily managed, like diabetes, not for more
severe comorbidities.
Many key pieces of the needed continuum of care are simply not
covered or are reimbursed at such low levels that too few providers
will offer them. Day programs,\19\ which provide trauma-informed,
behaviorally based therapeutic services, which teach children how to
develop safe adaptive behaviors, emotional self-
regulation, and pro-social skills, are an important example. Without a
significant enough increase in rates for pediatric mental health
services, we will never be able to provide the full continuum of care
that our youth need. This is not acceptable, especially when getting
this right will mean our children receive the care they need at the
appropriate level, maximizing the likely success of the treatment,
ensuring that they are not taking a higher acuity spot desperately
needed by another child, and more wisely spending health-care dollars.
---------------------------------------------------------------------------
\19\ More information on CHOP's Intensive Emotional and Behavioral
Services can be accessed here (https://www.chop.edu/centers-programs/
childrens-intensive-emotional-and-behavioral-services).
---------------------------------------------------------------------------
conclusion
Our mental health-care system is not equipped to give our children
the support they need when they need it. If the right interventions are
put in place, they would build on our children's remarkable resilience
and place them on a better trajectory. Our children are in crisis,
which means we are in crisis as a Nation. Although the pandemic
deepened the crisis, it has raised awareness on this issue, creating an
important and rare opportunity to make fundamental changes in the way
we care for our children.
Thank you again for the opportunity to provide this testimony. I
urge you to take this opportunity to act swiftly and decisively to save
children in crisis and diminish the chances of a repeated emergency of
this magnitude.
Appendix A: Organizations Participating in the Sound the Alarm for Kids
Campaign, along with the Children's Hospital Association, American
Academy of Pediatrics, American Academy of Child and Adolescent
Psychiatry, and 70+ (https://www.soundthealarmforkids.org/a-national-
emergency/) Children's Hospitals
AIDS Alliance for Women, Infants, Children, Youth and Families
American Academy of Family Physicians
American Foundation for Suicide Prevention
American Hospital Association
American Mental Health Counselors Association
American Muslim Health Professionals (AMHP)
American Psychiatric Association
American Psychological Association
America's Essential Hospitals
Association of Children's Residential and Community services
(ACRC)
Catholic Health Association
Center for Law and Social Policy (CLASP)
Child Welfare League of America
Children and Adults with Attention-Deficit/Hyperactivity
Disorder (CHADD)
Children's Defense Fund
Clinical Social Work Association
Eating Disorders Coalition for Research, Policy and Action
Exceptional Families of the Military
Family Voices
Federation of American Hospitals
First Focus on Children
Global Alliance for Behavioral Health and Social Justice
International Society of Psychiatric Mental Health Nurses
Juvenile Protection Association (JPA)
Mental Health America
National Alliance on Mental Illness (NAMI)
National Association for Behavioral Healthcare
National Association for Children's Behavioral Health
National Association for Rural Mental Health
National Association of County Behavioral Health and
Developmental Disability Directors
National Association of Pediatric Nurse Practitioners
National Association of School Psychologists
National Association of State Mental Health Program Directors
National Council for Mental Well-being
National Latinx Psychological Association
National League for Nursing
National Military Family Association
On Our Sleeves--The Movement for Children's Mental Health
Psychotherapy Action Network (PsiAN)
REDC Consortium
RI International, Inc.
Sandy Hook Promise
School Social Work Association of America
School-Based Health Alliance
Social Current
Society for the Prevention of Teen Suicide
Society of Adolescent Health and Medicine
The Baker Center
The Barry Robinson Center
The Jed Foundation
The Kennedy Forum
The National Alliance to Advance Adolescent Health
The Trevor Project
Tricare for Kids Coalition
Trust for America's Health
United Way Worldwide
WellSpan Health
Youth Villages
Appendix B: Visual Representation of Recommendations Along the Care
Continuum and Time to Impact (Now vs. Future) \20\
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\20\ Strengthening Kids' Mental Health Now. Children's Hospital
Association (https://www.
childrenshospitals.org/content/public-policy/policy-position/
strengthen-kids-mental-health-now-bill-would-invest-in-mental-health).
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
.eps__
Questions Submitted for the Record to Tami D. Benton, M.D.
Question Submitted by Hon. Robert P. Casey, Jr.
Question. On page 6 of your testimony, you note that ``early care
and education programs, child care, and preschool prevention programs
have been overlooked and underfunded.'' I strongly agree that we must
invest in and work through evidence-based early childhood programs to
equip kids with socio-emotional life skills and increase their
resilience. When it comes to preventing mental health challenges later
in life, we should think about what support we can provide every stage
of a child's life, including their earliest years.
How can we better integrate infant and early childhood mental
health into the continuum of care for children?
Answer. When using proven techniques, services provided to young
children help them build social-emotional life skills, which can set
the child on a pathway to greater resilience and prevent mental health
crises at later ages. Promptly investing in basic behavioral health
technique training for childcare providers and Pre-K teachers will give
our educators the support they need to teach our youngest the social-
emotional life skills and regulation tools they need to participate in
these important developmental settings and enter kindergarten ready to
learn and thrive. Preventive mental health interventions reduce the
risk of a child suffering a mental health crisis and are cost-
effective.
Within early education, there is another distinct crisis that
exists as the result of suspensions and/or expulsions of babies and
toddlers from child care and Pre-K settings for behavioral concerns,
and this problem falls disproportionately on Black boys. If you take a
moment to imagine being told that nothing can be done for your 2-year-
old's behavior, and he is being expelled from child care--the message
to both the child and the parents is damaging in the moment and over
time.
Remarkably, just by giving parents and other caretakers tools to
effectively address behaviors and emotions throughout children's
development, as they occur, will improve developmental outcomes,
preventing emotional and behavioral problems across the life span. At
CHOP, we provide behavioral health support to parents, supporting
healthy social, emotional and behavioral development. One such program
is the Child Adult Relationship Enhancement in Primary Care (PriCARE)
program, a 6-session group parent training designed to teach positive
parenting skills; other programs include the Early Head Start Program
for at-risk parents. Early intervention, services for young children
that build upon the natural learning opportunities that occur within
the daily routines of a child and their family, can effectively give
children tools to overcome delays and manage disabilities.
______
Question Submitted by Hon. Maggie Hassan
Question. We know that youth anxiety and depression rates are
skyrocketing, and that strong social relationships improve a child's
overall well-being. I worry about children and youth who are
immunocompromised and might have trouble safely reconnecting with their
peers during the ongoing pandemic.
What can parents do to help their immunocompromised children
socialize with other youth while staying safe?
Answer. We know that children who are immunocompromised are at
higher risk of being infected with and suffering complications from
COVID-19. Parents can make sure kids and family members are vaccinated
(if eligible) and wear masks when seeing friends, as well as providing
opportunities for children to socialize with their peers outside where
the risk of infection is lower. It is also important that school
personnel be aware of a youth's need for distancing and masking, and
that there is an opportunity for private space if needed. Communication
with the school about the child's management at school and daily
activities and contacts will allow the parents and child to feel
supported. All will feel better with effective communication.
Additionally, communities should prioritize in-person learning for
school-age children. This will require not only ensuring there is
adequate financial support to safely return to the classroom, but also
making plans to support the emotional well-being of youth as they
reacclimate to in-person socialization and catch up on missed
academics. Expanding the settings in which mental health services are
delivered to meet families where they are, including in schools as
students return to classrooms, can help ease this transition.
______
Submitted by Hon. Sherrod Brown,
a U.S. Senator From Ohio
Akron Children's Hospital
One Perkins Square
Akron, Ohio 44308-1062
Phone 330-543-1000
www.akronchildrens.org
Statement of Steven Jewell, M.D.,
Director of Pediatric Psychiatry and Psychology
Chairman Wyden, Ranking Member Crapo, members of the United States
Senate Committee on Finance, thank you for the opportunity to submit
our statement, which outlines the position and perspective of Akron
Children's Hospital regarding behavioral health.
Acknowledgement of Surgeon General's Advisory
We appreciate the Surgeon General's recent advisory on ``Protecting
Youth Mental Health,'' that highlights the long-standing access and
workforce issues that have plagued the mental health system for
children and youth across the country for decades, and which have been
significantly aggravated by the COVID-19 pandemic. In fact, pre-
pandemic in 2019 suicide became the leading cause of death for children
ages 10-14 in the State of Ohio, and the second leading cause of death
for those ages 15-34. Reflective of the increasing demand for
behavioral health services even before the pandemic struck, that same
year Akron Children's Hospital's behavioral health outpatient volumes
increased over 45 percent for mental health therapy services and over
29 percent for psychiatric services.
Within just a few months of the beginning of the pandemic, experts
began predicting a mental health pandemic that would inevitably follow
on the heels of the viral pandemic. As the stress and trauma to
children and families caused by the pandemic persisted, we saw further
increases in demand for behavioral health services, as well as
increasing rates of suicide attempts and completed suicides among
youth, especially girls. By late 2021 (ironically the year that the
Annapolis Coalition on the Behavioral Health Workforce celebrated 20
years since it was founded to address the behavioral workforce
shortage), there was a general recognition that the longstanding
workforce shortage had also been exacerbated by the pandemic, as it
became increasingly difficult to recruit mental health professionals
(especially those with specialized training in serving the needs of
youth) to address the increasing needs of youth presenting in crisis.
Leaders in the field soon began calling for action. In October 2021 the
American Academy of Child and Adolescent Psychiatry, the American
Academy of Pediatrics and the Children's Hospital Association declared
a ``national state of emergency'' in child and adolescent mental
health, which they correctly noted required ``urgent government
action.'' Surgeon General Dr. Vivek Murthy answered that call in
December 2021 with his advisory, calling for ``a swift and coordinated
response to this crisis.'' We are grateful for his decision to shine a
light on this crisis, and his comprehensive set of recommendations that
all of us can begin to implement with the goal ``to improve the mental
health of children, adolescents, and young adults.''
Akron Children's Perspective
During the pandemic, Akron Children's Hospital has experienced an
increase in youth and adolescents presenting in the emergency
department with suicidal ideation and suicide attempts. The complexity
and acuity of patients admitted to the inpatient psychiatric unit has
increased significantly as evidenced by the number of nursing
specialties required for patient care. In addition, aggressive
behaviors among the patient population have resulted in more serious
staff injuries resulting in an increasing number of days absent from
work. In the ambulatory settings, referral volumes are extremely high.
In some areas, families seeking services are waiting up to six months
to be seen by a behavioral health specialist.
Current Efforts
Facing the same challenges to providing behavioral health services to
children and youth that other organizations do, Akron Children's
Hospital has embarked on a strategic plan to create a system of care
that not only capitalizes on our existing resources, but also leverages
those by partnering with pediatric primary care providers (PCPs) and
community mental health centers (CMHCs) across our more than 30-county
service area in northeast Ohio, in an attempt to mitigate existing
barriers to care. The challenges we are attempting to address include
the stigma of mental illness, under-identification of children in need
of services, the above-noted behavioral health workforce shortage, and
significant gaps in available services in the community (especially for
youth with more severe mental illness). Our strategy includes the
following interventions:
1. Addressing stigma by embedding masters' level therapists in all
of our pediatric primary care offices, thereby providing care in a
natural setting, allowing for ``warm hand-offs,'' and encouraging
informal consultation between therapists and PCPs;
2. Addressing under-identification of youth with mental illness by
an annual screening process in the primary care offices for all youth
12 years of age and older, to identify youth in need of services
earlier in the course of their illness;
3. Addressing the behavioral health workforce shortage by
enhancing PCPs' confidence and competence managing mild to moderate
mental illness in their office through various supports (including
telepsychiatry, electronic consults, and telementoring using the
Project ECHO format), and creating a structured triage process to
identify and prioritize referral of more severely mentally ill youth
from primary care to more specialized services; and
4. Addressing the gaps in available services in the community by
bringing up several regional behavioral health centers across our
geographic footprint, each of which house programming for more severely
mentally ill youth, tailored to the needs of the local community.
The overall intent of the plan is to create a ``meta-system'' of care
layered on top of and in collaboration with the existing county-based
systems of care, but taking care not to compete with existing community
mental health system resources.
In another effort to address the workforce issues, we are expanding our
child and adolescent psychiatry and pediatric psychology fellowship
programs, and are in the process of establishing a fellowship for child
psychiatric advanced practice nurses. This will include partnering with
local agencies and universities to create clinical rotations that offer
a comprehensive learning experience. The goal of these programs is to
expose fellows to multiple clinical settings and patient populations
while retaining them within the local community workforce.
For Your Consideration
Finally, as we move forward with this strategic plan we recognize that
there are interventions that could be beneficial not only in our local
service area, but also on a national scale in this effort to protect
youth mental health, and would like to share those with you.
(1) Increase availability of behavioral health promotion/
prevention/early intervention services in the community, such as:
(a) Enhance suicide prevention activities in communities (many
have a structure addressing needs of adults, but not youth);
(b) Enhance mental health screening of children and youth in
primary care for the purpose of case-finding, early identification and
early intervention; and
(c) Enhance availability of screening, mental health services,
and risk assessment capacity in schools.
(2) Integration of behavioral health services into primary care:
(a) Successful and meaningful integration of behavioral health
services into primary care on a national level holds the promise of
resolving many of the most vexing barriers to the effective provision
of behavioral health services to youth, including (as noted above)
stigma, workforce shortage, and the need for early identification and
intervention.
(b) However, this requires a number of activities that are not
billable in a fee-for-service environment. These include, among other
activities:
(i) developing the capacity in the primary care practice
for regular screening and ongoing monitoring of response to treatment
using standardized tools;
(ii) creation of a roster of patients within the
practice identified as needing behavioral health services, and
conducting an ongoing systematic case review of their progress in
treatment;
(iii) embedding a behavioral health-care manager within
the primary care practice to take responsibility for conducting/
overseeing the above activities; and
(iv) providing ongoing psychiatric consultation to the
PCPs, thereby leveraging the psychiatrist's time to serve a larger
population than could be served with direct visits alone.
(c) The Collaborative Care Model (CoCM)--developed and studied
by the University of Washington's AIMS Center (http://uwaims.org)--for
treating common mental disorders in primary care settings is an
evidence-based strategy recognized as a best practice for improving
patient outcomes and includes all of the above-described elements. CoCM
services are currently reimbursable by Medicare, and a few State
Medicaid programs (e.g., Maryland, New York, North Carolina, and
Washington, but not on a national level).
(d) Thus, authorizing Medicaid (and incentivizing private
insurers) to reimburse primary care practices for implementation of the
evidence based CoCM for youth could have a substantial impact on the
behavioral health needs of the youth across the Nation, and address
many of the challenges described above.
Thank you for your time and attention to this issue of critical
importance to the overall health of the children, youth and young
adults of this Nation. If we can be of any further support or
assistance to this initiative, please do not hesitate to contact us.
______
Prepared Statement of Hon. Mike Crapo,
a U.S. Senator From Idaho
Thank you, Mr. Chairman, and thank you to our witnesses for joining
us today as we discuss ways to respond to mental health challenges
impacting children and adolescents across the country.
According to recent reports from the CDC, the number of young
people dealing with depression, anxiety, and suicidal thoughts has
unfortunately risen during the pandemic, as social isolation has taken
its toll on far too many children and adolescents. Although it appears
the pandemic is subsiding and our return to normalcy may be imminent,
we cannot ignore the lasting effects of the past 2 years on the social
and emotional well-being of children.
We should do all that we can, within our jurisdiction, to increase
access to high-quality mental health services, and reduce the causes of
delayed and forgone treatment. While mental health issues affect people
of all ages, children's needs are often different from those of adults,
necessitating carefully tailored solutions.
As this committee works in a bipartisan way to advance the
conversation on mental health, we must not only identify the complexity
and scope of the problems at hand, but also explore innovative,
sustainable, and concrete policy solutions. I look forward to working
with my colleagues on both sides of the aisle to develop meaningful
measures to meet some of the Nation's mental health challenges,
including by expanding access to telehealth services, supporting our
mental health workforce, and better integrating physical and mental
health-care services.
Children can--and often do--benefit from services delivered via
telehealth. While we often focus our telehealth discussions on
Medicare, where key access gaps and barriers remain, this committee
should also prioritize clarifying and expanding care delivery options
for children covered by Medicaid, regardless of geographic location.
Additionally, we should work to maintain a strong mental health
workforce with the capacity to care for all who need services. These
efforts will prove particularly crucial as health-care professional
burnout, steep regulatory demands, and other strains jeopardize long-
term provider retention and capacity.
We have clear opportunities for improvement at every level. I
regularly hear from front-line providers, as well as State
policymakers, seeking the flexibility to innovate and craft targeted,
local solutions to the challenges facing their communities.
Their ideas and input will play a critical role in this process,
especially as we look to bridge gaps in care, better integrate physical
and behavioral health services, and promote value-based payment models
that put patients first. If structured effectively, these reforms could
prove game-changing for populations of all ages, including young
people.
Finally, no conversation on mental health-care reforms for children
and young adults would be complete without input from those whom the
policies intend to empower and support. To that end, Trace, thank you
for your willingness to join us today to share your perspective.
We have the opportunity to better support children, their families,
and their providers, by enhancing mental health outcomes across the
United States. Moreover, we can--and must--do so while honoring this
committee's strong tradition of
member-driven, bipartisan, and fiscally responsible legislative
solutions.
Thank you to our witnesses for agreeing to share their expertise
from across the continuum of care. They have provided invaluable
services during these unprecedented times, and I look forward to
hearing their testimonies.
______
Prepared Statement of Sharon Hoover, Ph.D., Professor, Child and
Adolescent Psychiatry; and Co-Director, National Center for School
Mental Health, University of Maryland School of Medicine
I want to express my thanks to you, Chairman Wyden, for the
invitation to speak with the committee today and for your leadership on
the issue of mental health in our Nation, including the impact on
youth. Thank you also to ranking member Senator Crapo and to all of the
committee members for your vision to improve the mental health and
well-being of our young people and for the opportunity to be here with
you today to discuss these important issues.
I am speaking to you from my perspective as a co-director of the
National Center for School Mental Health, funded by the U.S. Department
of Health and Human Services, and as a professor of child and
adolescent psychiatry. I also speak to you through my lens as a parent
to three teenagers, all of whom had their learning landscape
significantly altered during COVID, with almost a year of virtual
education. They, along with most children across the globe, had
significant disruption to their learning and well-being, though I am
fortunate that my kids are now in school and doing well.
But we know that many are suffering. Even before the pandemic,
youth mental health challenges were rising, with suicide being the
second leading cause of death for youth ages 10-24.
As noted by Surgeon General Murthy during last week's hearing, one
of the most central tenets of creating accessible and equitable systems
of care is to meet people where they are. For most young people, this
is in schools.
I often think back to a story that my dad, who is now 85, told me
about his first day of school. He grew up in a very small town in rural
West Texas called Spur. They didn't have pre-K or Kindergarten, so it
was first grade, and on that first day he recalls that he and his peers
received toothbrushes from their classroom teacher; It was the first
toothbrush he ever owned.
I remember asking him, ``You didn't have toothbrushes?'', to which
he replied, ``No, my family wouldn't have spent money on toothbrushes
back then.'' Mind you, my dad went on to a long career in computer
science where he helped create the coding to put our astronauts on the
moon. He often credits those teachers in his early years who cared
about him with setting him on that path. When I consider that moment
when he received his toothbrush on the first day of school, I think of
it as a classic example of how our schools are a vital place to promote
our children's health and well-being.
We cannot rely on our health-care system alone to support the
mental health and well-being of young people. We know on average people
do not get into care for over a decade after their initial onset of
symptoms and half of mental illnesses begin during the school age
years.
Our traditional approach to mental health care has not leveraged
the natural venues where our young people access support; It is akin to
waiting for toothaches, cavities, and abscesses until a child gets
proper dental care. Instead, we should do the equivalent of passing out
toothbrushes and providing preventive and early dental care, by
offering every child in every school the social, emotional, and mental
health supports they need to be successful.
Increasingly, schools have comprehensive school mental health
systems, reflecting partnerships between the education and behavioral
health sectors to support a full continuum of mental health supports
and services, from promotion to treatment.
Every child deserves to have this type of mental health support in
their school. Schools that have these systems in place are doing this
because they recognize that:
Poor mental health leads to poor learning; and
Positive mental health promotes academic and life success.
When we provide mental health promotion for all students and
accessible mental health interventions in schools, we take positive
steps to remedy student inequities in both education and health care.
When treatment is delivered in the school setting, youth are far more
likely to be identified early, and to initiate and complete care.
There are many policy and funding opportunities advance a full
continuum of mental health supports and services in all schools, and
Congress has the opportunity to support investment and technical
assistance to ensure that young people get the mental health support
they need.
In my written testimony, I provide detail on several steps that
Federal and State leaders can take to advance comprehensive school
mental health systems.
We have witnessed many States adopt new policies to advance school
mental health systems. Tomorrow, the Hopeful Futures Campaign, a
coalition of national organizations committed to ensuring that every
student has access to effective and supportive school mental health
care, is releasing the first ever ``America's School Mental Health
Report Card and Action Center,'' with individual report cards for all
50 States and DC. These school mental health report cards highlight
accomplishments and provide important action steps to help address the
children's mental health crisis in every State. They serve as a great
starting point for policymakers who want to strengthen school mental
health supports and policies in their communities. You can find the
report cards at https://hopefulfutures.us/ starting tomorrow morning.
Today, Americans across the country are united in their concern
about the mental health of our young people and the impact it has
throughout their lives.
I want to express my gratitude to you all for opening up this
important discussion on youth mental health, for recognizing schools as
an essential place to strengthen our children's well-being, and for
committing to investing now to create hopeful futures for our Nation's
youth.
All schools in the United States should have Comprehensive School
Mental Health Systems that:
- Implement organizational and individual strategies to promote
educator well-being.
- Offer mental health literacy for K-12 staff and students
including knowledge of obtaining and sustaining positive mental health,
understanding mental illness, and promoting help-seeking.
- Integrate social emotional learning into the K-12 curricula to
promote self-awareness, self-management, responsible decision-making,
relationship skills, and social awareness.
- Assess and engage in continuous improvement toward positive
school climate.
- Conduct regular student well-being check-ins to assess
subjective well-being, mental health, connectedness, and supports.
- Hire, retain, and offer ongoing professional development to a
full complement of student support professionals, including school
psychologists, school social workers, and school counselors.
- Establish formal partnerships (e.g., memoranda of understanding)
with community behavioral health providers to offer on-site school
mental health services and supports and to facilitate referrals and
coordination of community-based mental health services.
- Offer school-based, multi-tiered mental health supports and
services to promote students' academic, social, and psychological
development
Policies to Support Universal Mental Health Promotion and Prevention
Policies
Require the selection of indicators of student mental health and
well-being as a core metric of school performance under Federal
education funding, with provisions to assist schools as they strive to
perform well on these indicators. Indicators may include school
climate, student-reported subjective well-being and distress, and
reports of school connectedness.
Incentivize teaching education programs to include mental health
literacy to improve the capacity of the educator workforce to: promote
mental health of all students in the classroom, including teaching of
social-emotional learning competencies; identify mental health concerns
and link students to needed supports and services; reduce stigma
related to mental illness; and promote student and family help-seeking.
Establish mental health as a State-required component of K-12
curricula, with efforts in New York and Virginia as examples. The
Federal Government could support this State-level effort by passing a
resolution encouraging States to follow existing State efforts to
integrate mental health into curricula and by providing direct funding
for educator training and ongoing professional development.
Leverage Federal title I and title IV funding to provide
universal mental health programming for students, including social-
emotional learning programming. Joint guidance by the U.S. Department
of Education and the U.S. Department of Health and Human Services could
support States as they navigate these funding mechanisms to support
universal mental health in schools.
Expand Federal grants to State and local education and
behavioral health authorities to increase mental health awareness and
promotion in schools. This could include the expansion of grant
programming initiated in recent years by SAMHSA (e.g., Project AWARE)
and the U.S. Department of Education (School Climate Transformation)
that require funded States to partner with three local jurisdictions to
promote student well-being and mental health training and awareness for
school staff, and then to scale successful efforts statewide.
Policies to Support Early Identification, Intervention, and Treatment
in Schools
Expand existing Federal workforce development programs (e.g.,
Behavioral Health Workforce Education and Training Program, National
Health Service Corps, Minority Fellowship Program) to increase the
school mental health workforce. This strategy can also be applied to
Federal loan repayment programs by increasing incentives for providers
who choose schools as a service setting.
Expand Federal, State, and local funding to ensure adequate
staffing and professional development for student instructional support
personnel, including school psychologists, school social workers,
school counselors and school nurses. Funding expansion could include
increased investments in title I of the Every Student Succeeds Act
(ESSA) to provide additional mental health staffing for students living
in poverty and in title I, title II, and title IV of ESSA and IDEA to
increase opportunities for professional development. State and local
investments could include competitive salary and benefits packages to
recruit and retain school mental health providers and supplementing
Federal funding for staffing and professional development.
Require health plans to reimburse for mental health screenings
conducted in schools. Follow guidance from the American Academy of
Pediatrics and the American Academy of Child and Adolescent Psychiatry
to cover universal mental health screening as a mechanism for improving
mental health and reducing mental illness. Coverage should include
screening conducted during well-child exams in pediatric primary care,
and also extended screening conducted in schools.
Maximize Medicaid, Children's Health Insurance Program (CHIP),
and private reimbursement for school mental health services, including
early identification, intervention and treatment. This may include
better understanding and leveraging existing State Medicaid allowances
for school mental health or the initiation of State plan amendments to
improve school mental health coverage. As outlined in the 2019 Joint
Informational Bulletin from The Centers for Medicaid and Medicare
Services (CMS) and (SAMHSA), several States already access Medicaid and
other payers, including private insurers, to cover school and community
professionals' delivery of mental health services in schools. The
Centers for Medicaid and Medicare Services (CMS), the U.S. Department
of Education and the U.S. Department of Health and Human Services could
offer technical assistance to States seeking to improve Medicaid and
other payer coverage of school mental health. *
Expand reimbursement and technical assistance for telemental
health services in schools. Given the current national shortage of
mental health specialists, particularly in rural settings, schools will
benefit from access to telemental health consultation and direct
service, facilitated by public and private insurance coverage and
Federal- and State-supported technical assistance.
Implement accountability mechanisms that require the
implementation of high-quality, evidence-based practices that align
with national performance standards for school mental health. Federal,
State, and local investments should shift their metrics away from
counting frequency and duration of services to measuring the
implementation of national best practices for school mental health care
and impact of school mental health services provision on psychosocial
and academic outcomes.
*Additional detail on financing school mental health:
Successful systems draw from a wide array of sources, including
(but not limited to) legislative earmarks and Federal block and project
grants (e.g., Project AWARE State Education Agency Grants), State or
county funding, fee-for-service revenue from third-party payers
(including State Children's Health Insurance Programs, Medicaid, and
commercial insurance), and private individual donors and private
foundations.
Of note, Medicaid is the backbone of the school mental health
system in all 50 States and DC, providing sustainable funding for
services to students delivered by mental health professionals,
including school psychologists, school counselors, school social
workers and more.
Sixteen States have successfully expanded their school-based
Medicaid programs to cover services--including mental health--delivered
in schools to all students. These States have experienced or predict a
significant increase in Medicaid funding allowing school districts to
hire more staff and better support the school health and mental health
professionals in schools.
Medicaid also allows school districts to set up partnerships with
community-based mental health providers, like community mental health
centers. Through these partnerships, schools can increase access to
services.
Congress can support student mental health by encouraging all
States to cover all medically necessary mental health services,
including prevention services, for all Medicaid enrolled students and
by ensuring school Medicaid programs have updated guidance, best
practices, and the technical assistance they need.
______
Questions Submitted for the Record to Sharon Hoover, Ph.D.
Questions Submitted by Hon. Sherrod Brown
school-based mental health care
Question. In the midst of the pandemic, children and young adults
have faced unprecedented challenges, ranging from dramatic shifts in
social interactions and schooling to the tragic loss of family members
and caregivers, among numerous other struggles. Depressive and anxiety
symptoms have doubled, with 25 percent of youth experiencing depressive
symptoms and 20 percent experiencing symptoms of anxiety. In early
2021, emergency department visits for suspected suicide attempts were
51 percent higher for adolescent girls and 4 percent higher for
adolescent boys compared to rates for the same period in 2019. Yet,
preliminary data show a 32-percent drop in mental health service use
among children covered by Medicaid and CHIP from March 2020 to February
2021 compared to the same period in the prior year. Many experts
attribute this disparity to pandemic-related school closures, which
limited or suspended access to mental health care through those
settings.
1. As outlined in the 2019 Joint Informational Bulletin from The
Centers for Medicaid and Medicare Services (CMS) and SAMHSA, several
States already access Medicaid and other payers, including private
insurers, to cover school and community professionals' delivery of
mental health services in schools.
How can full service community schools \1\ and schools that
provide comprehensive mental health-care services better coordinate
with local service providers to meet the needs of students covered by
Medicaid and CHIP?
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\1\ https://oese.ed.gov/offices/office-of-discretionary-grants-
support-services/school-choice-improvement-programs/full-service-
community-schools-program-fscs/.
Answer. Better coordination between full service community schools
and schools that provide comprehensive mental health services and local
services providers is key to meeting the needs of students covered by
Medicaid and CHIP. Detailed below are best practices States are
implementing to improve coordination:
Issue Clear Guidance That Encourages Partnerships Between Local Service
Providers and School Districts
Many States do not provide school districts and local service
providers with guidance to support partnerships. When in place,
guidance can play a key role in facilitating partnerships and ensuring
both parties understand the value of collaborating and how to establish
effective partnerships.
For example, a key element of Missouri's expansion of their school-
based Medicaid program was the way it encouraged partnerships with
community-based mental health providers to increase behavioral health
services in schools.\2\ This leveraged the existing relationships that
many school districts had with community-based providers, by clarifying
that these providers can be reimbursed for delivering services in
schools, as long as they are a qualified Medicaid provider with the
required licensure and credentials. Partnering with community-based
providers also offered a route to expanding school-based behavioral
health services for the many school districts in the State that do not
participate in the school-based Medicaid program, or had concerns about
their bandwidth to do additional Medicaid billing.\3\
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\2\ Missouri Department of Social Services, Behavioral Health
Services in a School Setting, https://dss.mo.gov/mhd/providers/pdf/
bulletin40-54_2018apr17.pdf.
\3\ Healthy Schools Campaign, Expanding School-Based Medicaid in
Missouri, https://drive.google.com/file/d/
1cWfagNHY_tuxD7PbI_Iqbnk8uAMU7cmn/view.
The National Center for School Mental Health (NCSMH,
www.schoolmental
health.org), funded by the U.S. Department of Health and Human
Services, Health Resources and Services Administration, established
national performance standards for school-community teaming. The NCSMH
issued the corresponding School Mental Health Systems Quality Guide:
Teaming,\4\ providing States and districts guidance and tools for
establishing effective school-community partnerships that leverage
multiple funding resources, including Medicaid. As outlined in the
Guide, a process that has been successful in many communities to foster
school-community partnerships is the establishment of a request for
proposals (RFP) issued by school districts to solicit engagement of
community behavioral health partners with clear expectations for
school-based service provision, data gathering, target outcomes, and
funding.
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\4\ National Center for School Mental Health, School Mental Health
Quality Guide: Teaming, https://www.schoolmentalhealth.org/media/SOM/
Microsites/NCSMH/Documents/Quality-Guides/Teaming-7.16.21.pdf.
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Facilitate Data Sharing Between Local Service Providers and School
Districts
Ensuring data, both aggregated and disaggregated, can be shared
between local services providers and school districts is needed to
support care coordination and ensure the children in greatest need of
services are identified and supported. Multiple States are taking steps
to facilitate data sharing across child serving agencies to better
target services and supports.
For example, the District of Columbia improved coordination and
service delivery by implementing a data sharing agreement between the
District of Columbia State Board of Education, District of Columbia
Department of Health, and the DC Department of Health Care Finance (the
District of Columbia's Medicaid agency). The agencies collaborated to
ensure compliance with the Family Educational Rights and Privacy Act
and used the data to target outreach and resources to schools and
students with the greatest unmet needs.\5\
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\5\ Healthy Schools Campaign, Sharing Data to Meet Student Health
Needs in Washington, DC, https://healthyschoolscampaign.org/blog/
sharing-data-meet-student-health-needs-washington-d-c/.
The State of Connecticut partnered with a purveyor organization,
the Child Health and Development Institute (CHDI, www.chdi.org), to
establish a statewide electronic platform, the EBP Tracker, to collect
data on evidence-based interventions being delivered in schools and
other community settings. Results from their analyses show that the use
of EBPs delivered in schools resulted in improved psychosocial and
educational outcomes and reduced or eliminated disparities for children
of color compared to usual care.\6\
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\6\ Child Health and Development Institute, EBP Tracker, https://
www.chdi.org/our-work/mental-health/evidence-based-practices/ebp-
tracker/.
Additional examples and best practices for data sharing between
community providers and school districts are available in Data Sharing
Across Child-Serving Sectors: Key Lessons and Resources, a report by
Nemours Children's Health System and Mental Health America.\7\
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\7\ Data Sharing Across Child-Serving Sectors: Key Lessons and
Resources, Nemours Children's Health System and Mental Health America,
https://www.movinghealthcareupstream.org/wp-content/uploads/2020/01/
data-sharing-brief.pdf.
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Leverage Telehealth to Connect School Districts With Local Service
Providers
Across the country, telehealth is increasingly being used to
connect students to local service providers to ensure they receive
necessary school health services. The partnerships require coordination
between all parties and create an important opportunity to amplify the
impact of available providers.
For example, in 2016, South Carolina's Governor signed S.B. 1035
into law to increase access to telehealth, including in schools. As of
2019, the State's telehealth program has expanded to over 80 schools,
focusing on schools with students who experience the greatest health
disparities. The South Carolina Department of Education and South
Carolina Medicaid were key in expanding telehealth services. Through
the telehealth program, school nurses are linked with community
providers to coordinate acute and chronic disease management services
as well as mental health services.\8\
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\8\ Building a School-Based Telehealth Program in South Carolina,
Healthy Schools Campaign, https://healthystudentspromisingfutures.org/
wp-content/uploads/2019/07/SouthCarolinaTele
healthCaseStudy.pdf.
Question. In your testimony, one of the policies you recommend to
better support early identification, intervention, and treatment in
schools is to ``maximize Medicaid, CHIP, and private reimbursement for
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school mental health services.''
Can you please elaborate on this recommendation?
Answer. Sustainable funding streams are critical to better
supporting early identification, intervention and treatment in schools.
Currently, school districts fund the delivery and implementation of
these services and programs through a patchwork of funding, often
including one-time grant funds that are not sustainable and time-bound.
Supporting States and school districts in leveraging health-care
funding to deliver this work is necessary to fully leverage the role
schools can play in meeting the mental health needs of children and
youth.
Currently, many school districts access Medicaid and CHIP funding
to support the delivery of school health services but very few are able
to access private insurance since private insurers rarely recognize
schools as eligible sites of service delivery. When it comes to
Medicaid and CHIP funding, only 16 States allow school districts to
bill Medicaid for services delivered outside of an Individualized
Education Program (IEP). Since early identification and intervention
services are rarely included in a students' IEP, there is a need to
ensure the remaining 34 States and the District of Columbia expand
their school Medicaid programs to allow school districts to bill for
all medically necessary services delivered to all Medicaid enrolled
students.
Community-based and community-linked providers, including school-
based health centers, also bill Medicaid and CHIP for eligible services
and are better positioned to seek reimbursement from private insurers.
However, there is still a need to support these providers in maximizing
funding for services delivered in schools since providers may not
understand they can bill insurance for school health services,
understand how to bill, or understand how to establish partnerships to
deliver these services. Ensuring community-based and community-linked
providers understand the opportunities for reimbursement is critical to
supporting partnerships between school districts and outside providers
and meeting student mental health needs.
Question. Would you suggest the Centers for Medicaid and Medicare
Services (CMS) and the U.S. Department of Education provide best
practices to States seeking to improve Medicaid and other payer
coverage of school mental health, in addition to offering technical
assistance?
Answer. Yes, there is a tremendous need for best practices to
support States and school districts in leveraging Medicaid and other
payer coverage and for additional technical assistance. In our work and
the work of partners with States and school districts across the
country, the need for best practices and technical assistance continue
to emerge as top requests of CMS and the U.S. Department of Education.
A best practices document that highlights the different ways States
and school districts are leveraging Medicaid funding and funding from
other payers to expand access to school mental health services and
programs can help break down siloes that exist between Medicaid and
education and ensure States and school districts understand the menu of
options for structuring their school Medicaid programs.
Question. As you state in your testimony, Medicaid is the backbone
of the school mental health system, and helps school districts
establish partnerships with other community-based mental health
providers which help increase access to services for students and the
broader community.
Can you please elaborate on the 16 States that have successfully
expanded their programs to cover services in schools? What are their
best practices for using Medicaid to build out services, hire
additional staff, and meet children where they are?
Answer. There are now 17 States that have successfully expanded
their school Medicaid programs: Arkansas, Arizona, California,
Colorado, Connecticut, Florida, Georgia, Kentucky, Louisiana, Maine,
Michigan, Minnesota, Missouri, North Carolina, New Hampshire, Nevada,
and South Carolina.\9\ In addition, Illinois, Indiana, New Mexico,
Oregon, and Virginia are in the process of expanding their school
Medicaid programs. All 50 States and the District of Columbia have
school Medicaid programs that allow school districts to seek Medicaid
reimbursement for Medicaid eligible services included in a student's
Individualized Education Program (IEP) or Individualized Family Service
Plan (IFSP). The 17 States that have expanded their programs allow
school districts to bill for additional services not included in a
student's IEP or IFSP. In the majority of these States, this means
allowing school districts to bill Medicaid for all medically necessary
services delivered to all Medicaid enrolled students. Expanding school
Medicaid programs to include services delivered outside of students'
IEPs or IFSPs presents a significant opportunity to increase access to
and resources for school mental health services.
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\9\ State Efforts to Expand School Medicaid Through the Free Care
Policy Reversal, Healthy Schools Campaign, http://bit.ly/
freecareupdate.
The majority of the 17 States that have expanded their school
Medicaid programs did so in the last 3 years. As a result,
implementation and documentation of the impact of this policy change
was impacted by COVID-19 and the resulting school building closures.
For many States, the 2021-2022 school year was the first full year of
program implementation. As a result, data is still being collected on
the overall impact. With that being said, initial data and projections
are promising and indicate a significant increase in Medicaid revenue
generated by the program and, in many cases, an increase in school
health providers. For example, Michigan is one of the 16 States that
has expanded their program. The State has been able to use the increase
in Medicaid funding, coupled with an investment from the State, to go
from 1,738 school-based behavioral health providers statewide to 2,975
school-based behavioral health providers statewide and increased school
nursing staff from 253 to 307.\10\
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\10\ U.S. Department of Education, Supporting Child and Student
Social, Emotional, Behavioral, and Mental Health Needs, https://
www2.ed.gov/documents/students/supporting-child-student-social-
emotional-behavioral-mental-health.pdf.
Best practices for using Medicaid to build out services, hire
additional staff, and meet children where they are include the
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following:
Align State education and State Medicaid qualifications for
school health providers. Many States are working to align their State
education and State Medicaid standards to ensure all qualified school
health providers are recognized as Medicaid eligible. This is a key
strategy to ensure that school districts are able to maximize Medicaid
reimbursement for the school Medicaid program and to incentivize school
districts to hire qualified school mental health professionals. For
example, States are increasingly adding marriage and family therapists,
behavior health analysts, registered behavior technicians and alcohol
and drug counselors as Medicaid eligible in the school-based setting.
Recognizing all qualified mental and behavioral health providers as
Medicaid eligible in the school-based setting is a key strategy to
ensuring schools are able to maximize the available mental health
workforce and receive sustainable funding to support access to these
providers in the long run.
Invest in State infrastructure to support implementation.
States with strong State infrastructure to support implementation of
the school Medicaid program are able to better leverage Medicaid funds
to expand access to school health services. This infrastructure
includes training for school districts on program implementation, a
designated website to house all program related materials, ongoing
technical assistance for school districts including regular trainings
and help desks and technology platforms, including those that support
the use of telehealth and electronic health records.
Build cross-agency collaboration. Dedicated school Medicaid
staff in both the State education agency and State Medicaid agency
level who can collaborate to implement a State's school Medicaid
program is critical. The States that have the strongest school Medicaid
programs are those with dedicated school Medicaid staff in both the
State education agency and State Medicaid agency who can coordinate
program implementation, oversee training and technical assistance and
collaborate to develop program resources. For example, Louisiana was
the first State to expand their school Medicaid program and has used
the additional Medicaid revenue, in addition to COVID relief funding,
to hire dedicated staff in both the State education and State Medicaid
agencies to oversee the program. In addition, the State agencies have
worked together to build out a school Medicaid resource library to
support school district implementation.\11\
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\11\ Louisiana Department of Education, School-Based Medicaid
Resources, https://www.louisianabelieves.com/schools/public-schools/
school-based-medicaid-services.
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Reinvest school Medicaid revenue in school health and wellness
programs: In many States, revenue generated by the school Medicaid
program goes to school districts' general revenue fund and is not
required to be reinvested in school health and wellness programs and
services. A few States, including California, Colorado, and Louisiana,
require revenue generated by the school Medicaid program be reinvested
in school health and wellness activities. This is a key strategy to
ensure additional Medicaid revenue ultimately supports school health
and wellness and is used to strengthen and expand the delivery of
school health services.
Question. What can the other 34 States learn from what these 16
States are doing well?
Answer. In addition to the best practice highlighted above, the
States that have not expanded their programs to date can learn the
following from those that have:
States should expand their programs to cover all medically
necessary services delivered in the school-based setting. States are
amending their State Medicaid plans to allow school districts to bill
Medicaid for services delivered to Medicaid enrolled students that are
included in an IEP, IFSP, 504 plan, other individualized health or
behavioral health plan, or where medical necessity has been otherwise
established. This is important because it allows States and school
districts the flexibility to cover all the services a student may need
that can be provided in a school-setting by a qualified provider.
Further, it signals that the school is simply the site of service at
which a Medicaid enrolled student can get care--rather than as a unique
benefit. CMS has been highly supportive of States making this change.
States should include the school Medicaid program under the
Early and Periodic Screening, Diagnostic, and Treatment (EPSDT)
benefit. Under the advice of CMS, States are recognizing their school
Medicaid programs as a part of their EPSDT benefit. This is an
important change that enables school districts to bill for any EPSDT
service delivered by any Medicaid enrolled provider recognized under
EPSDT.
Cross-agency coordination is key to successful expansion and
implementation. As States move forward with expanding their school
Medicaid program it is critical that one agency does not lead this work
alone. While the Medicaid State plan amendment must ultimately be
submitted by the State Medicaid agency, States are best setup for
success when the State Medicaid agency collaborates with the State
education agency to make policy decisions and ideally collects input
from school districts as well. It is also critical that the State
education agency plays an active role in implementation of the expanded
program, including supporting school district training and
communicating with school districts about the programmatic changes.
Question. How can Congress support and encourage more States to
expand their school-based Medicaid programs to cover more services,
including mental health services?
Answer. Congress can support school Medicaid by working with CMS to
modernize the existing school guidance and promoting best practices in
school Medicaid, including in prevention and mental health services.
CMS' school Medicaid guides were last updated in 2003 and 1997. Updated
guidance is key to ensuring States and school districts understand how
to implement the school Medicaid program without exposing themselves to
risk of audit. A number of States are hesitant to move forward with
expanding their school Medicaid programs because the current guides
from 1997 and 2003 explicitly state that schools cannot bill Medicaid
for services delivered outside of an IEP or IFSP. While this position
was clearly changed with a 2014 State Medicaid directors letter, States
are hesitate to move forward until guidance is updated to reflect this
policy change.\12\
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\12\ Centers for Medicare and Medicaid Services, Medicaid Payment
for Services Provided Without Charge (Free Care), https://
www.medicaid.gov/federal-policy-guidance/downloads/smd-medicaid-
payment-for-services-provided-without-charge-free-care.pdf.
Additional ways in which Congress can support and encourage States
---------------------------------------------------------------------------
to expand their school-based Medicaid programs include the following:
Provide funding to CMS for the establishment of a technical
assistance center to support States and school districts who want to
improve the delivery of Medicaid mental health services in schools.
Provide funds to States to work with small and rural school
districts to do planning and technological improvements to participate
in school Medicaid.
Provide an increased FMAP for any mental health service
delivered in a school-based setting by a district-employed provider or
a community-based provider.
______
Prepared Statement of Jodie L. Lubarsky, M.A., LCMHC, Vice President of
Clinical Operations, Youth and Family Services, Seacoast Mental Health
Center, Inc.
Chairman Wyden, Ranking Member Crapo, Senator Hassan, and members
of the U.S. Senate Committee on Finance, I want to thank you for the
opportunity to testify and submit a written statement regarding
pediatric mental health.
In March of 2020, life as we once knew it changed for all of us. As
adults, we made many quick pivots to respond and adapt to the COVID-19
pandemic. As we made many adaptations in both our personal and
professional lives, we had our past experiences to reflect upon. When
faced with the new and often unpredictable challenges the pandemic
created, we pulled from our toolbox of coping strategies. We knew who
we could turn to for the extra support we might have needed as we
navigated those challenges. But, for most of the youth in our country,
they were left feeling paralyzed, stymied, hopeless, and scared. For
many youth, this was their first experience with grief, trauma,
depression, or anxiety. Life for them had completely changed and their
worlds were turned upside down. The uncertainty, social isolation, and
stressors related to the pandemic, have left many kids unable to cope
or understand the breadth and depth of this experience. For some youth,
there is no trusted adult to support them during this critical
developmental period. Many lack a social support network. Many remain
isolated from peers and other trusted adults. And, for too many youth,
their only means of symptom relief is contemplating death.
We are learning that teenage girls have begun to demonstrate an
increase in the acuity of their symptom presentation. Data from the
Centers for Disease Control and Prevention indicates a 51 percent
increase in suicide attempts by teenage girls ages 12 to 17. LGBTQ+
youth continue to have higher rates of suicide than their heterosexual
peers. And, according to a Wisconsin NPR piece in March 2021, data from
2020 demonstrated that ``the percentage of emergency department visits
for mental health emergencies rose by 24 percent for children between
the ages of 5 and 11 and 31 percent for those 12 to 17, compared with
2019.'' Youth mental health has become the secondary pandemic to the
COVID-19 pandemic.
As mental health needs rose for pediatric patients, the
availability of services continues to become more scarce. Youth are
presenting to hospital emergency rooms in a state of psychiatric
crisis. Many who are assessed and meet the criteria for psychiatric
inpatient level of care will be faced with boarding in an emergency
room for days, weeks and sometimes months until a bed becomes
available. Emergency room boarding often creates more distress,
decompensation in psychiatric symptoms, and increased traumatic
exposure, while receiving no mental health care until the inpatient bed
becomes available. Staffing shortages in both outpatient and inpatient
settings due to an exhausted, depleted, and underpaid mental health
workforce has only prolonged access to care for pediatric patients.
Without adequate funding and reimbursement structures from both
Medicaid and private payers, mental health providers are left with the
difficult decision to leave the nonprofit world and enter the for-
profit world in order to make a livable wage. During the pandemic,
there were two 3-percent increases to Medicaid rates.
And while that is appreciated, prior to those two increases there
had not been meaningful increases in Medicaid rates in over 20 years.
Without a realistic reimbursement structure based on current cost of
living, centers are losing staff who can no longer afford to work in
mental health settings. Some mental health centers are reporting a 40-
percent turnover in staffing, during the pandemic, leaving no workforce
available to attend to the critical and fragile needs of pediatric
patients. And for the mental health workforce that remains, they are
often left supporting higher caseloads than their private practice
peers, with limited time while attending to significant administrative
tasks that private mental health providers are not expected to
complete.
While we can discuss an ideal service array, evidence-based
practices, and the ideal care setting, none of this can be provided
without a robust, well-trained, adequately compensated, and sustainable
mental health workforce from all professional disciplines and degree
levels. Simply put, we need to be able to adequately compensate the
mental health workforce in order to have a sustainable and robust
mental health workforce to provide high-quality, timely, adequate care
to our pediatric population.
Mental health care needs to be both accessible and realistic. A
continuum of care must include prevention, intervention, and education.
As schools return to in-person learning environments, teachers,
paraprofessionals, guidance counselors, and building administrators are
witnessing the exacerbated mental health needs of the students entering
school buildings every day. Faced with the added pressures of testing
students and overwhelming them with missed academic instruction,
teachers report feeling professionally stretched and uncertain of how
to support the social and emotional health needs of students. Teachers
are not provided training on pediatric mental illness. Teachers do not
know how to intervene. A component of prevention should be affording
schools the professional development time needed to better understand
pediatric mental health and for educators to become certified in Youth
Mental Health First Aid. Youth Mental Health First Aid would provide
educators with a foundational understanding of the signs and symptoms
of an emerging mental health need, how to offer timely support, and
bridging a student to the appropriate mental health professional and
level of care to attend to the student's mental health needs.
There is no one-size-fits-all option for mental health care. The
pandemic created the opportunity to reduce barriers to accessing care
with the expansion of telehealth services. In addition to telehealth,
mental health care provided in the office, home, community, and school
settings needs to be supported and adequately reimbursed for by both
Medicaid and private payers. Different levels of care need to exist
within the intervention continuum. Traditional office-based therapy
does not meet all mental health needs and not all pediatric mental
health patients will require an inpatient level of care. Intensive
outpatient or partial hospitalization programs need to be established
and adequately funded to be sustained in the mental health treatment
continuum. Mental health providers should be adequately reimbursed by
all payers to sustain a variety of treatment and programming options.
And, evidenced-based practices should be reimbursed at enhanced rates
to account for the required clinical consultation, professional
development, and time to complete required fidelity implementation
reviews.
A bipartisan spirit to adequately fund pediatric mental health
services is one of many ways to address the growing pediatric mental
health surge. Care must be affordable, available, and mental health
providers must be adequately reimbursed to sustain a mental health-care
workforce. Telehealth and telephonic services must remain an option
within the service array to reduce barriers to accessing care, but not
be the primary option for care delivery. But we must erase the stigma
associated with mental illness to make a meaningful impact! The stigma
and shame that continues to persist for individuals struggling with
mental illness continues to be a significant barrier to recognizing the
need for and accessing mental health care. Respect, compassion, and
patience must be afforded to every person struggling with their mental
health. We must all act as ambassadors for reducing the stigma
associated with having a mental illness and accessing appropriate care.
One in five individuals will struggle with a serious mental illness,
yet most individuals will delay accessing care for 10 years after the
onset of symptoms. Fifty percent of all lifetime mental illness begins
by age 14 and 75 percent by age 24. We have an obligation to provide
prevention and early intervention and to offer hope and recovery for
all children and adolescents struggling with their mental health. We
know that suicide is the second leading cause of death among people age
10-34, yet we continue to stigmatize those who seek care. We continue
to shame those with struggle. Until we can acknowledge, treat, and
offer respect to all individuals with mental illnesses and offer mental
health patients the same respect we would provide any individual
receiving care for a physical health issue, we will never be able to
make a meaningful difference. We all need to challenge the stigma that
persists. We all need to advocate on behalf of those who are struggling
with their mental health because at any moment, they could be us, our
child, or a loved one.
______
Questions Submitted for the Record to Jodie L. Lubarsky, M.A., LCMHC
Questions Submitted by Hon. Sherrod Brown
school-based mental health care
Question. In the midst of the pandemic, children and young adults
have faced unprecedented challenges, ranging from dramatic shifts in
social interactions and schooling to the tragic loss of family members
and caregivers, among numerous other struggles. Depressive and anxiety
symptoms have doubled, with 25 percent of youth experiencing depressive
symptoms and 20 percent experiencing symptoms of anxiety. In early
2021, emergency department visits for suspected suicide attempts were
51-percent higher for adolescent girls and 4-percent higher for
adolescent boys compared to rates for the same period in 2019. Yet,
preliminary data show a 32-percent drop in mental health service use
among children covered by Medicaid and CHIP from March 2020 to February
2021 compared to the same period in the prior year. Many experts
attribute this disparity to pandemic-related school closures, which
limited or suspended access to mental health care through those
settings.
Teachers, staff, and faculty are often the first line of defense
when identifying signs of mental distress in a student.
What structural supports can schools adopt so that educators are
better equipped to conduct regular student well-being check-ins and
identify and support students exhibiting signs of mental distress or
trauma, including signs of Adverse Childhood Events (ACEs)?
Answer. As a mental health provider within a community mental
health center, we have been able to partner with schools in our region
to deliver mental health services to students during their academic
day. It has offered insight into both the needs of the students and
what the education staff encounter when providing instruction.
When considering the structural supports that a school may need to
adopt in order to better equip themselves to support student well-
being, we must begin with better education to community members, school
boards, administrative leaders, and parents about pediatric mental
health. There seems to be a large cohort of individuals who do not
understand that one in five children will be diagnosed with a mental
health condition or that 40 percent of all mental health needs arise
during childhood and adolescence. These community members have failed
to recognize the importance of early intervention as a tool for
preventing long-term mental health decompensation in children. Simply
stated, the sooner we intervene the greater opportunity for recovery.
As a result, schools in our State report having to change their consent
to provide mental health care in schools from using language that says,
``mental health'' to ``behavioral health'' due to community protests.
Rather than utilizing an opt-in process for participation, schools are
shifting to opt-out language in consent for participation forms. When
community members create barriers to providing care in school settings,
it seems to leave very few options for interventions. In an ideal
world, all guardians of children enrolled in public and private school
settings would be required to participate in social emotional programs
to provide them with a foundational understanding of pediatric mental
health, signs and symptoms, and treatment options for pediatric
patients. Programs would be targeted at erasing the stigma, so schools
and mental health providers can deliver care without barriers or
interruption. Utilizing evidenced-based universal screeners like the
PHQ-9 or Brief Columbia Suicide Severity Rating Scale will allow for
early identification of a student's needs and an opportunity to bridge
the student to mental health supports outside of the school setting in
an informed manner. This early identification would provide early
assessment of adverse childhood experiences and an opportunity to
provide clinical and social supports to pediatric patients. When
schools adopt the usage of screeners used by pediatricians and mental
health-care providers, it allows them to speak a common language with
those professional in order to support pediatric mental health needs
and refer patients to the most appropriate level of care.
Question. What tools, resources, and guidance are necessary to
ensure schools meet current student needs and adopt a model of
prevention moving forward?
Answer. I must acknowledge that my background is not one of
academics but of community mental health. As someone who has worked
with schools in my current role for over 15 years and more specifically
reflecting upon the last 2 years, it appears schools could use more
support on the implementation of social emotional programs in academic
settings. Educators in our community have reflected on the significant
pressure they are facing to catch students up on the academics that
they may have been lost during the pandemic. They report pressure from
school boards, administrators, and caregivers to force an accelerated
style of learning in order to cover missed material and increase test
scores. Many educators report having no background or knowledge about
pediatric mental health care, yet they see the mental health needs of
their students walk into their classrooms every day. They report a
frequent dilemma of trying to support unique emotional needs without
foundational mental health training and the stress of administrating
assessment exams while trying to complete their classroom instruction.
A clearinghouse for educators similar to Substance Abuse and Mental
Health Services Administration that mental health-care providers use
that recommends
evidence-based social emotional programs for schools that are
culturally and linguistically considerate of the unique pediatric
emotional and developmental needs will allow districts to select
programming that can be braided into academic curriculums without
directly disrupting academics. Schools should be viewed as a component
of the prevention spectrum. Schools should consider their role to
identify pediatric mental health needs in students as an opportunity to
bridge a student over to structured mental health-care supports.
Programs like Project AWARE that utilize multi-tiered systems of
identification and support in collaboration with mental health-care
providers allows schools to play a role in pediatric mental health care
without having to deliver all the mental health supports that a student
might need, especially since many educators and guidance counselors do
not have the same training can mental health-care providers to diagnose
and treat mental illness.
Training all educators, paraprofessionals, auxiliary staff, and
building administrators in Youth Mental Health First Aid is another
component of prevention spectrum. YMHFA trains adults to recognize
signs and symptoms, strategies for offering support, and bridging a
youth and their family to appropriate mental health services when the
need arises. It provides the foundational understanding that many
educators lack and would offer much needed training and resources to
those adults who might be the first point of contact for a student
experiencing a mental health crisis in the classroom, on the
playground, in the cafeteria, or at after school activities.
Question. What resources, technical assistance, or other supports
can Congress provide to attract and retain high-quality, certified
mental health providers in schools, particularly in low-income areas?
Answer. As Congress considers more resources, technical assistance,
or other supports to attract and retain high quality certified mental
health providers, Congress should continue to support and expand loan
forgiveness programs. While the Student Loan Repayment Program (SLRP)
has been helpful, access by professionals has been limited. With a
limited number of eligible spots and funding, not every professional
who could be eligible is able to access the program when the funding
has been exhausted. Increased funding to SLRP and creating more
eligibility opportunities for staff employed in settings than serve
disadvantaged populations would attract and retain more staff based on
the forgiveness expectations of the SLRP. Many staff view the
forgiveness of their student loans as a benefit when considering
employment in non-profit settings. For many staff, after completing
their forgiveness expectation, they continue to remain employed at the
organization and take advantage of additional educational or
professional development opportunities.
Creating a deliberate crosswalk between higher education settings
and mental health centers that offer accessible and affordable
education at both the bachelor's and master's level would assist in
attracting and retaining staff. For full-time employees who need to
continue working while attending school, being able to access their
academics in their work environments promotes and supports professional
development. This concept of offering class work on-site at
organizations also creates a direct funnel of internship candidates who
then can become employed at those organizations. Two goals are
achieved: (1) The employee achieves a higher education degree without
financial or occupational disruption, and (2) the employer has access
to a pool of mental health-care candidates for the mental health
workforce. When considering educational opportunities for mental
health-care professionals, a structure needs to be created to offer
paid internships. Most bachelor's and master's level interns are not
compensated for their internship experiences. They are often faced with
going to school full-time and engaging in a meaningful internship,
while potentially maintaining part- or full-time employment to meet
their basic needs.
The opportunity to pay interns is impacted by funding and
reimbursement rates. Although there were two 3-percent increases to
Medicaid rates in the past 2 years, there had not been meaningful rate
increases in over 20 years. Mental health services should be reimbursed
at rates that are competitive with a private practice market to allow
employers to offer competitive wages to the mental health-care
workforce if the workforce is to be sustained. A colleague reported
that at her center, staff at the bachelor's level can make more working
in the retail market than they can delivering behavioral supports to
pediatric patients. Over the past 2 years, Centers report a rolling
turnover rate in staffing of 40 percent. Staff often cite poor wages,
stress, and administrative burdens associated with mental health-care
documentation as reasons for seeking other employment, often outside of
the mental health-care field.
Increasing reimbursement rates and compensating providers for non-
billable events related to the implementation of Evidence-Based
Practices (EBPs) are two considerations for sustaining the workforce.
While EBPs are highly beneficial, they are expensive in relation to
nonbillable activities involved with implementation and ongoing
utilization. True implementation of an EBP is more than providing a
staff person with a manual and setting them off to their office to
provide the work if we want to guarantee that it is done correctly and
to fidelity. For most EBPs, in order to practice to fidelity, there
should be weekly consultation with a trained expert, on-going review of
the materials that are used for the EBP during and outside of
consultation, preparation time by the practitioner for sessions, data
collection, and a lengthy fidelity review process with expert trainers.
None of these activities are eligible for reimbursement and often
create drift from EBP utilization.
______
Prepared Statement of Trace Terrell, Lead Intervention
and Outreach Specialist, YouthLine
Thank you, Chairman Wyden, Ranking Member Crapo, and the other
members of the committee, for the opportunity to represent the youth
perspective as it pertains to mental health.
My name is Trace Terrell, I use he/him pronouns, and I am a 17-
year-old from Oregon. Before I share more about myself, I would first
like to tell you some things I have heard from teens across the
country: 4:07 p.m.: I just need someone to talk to; 4:37 p.m.: my dad
hit me but you can't call the cops; 9:45 p.m.: I'm afraid I might be
pregnant; 5:23 p.m.: I need therapy but my family can't afford it; 6:28
p.m.: I just failed my math test; 8:07 p.m.: I just lost my dad and I
can't stop crying; 6:42 p.m.: I want to kill myself.
These are just some examples of the many conversations that I
respond to as a volunteer with YouthLine, a free, confidential, teen-
to-teen crisis help support hotline located in Oregon. Whether helping
someone navigate complicated feelings about their sexuality or working
with others to develop comprehensive safety plans, I spend 3\1/2\ hours
every week responding to a variety of mental health challenges
experienced by teens across the country, with an emphasis on the fact
that no problem is ever too big or too small.
I became involved with YouthLine during my freshman year of high
school. As someone who struggled with depression, suicidal ideation,
eating disorder behavior, and anxiety throughout middle and early high
school, I, for the longest time, believed that no one could relate to
my experiences. However, as I became more involved with YouthLine, I
began to see my challenges reflected in those who contacted the line.
Whether it was the shared experience of wishing to wake up straight or
the common struggle of access to care, I realized that my challenges
were a microcosm of public health issues that affected hundreds of
thousands of teens across the country.
As more and more teens start to have conversations about mental
health and engage in help-seeking behaviors, the need for expansive and
intersectional mental health efforts has never been so needed. Since
YouthLine's inception, we have experienced an annual increase in
contact volume of about 15 percent annually, with an additional
increase of 3 percent-5 percent since the COVID-19 pandemic started 2
years ago.
So, what can we do to address the youth mental health crisis?
1. We must centralize our efforts in schools.
From my experience and many of my peers, mental health efforts in
schools are lacking. Day after day, I hear my friends and those on the
line voice about how inaccessible school counselors are due to being
overworked and overloaded. This is an especially difficult challenge
for the many teens who rely on school mental health professionals for
crisis care. We must either provide funding for more mental health
professionals or funding for additional staff who can assume some of
the overwhelming workload placed on counselors.
We must also create a streamlined approach to free mental health
screenings and referrals. At my school, four out of every five
referrals to external resources are not carried out. Let that sink in:
80 percent of referrals go nowhere. Someone who needs help, should
receive help. We need funding for schools to develop meaningful and
sustainable partnerships with School-Based Health Centers, CCBHCs,
county and State governments, community organizations, and primary care
facilities.
Last, we need to provide funding and technical support for State
mental health education standards. In ninth grade, my health class
spent less than a week on our mental health curriculum that only
addressed the symptoms of mental illnesses. Students should learn about
engaging in real-world help-seeking behaviors, developing systems of
self-care, and supporting our friends with mental health struggles,
because statistics show we turn to each other before anyone else. That
can only be done with a comprehensive and evidence-based mental health
curriculum that invites the active participation of school, community,
and youth leaders.
2. We need to address the pressing challenges that young people
continue to face in accessing mental health care.
While I'm no expert in policy solutions, I am someone with lived
experience. I know what it's like to be a teen--today--struggling with
mental health. And I know what it's like to offer support to teens in
crisis.
On and off the lines, the most common struggles I see expressed by
my peers in regard to accessing mental health care are: (1) financial,
transportation, and broadband barriers; (2) the urban/rural divide in
mental health care; (3) the lack of mental health professionals and
adequate follow-through care; and (4) the stigma around mental health.
These issues are incredibly real.
When I sought help from a mental health professional, my options
were limited. In my rural community, there is only one State-funded
behavioral health clinic. While I was able to attend virtual
appointments, I'm not sure I would have been able to get the help I
needed without Telehealth. For someone who lives on the outskirts of
town like I do, coordinating safe transportation would have been a
challenge.
Sadly, my experience isn't isolated. My friends have struggled to
receive professional mental health services because it's too expensive
for their families, not covered entirely by their insurance, too far
away to be accessed, or inaccessible because of unreliable Internet
access. Financial, transportation, and broadband barriers are even more
prevalent and intensified in rural areas, which is why we need funding
for isolated communities to develop robust mental health
infrastructure. Most importantly, we need to bring care to where people
are--and for teens, that's in schools or at home. We must fund
accessibility before we fund new initiatives.
In addition, the lack of mental health professionals and adequate
follow-through care prevents teens from receiving the help they need.
On the lines, we often have people who reach out more than once,
whether that's between therapy appointments or simply because there is
no one in their lives they can go to for support. Although YouthLine is
a crisis service and not meant for long-term care, we're often some
teens' first step in accessing professional mental health services.
We know from a study of the National Suicide Prevention Lifeline
that about 18 percent of the 2 million people who call every year are
under 25 years of age, which means there are about 360,000 young people
reaching out for help. We also know that teens are more likely to talk
to teens. One of the ways we could approach the lack of mental health
professionals is by funding a national YouthLine. What youth need is to
be able to call the National Suicide Prevention Line, press a number,
and have the opportunity to connected with another trained teen. Think
of it as an off-ramp like the Veterans Crisis Line.
Finally, addressing the stigma around mental health means building
on our existing efforts and encouraging people with lived experience to
share their stories. I share my story to ensure others in similar
situations know that they're not alone. However, too often our lived
experiences are overlooked in legislative work. We must make every
effort to invite and incorporate personal storytelling in this work.
3. We must invite youth to the table and value their insights as
natural partners in this work.
I am just one of 165 YouthLine volunteers.
What does that tell you?
Youth aren't afraid to talk about mental health--if anything,
adults are.
Across the country, young people are mobilizing and advocating for
mental health like never before. Beyond YouthLine, I have been involved
with organizations like Active Minds, through whom I and millions of my
peers help to change the narrative for how we talk about, value, and
seek care for our mental health. I have also been able to serve as part
of the National Mental Health Advisory Board, facilitated by Well Being
Trust, Young Invincibles, and Active Minds. During my time, I helped to
guide the development of a digital mental health advocacy toolset to
empower future youth mental health leaders in enacting change on a
local, State, and national level. In all of this, I have seen my peers
speak at school board meetings about the importance of mental health
excused absences, foster upstream suicide prevention in elementary and
middle schools, and meet with local and State legislators.
We believe in the power of peer-to-peer mental health support.
We believe in the power of robust, youth-led mental health
coalitions.
We believe in the power of our generation to create meaningful and
sustainable change.
But most of all, we believe that we deserve a seat at the table.
We need to recognize youth as stakeholders in this work. We can do
this by funding the countless youth-led mental health coalitions across
the country; by funding new opportunities for youth to be involved in
legislative work on the local, State, and national level; and by
funding organizations that can make sure the voices and sentiments of
youth are captured and shared.
If there's anything I want to leave with you today, it's this:
teens are talking--and we need you to listen.
At YouthLine, we know that what we do makes a difference in the
lives of young people across the country. And we know that because of
what we hear from teens after--after we've connected them to help,
after we've talked about self-care, and after we've helped them find a
path forward.
6:26 p.m.: I feel so much better talking.
7:34 p.m.: there's no one else in my life I could have talked
to.
8:34 p.m.: if it weren't for this conversation, I wouldn't be
here today.
Thank you.
______
Prepared Statement of Hon. Ron Wyden,
a U.S. Senator From Oregon
During this morning's hearing on the youth mental health epidemic,
the committee has an opportunity to build on last week's excellent
discussion with Surgeon General Dr. Murthy. Last Tuesday, Dr. Murthy
told us that mental health problems often show up first when people are
young, but the average delay between the onset of mental health
symptoms and the beginning of treatment is 11 years. Those are, in his
words, ``11 long, confusing, isolating, and painful years.''
That is a figure worth a thousand words, but more than anything, it
says that our approach to mental health care is severely out of whack,
and it's failing our young people from the very beginning.
First, mental health care must start much earlier. Earlier
screenings. Earlier interventions. Earlier discussions with primary
care doctors. There's also a big need to step up our mental health
efforts in schools and in the community.
Those are also places where trained professionals can spot symptoms
right from the outset and refer young people to a psychiatrist when
necessary. The challenge is, school counselors are overwhelmed,
community-based programs are too few, and referrals are inconsistent.
Mental health care simply isn't starting early enough, and it's not
reaching young people where they are, particularly kids in rural areas.
Number two, the country must have better crisis care. The 11-year
treatment gap is a sign that young people are struggling, going without
the treatment they need, and heading down a path toward crisis. The
fact is, the system too often fails them when they're in crisis too.
The pandemic has driven a shocking increase in self-harm among
young people. Suicide attempts among teen girls resulting in
hospitalizations recently jumped more than 50 percent. Far too many of
these young people in distress are spending days or weeks boarded in
emergency departments. For the bulk of that time, they're probably
alone. Imagine feeling a sense of extreme isolation clashing with the
chaos and commotion of the emergency department buzzing outside your
door.
Just yesterday I spoke with a group of Oregon health-care providers
and physicians who are concerned that in many of these situations,
young people who wind up in emergency rooms aren't even seeing
practitioners with the right training in mental health. The emergency
room is no place for a kid in crisis to spend day after day after day,
but it's all too common. Young people deserve better.
Third, solving these challenges is going to require creativity from
the public and private sectors. The Children's Health Insurance Program
and Medicaid, which is the largest single payer of mental health care
for young people, can help spark new solutions. These efforts will be
essential to make sure mental health is treated with the same
consistency and focus given to physical health.
Bottom line, you cannot have mental health business as usual,
because business as usual is failing too many young people at every
point--from the first sign of symptoms to the most critical moments of
crisis. There's a lot for the committee to discuss today on these
issues.
We're fortunate to be joined by an excellent panel, whom I'll
introduce shortly. Again, I want to thank Senators Carper and Cassidy
for heading up our efforts on youth mental health. Next, I'll turn to
Senator Crapo for his opening remarks.
______
Communications
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American Hospital Association
800 10th Street, NW
Two CityCenter, Suite 400
Washington, DC 20001-4956
(202) 638-1100
On behalf of our nearly 5,000 member hospitals, health systems and
other health care organizations, our clinician partners--including more
than 270,000 affiliated physicians, 2 million nurses and other
caregivers--and the 43,000 health care leaders who belong to our
professional membership groups, the American Hospital Association (AHA)
appreciates the opportunity to submit this statement for the record as
the Committee on Finance examines ways to protect the mental health of
our nation's youth. We applaud you for your leadership in this area,
and we look forward to continuing to work with you to advance the
health of the communities we serve.
As America enters the third year of the COVID-19 pandemic, health care
providers are confronting a landscape deeply altered by its effects,
including the emergence of behavioral health care as an even greater
challenge than in previous years.
While behavioral health care has long been underfunded,
underappreciated and stigmatized, the pandemic has intensified the
unmet need for services and has led to heightened difficulties for
individuals with behavioral health conditions in accessing care.
In freestanding psychiatric hospitals, behavioral health units of acute
care hospitals, emergency departments and hospital outpatient
departments across the nation, our member hospitals are facing
increasing demand for services to help patients deal with anxiety,
depression, substance use disorder and other behavioral health
conditions. Reported increases in domestic violence and child abuse
cases, financial stress, and a lack of community resources have set the
stage for an exacerbated behavioral health crisis. For children and
adolescents who have faced disrupted daily routines or who see parents
dealing with job loss and other stressors, the consequences of the
COVID-19 pandemic on their behavioral health are even more pronounced,
as is their inability to access needed services on a timely basis.
To amplify the call to address these urgent issues, the AHA has joined
the Sound the Alarm for Kids initiative, which comprises more than 50
organizations united to raise awareness and urge immediate action to
support the mental health of children, adolescents and their families.
We are proud to work alongside these many organizations in this effort.
Over the past two years, Congress has enacted several significant laws
aimed at providing relief from the social and economic impacts of the
pandemic. Several provisions contained in these laws are designed to
address the behavioral health care crisis, but some gaps remain. To
further address the issues brought about or intensified by the
pandemic, the AHA supports additional approaches to help ensure
improved access to needed comprehensive, affordable and quality
behavioral health services for youth.
PSYCHIATRIC BED SHORTAGES
As behavioral health needs are increasing across the nation, we see an
alarming trend of decreasing behavioral health services in many
communities, leading to severe challenges in providing inpatient
psychiatric care to children and adolescents. Bed shortages lead to
``boarding'' in acute-care hospital emergency departments (EDs) and in
non-psychiatric units as patients await available inpatient psychiatric
beds. Although little data is available regarding boarding times for
children and adolescents, our hospital members report untenable
crowding in their EDs, with some describing a crisis in their
communities.
Many young patients are presenting in the ED with suicidal ideation or
after having attempted suicide, but our members report that the
patients frequently must wait days or even weeks to be admitted to a
psychiatric hospital or unit for treatment. According to the Centers
for Disease Control and Prevention (CDC), over the past decade, suicide
rates in the United States have increased dramatically. Suicide now
ranks as the tenth leading cause of death for all Americans and the
second leading cause of death for Americans between the ages of 10 and
34.
The demand for mental health treatment after suicide attempts has
increased during the pandemic; as reported by the CDC, the number of ED
visits by adolescent girls following suicide attempts was more than 50%
higher in 2021 than in 2019. However, at the same time the number of
beds has decreased, as some hospitals have had to reduce bed capacity
due to COVID-19 concerns, as well close units temporarily to
accommodate COVID-19 patients.
PROVIDER SHORTAGES
As with psychiatric beds, the demand for child and adolescent
psychiatrists far outstrips the supply. Prior to the COVID-19 pandemic,
in 2019, the Academy of Child and Adolescent Psychiatry estimated the
number of practicing child and adolescent psychiatrists in the U.S. at
8,300 and the number of youths in need of their services at more than
15 million. That figure fell far short of the U.S. Bureau of Health
Professions' projection that in the year 2020, more than 12,000 child
and adolescent psychiatrists would be necessary just to maintain the
level of services that had been provided in 2000. Lack of access to
providers is even more acute in rural areas, according to the Health
Resources and Services Administration, which reports that 61% of areas
with a mental health professional shortage are rural or partially
rural.
Because the number of Medicare-funded residency slots for all
physicians, including psychiatrists, has only increased by 1,000 since
1996, Congress needs to act to increase the number of slots available.
The AHA supports legislation that would lift the caps on residency
positions, thereby helping to alleviate physician shortages that
threaten access to care.
Additionally the AHA urges Congress to establish scholarships, bolster
loan forgiveness programs and provide additional financial supports
that will encourage providers to specialize in children's behavioral
health care. Congress also should examine payment rates to ensure that
reimbursement structures pay providers fairly for the services they
render.
The AHA also supports robust funding for the Health Resources and
Services Administration's Title VII and Title VIII programs, including
the National Health Service Corps and the nursing workforce development
program. To support diversity in the behavioral health workforce, we
support increasing funding for Centers of Excellence and the Health
Careers Opportunity Programs, which bolster recruiting and retaining
underrepresented groups in the health care workforce.
THE CHILD SUICIDE PREVENTION AND LETHAL MEANS SAFETY ACT
In working to care for survivors of suicide and implement preventive
services for those who may be at risk, hospitals recognize the
importance of identifying and mitigating suicide risk factors, such as
ready access to lethal means. However, millions of Americans live in
areas with severe shortages of mental health professionals, and these
shortages are especially acute in rural and low-income urban
communities.
To help remedy this situation, the AHA has endorsed the Child Suicide
Prevention and Lethal Means Safety Act (S. 2982/H.R. 5035), legislation
that would fund training programs to help health care workers identify
those at high risk for suicide or self-harm. The bill also would
promote expertise among the emerging health care workforce by providing
grants to facilitate suicide prevention training at health professions
schools.
MITIGATING THE IMPACT OF VIOLENCE ON CHILDREN AND ADOLESCENTS
Every day, hospitals and health systems provide critical, lifesaving
care to victims of violence. However, when violence occurs, the victims
are not limited to those killed or physically injured; the impact on
families and the surrounding community can affect the health of the
entire community. Numerous studies have documented the behavioral and
physical health effects on children and adolescents who have been
exposed to violence.
Through the AHA's Hospitals Against Violence (HAV) initiative, our
members share information about their efforts to help combat community
violence using Hospital-based Violence Intervention Programs (HVIPs).
HVIPs work to reduce retaliation and recidivism by engaging patients in
the hospital during their recovery. This valuable and effective work
continues after patients are discharged, providing an important network
of support during their outpatient care.
To reinforce the work of these important programs, the AHA supports the
Preventing and Addressing Trauma with Health Services (PATHS) Act (S.
2873), a bill that would provide grants for high-quality, culturally
competent trauma support and mental health services for individuals in
communities affected by violence. The funds authorized by this bill
would assist hospitals and health systems in advancing the work of
HVIPs and their goal of fostering safer communities.
INTEGRATING BEHAVIORAL HEALTH AND PHYSICAL HEALTH
Behavioral health disorders have significant impact on the physical
health of children and adolescents. Many of our member hospitals and
health systems are working to create one system of care with multiple
entry points for patients with multiple conditions and to integrate
behavioral health services into every patient's experience. This
approach enables providers to effectively treat the whole patient--both
their physical and behavioral health care needs.
As providers work to integrate behavioral health care for children,
major factors to consider are developmental challenges and delays,
including issues related to autism, speech and sexual reaction. These
factors influence how behavioral conditions present and are best
treated, as well as which non-medical services children might need to
realize improvement, such as speech-language pathology and case
management involving a child's family and support system.
Another major consideration is the influence of, and interaction with,
other entities, including the child's family members, school and the
judicial system. For children, any treatment or screening procedures
will almost certainly overlap with other institutional protocols.
AT-RISK CHILDREN AND ADOLESCENTS
The needs of at-risk children and adolescents deserve special
attention. First and foremost, focusing sufficient resources on their
needs, such as eligibility for and access to early screening for
behavioral health conditions, will help reduce the likelihood of their
involvement in the child welfare or juvenile justice systems. The input
of parents, foster parents, the foster care system and schools are
essential in ensuring optimal, culturally sensitive behavioral health
care for these youth. In addition, close coordination is necessary with
programs that support their social needs and provide meaningful health
care coverage upon transition out of the child welfare or juvenile
justice system. This includes partnerships with crisis intervention
organizations that can respond to school-based issues.
ENFORCEMENT OF MENTAL HEALTH AND SUBSTANCE USE DISORDER PARITY LAWS
In addition to needing access to behavioral health care services,
children, adolescents and their families need the behavioral health
care benefits that our laws mandate. The Paul Wellstone and Pete
Domenici Mental Health Parity and Addiction Equity Act, enacted in
2008, requires insurance coverage for mental health conditions,
including substance use disorders, to be no more restrictive than
insurance coverage for other medical conditions. Most insurers and
health plans comply with the more straightforward aspects of the law
that relate to cost sharing and numerical limits on treatment, such as
annual inpatient day limits--known as Quantitative Treatment Limits.
Unfortunately, health plans and insurers generally are not yet meeting
the requirements of the law that govern how they design and apply their
managed care rules, called Non-Quantitative Treatment Limits, or NQTLs,
to these services. NQTLs are related to benefit plan design, such as
requiring preauthorization before services are rendered, or imposing
extra review processes for medical necessity or medical
appropriateness. To save money, some plans limit coverage for medicines
prescribed to treat behavioral health conditions by requiring patients
to try less expensive drugs first before ``stepping up'' to the more
costly drug actually ordered by the provider. This approach is called
step therapy protocol, and its use can delay needed treatment with
often catastrophic consequences for patients.
However, the federal entities charged with enforcing mental health and
substance abuse parity laws have not done a thorough job, and insurers
have taken advantage of that. To resolve the issue of insurance
companies' noncompliance, we need greater transparency, accountability
and enforcement of current laws. In the 116th Congress, the AHA
supported the Mental Health Parity Compliance Act introduced by
Senators Chris Murphy (D-CT) and Bill Cassidy (R-LA), legislation whose
provisions were incorporated into the Consolidated Appropriations Act,
2021 \1\ (CAA). Those provisions require health plans and issuers that
cover mental health and substance use disorder services as well as
medical and surgical benefits to create a comparative analysis of any
NQTLs that apply, and to provide such analyses whenever requested by
federal agencies. The CAA also requires the Departments of Labor,
Treasury and Health and Human Services to report to Congress annually
and issue additional guidance on NQTLs.
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\1\ https://www.congress.gov/116/bills/hr133/BILLS-116hr133enr.pdf.
Unfortunately, the 2022 report found that none of the comparative
analyses reviewed by the federal departments were in full compliance
with the law, and none contained required information. The AHA urges
Congress to exercise vigorous oversight of the federal agencies
responsible for ensuring that health plans comply with the MHPEA and
all its reporting requirements. Further, we support an increase in
federal penalties for noncompliance to help ensure that patients can
receive the behavioral health care benefits they are entitled to under
the law.
BATTLING STIGMA
Finally, the AHA continues to fight the stigma associated with seeking
behavioral health care. Children and adolescents may not seek the help
they need due to the stigmatization of mental health care. Often
parents may avoid seeking care for their children due to apprehension
that a mental health diagnosis will unfairly label them for the rest of
their lives. AHA member hospitals and health systems work to dispel
misperceptions about mental health disorders and treatment, and we have
launched the People Matter/Words Matter poster series to help health
care workers adopt patient-centered, respectful language around
behavioral health.
CONCLUSION
As a nation, we are just beginning to fully comprehend the effects of
the COVID-19 pandemic on the emotional well-being of the nation's
youth. America's hospitals and health systems recognize that our
collective efforts today to protect the mental health of children and
adolescents can have a lasting impact on their lives and the overall
health of our communities well into the future. We appreciate the
Committee's efforts to examine this issue and look forward to working
with you to advance policies to that end.
______
American Psychological Association
750 First Street, NE
Washington, DC 20002-4242
202-336-5800
202-336-6123 TDD
https://www.apa.org/
Statement of Arthur C. Evans, Jr., Ph.D., Chief Executive Officer
On behalf of the American Psychological Association (APA), please
accept our organization's written comments for the consideration of the
Senate Finance Committee for its hearing on ``Protecting Youth Mental
Health: Part II--Identifying and Addressing Barriers to Care.'' APA is
the nation's largest scientific and professional organization
representing the discipline and profession of psychology, with more
than 133,000 members and affiliates who are clinicians, researchers,
educators, consultants, and students in the field of psychology.
Through the application of psychological science and practice, our
association's mission is to have a positive impact on critical societal
issues.
To respond to the children's mental health crisis, APA urges policy
initiatives in the following key areas. While not all the policies and
programs referenced in this document are directly within the
jurisdiction of the Finance Committee, we raise them in keeping with
the committee's comprehensive consideration of policies affecting youth
mental health:
Strengthen the behavioral health workforce;
Improve Medicaid coverage policies and payment rates;
Increase access to school-based behavioral health services;
Promote integration of pediatric primary care and behavioral
health; and
Maintain and extend access to behavioral health services
provided via telehealth.
The COVID pandemic is particularly harming the mental health of
children and youth. During the first three-quarters of 2021, children's
hospitals reported a 14% increase in mental health-related emergencies
and a 42% increase in cases of self-injury and suicide, compared with
the same period in 2019.\1\ In recent months, children's hospitals
experienced their highest number of children ``boarding'' in hospital
emergency departments awaiting treatment.\2\ Surveys of households with
young children found high levels of childhood hunger, emotional
distress among parents, and frequent disruptions in child-care
services.\3\ Nearly 10% of U.S. children lived with someone who was
mentally ill or severely depressed,\4\ and since the start of the
pandemic over 167,000 children have lost a parent or caregiver to the
virus,\5\ further contributing to anxiety, depression, trauma, and
stress-related conditions in children. Aggressive action is needed to
address the adverse long-term impacts of the pandemic on the mental
health and well-being of children and adolescents.
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\1\ Children's Hospital Association. (2021). COVID-19 and
Children's Mental Health. Retrieved from: https://
www.childrenshospitals.org/-/media/Files/CHA/Main/Issues_and_Advocacy/
Key
_Issues/Mental-Health/2021/
covid_and_childrens_mental_health_factsheet_091721.pdf?la=en&
hash=F201013848F9B9C97FAE16A89B01A38547C7C5C7.
\2\ Children's Hospital Association. (n.d.). Emergency Room
Boarding of Kids in Mental Health Crisis. Retrieved from: https://
www.childrenshospitals.org/-/media/Files/CHA/Main/Issues_
and_Advocacy/Key_Issues/Mental%20Health/2021/
Boarding_fact_sheet_121421.pdf.
\3\ Center for Translational Neuroscience. (2021). RAPID-EC Fact
Sheet: Still in Uncertain Times; Still Facing Hunger. University of
Oregon. Retrieved from: https://www.uorapid
response.com/our-research/still-in-uncertain-times-still-facing-hunger;
Center for Translational Neuroscience. (2021). RAPID-EC Fact Sheet:
Emotional Distress On the Rise for Parents . . . Again. University of
Oregon. Retrieved from: https://www.uorapidresponse.com/emotional-
distress-on-rise-
again?utm_medium=email&utm_source=email_link&utm_content=baby_monitor_11
042021&utm_campaign=Q1_2022_Policy+Center_Resources.
\4\ Ullmann, H., Weeks, J.D., Madans, J.H. (2021). Disparities in
stressful life events among children aged 5-17 years. National Center
for Health Statistics, https://dx.doi.org/10.15620/cdc:109052.
\5\ Treglia, D., Cutuli, J.J., Arasteh, K., J. Bridgeland, J.M.,
Edson, G., Phillips, S., and Balakrishna, A. (2021). Hidden Pain:
Children Who Lost a Parent or Caregiver to COVID-19 and What the Nation
Can Do to Help Them. COVID Collaborative.
It is important to note that people of color remain at
disproportionately higher risk of infection, hospitalization, and death
from the virus.\6\ The pandemic has also exacerbated the impact of
historic disparities in access to behavioral health care among
communities of color, which has further harmed their mental well-being
since the start of this crisis.\7\ Rates of suicide, which have
traditionally been high predominantly among White and Native American
children, have risen sharply among Black youth.\8\ Black and Hispanic
children lost a parent or a caregiver at more than two times the rate
of White children, while American Indian, Alaska Native, Native
Hawaiian, and Pacific Islander children lost caregivers at nearly four
times that rate.\9\ Additionally, young people within other
marginalized populations, including those who identify as LGBTQ+ and
children with developmental and physical disabilities, have been
disproportionately impacted as well.\10\
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\6\ Centers for Disease Control and Prevention. (2021). Risk for
COVID-19 Infection, Hospitalization, and Death By Race/Ethnicity.
Retrieved from: https://www.cdc.gov/coronavirus/2019-ncov/covid-data/
investigations-discovery/hospitalization-death-by-race-ethnicity.html.
\7\ McKnight-Eily, L.R., Okoro, C.A., Strine, T.W., et al. (2021).
Racial and Ethnic Disparities in the Prevalence of Stress and Worry,
Mental Health Conditions, and Increased Substance Use Among Adults
During the COVID-19 Pandemic--United States, April and May 2020.
Morbidity and Mortality Weekly Report, 70(5), 162-166, http://
dx.doi.org/10.15585/mmwr.mm7005a3.
\8\ Sheftall, A.H., Vakil, F., Ruch, D.A., Boyd, R.C., Lindsey,
M.A., and Bridge, J.A. (2021). Black Youth Suicide: Investigation of
Current Trends and Precipitating Circumstances. Journal of the American
Academy of Child and Adolescent Psychiatry, https://doi.org/10.1016/
j.jaac.2021.08.021.
\9\ Treglia, D., Cutuli, J.J., Arasteh, K., J. Bridgeland, J.M.,
Edson, G., Phillips, S., and Balakrishna, A. (2021). Hidden Pain:
Children Who Lost a Parent or Caregiver to COVID-19 and What the Nation
Can Do to Help Them. COVID Collaborative.
\10\ Morning Consult and the Trevor Project. (2021). Issues
Impacting LGBTQ Youth. Retrieved from: https://
www.thetrevorproject.org/wp-content/uploads/2021/12/
TrevorProject_Public_
Final-1.pdf.
The need for greater investment in behavioral health care existed long
before COVID-19. Establishing a robust and effective mental health and
substance use disorder treatment system capable of delivering the
mental health resources our children and young people need will require
action across multiple fronts, ranging from improving access to the
full spectrum of high-quality treatment to addressing social
determinants of health. We must use the current crisis as an
opportunity to make major structural improvements and new, sustained
investments.
Strengthen the Behavioral Health Workforce
A strong behavioral health workforce is critical to combating the long-
term impact of the pandemic and remedying longstanding access gaps.
Even before COVID-19, the U.S. lacked an adequate supply of behavioral
health providers, including psychologists, with shortages expected to
worsen significantly by 2030.\11\, \12\, \13\
Rural communities, in particular, face major challenges in recruiting
licensed behavioral health care professionals.\14\ The rising
behavioral health needs associated with COVID-19 will make an already
bad situation worse.
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\11\ Bureau of Health Workforce. (2019). Designated Health
Professional Shortage Area Statistics. Health Resources and Services
Administration; U.S. Department of Health and Human Services. Retrieved
from https://data.hrsa.gov/hdw/Tools/MapToolQuick.aspx?mapName=HP
SAMH. Health Resources and Services Administration. (n.d.). Behavioral
Health Workforce Projections, 2016-2030: Clinical, Counseling, and
School Psychologists. Retrieved from: https://bhw.hrsa.gov/sites/
default/files/bureau-health-workforce/data-research/psychologists-
2018.pdf.
\12\ Health Resources and Services Administration. (n.d.).
Behavioral Health Workforce Projections, 2016-2030: Clinical,
Counseling, and School Psychologists. Retrieved from: https://
bhw.hrsa.gov/sites/default/files/bureau-health-workforce/data-research/
psychologists-2018.pdf.
\13\ Bureau of Labor Statistics. Occupational Outlook Handbook,
Psychologists. U.S. Department of Labor. Retrieved from: https://
www.bls.gov/ooh/life-physical-and-social-science/psychologists.htm.
\14\ Rural Health Information Hub. (2021). Rural Mental Health.
RHIhub, https://www.ruralhealthinfo.org/topics/mental-health.
Congress can strengthen the behavioral health workforce by providing
support for psychologist training programs in a manner similar to the
support it provides to medical professional training programs. Unlike
physicians, doctoral-level psychologists are not eligible for Medicare-
funded residency programs, which provide billions of dollars to support
the expansion of the physician workforce through Graduate Medical
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Education (GME).
The lack of support for psychology trainees under the nation's single
largest health insurance program makes it difficult to support training
programs. We urge Congress to establish Medicare coverage of behavioral
health services provided by psychology interns and postdoctoral fellows
(``trainees'') by directing the Centers for Medicare and Medicaid
Services (CMS) to develop a Medicare modifier--like the GE modifier
used for billing for services provided by medical residents--to allow
psychology trainees to bill for behavioral health-care services
provided under the supervision of a licensed psychologist.
Simultaneously, Congress should establish an add-on code to compensate
behavioral health clinicians for the non-clinical time they devote to
working with trainees, so that time spent teaching does not have to be
effectively donated by the clinician and carried out at the expense of
providing billable services.
Although some state Medicaid programs are already covering services
provided by psychology trainees, encouraging and incentivizing such
coverage in all state Medicaid programs would support training programs
and their growth. Both Congress and CMS previously endorsed providing
payments for clinical psychology training programs.
In addition to Medicare and Medicaid policy changes, reauthorization
and funding for programs administered by the Health Resources and
Services Administration (HRSA) and Substance Abuse and Mental Health
Services Administration (SAMHSA) is needed to strengthen the behavioral
health workforce.
To incentivize qualified providers to pursue careers delivering care to
underserved populations, APA encourages passage of the bipartisan
Mental Health Professionals Workforce Shortage Loan Repayment Act (S.
1578), which would authorize a new student loan repayment program for
mental health care professionals who commit to working in an area
lacking accessible care.
Because of the high level of training required, the cost of attending
graduate school is a significant barrier for entering the field of
psychology. Most psychology graduate students finance their education
by taking on substantial student debt, and graduate with an average
debt load of between $95,000 and $160,000. Close to half of doctoral-
level psychologists rely on loans to pay for graduate school, which
takes on average 5-6 years to complete.\15\ Data show that psychology
graduate students worry about the affordability of completing their
training requirements, experience difficulties focusing on their
studies as a result of trying to make ends meet, and struggle to afford
health care.\16\ At the same time, the imposition of higher interest
rates and multiple loan origination fees, as well as the elimination of
subsidized federal loans for graduate students, further increased the
cost of financing graduate education.\17\
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\15\ Doran, J.M., Kraha, A., Marks, L.R., Ameen, E.J., and El-
Ghoroury, N.H. (2016). Graduate Debt in Psychology: A Quantitative
Analysis. Training and Education in Professional Psychology, 10(1), 3-
13.
\16\ Lantz, M.M. (2013). Uncovering the graduate student economic
landscape: A difficult but necessary dialogue. Society of Counseling
Psychology Newsletter, 34, 22-23. Retrieved from: http://www.div17.org/
wp-content/uploads/SCP17-2013-9.pdf.
\17\ U.S. Department of Education. (n.d.). Federal Interest Rates
and Fees. Federal Student Aid. Retrieved from: https://studentaid.gov/
understand-aid/types/loans/interest-rates.
High levels of student loan debt impede workforce diversity in mental
health care fields, where demand for representative, culturally
competent providers is high.\18\ Due to a variety of factors, such as
lack of generational wealth, many students--including first-generation
students, those from communities of color, and those with a lower
socioeconomic background--working toward doctoral psychology degrees
disproportionately rely on student loans.\19\ The prospect of adding
further debt often disincentivizes the pursuit of advanced degrees, and
research shows that debt also impacts career choice by reducing the
probability that qualified professionals will enter public service
careers.\20\
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\18\ Sullivan, L., Meschede, T., Shapiro, T., and Escobar, F.
(September 2019). Stalling Dreams: How Student Debt is Disrupting Life
Chances and Widening the Racial Wealth Gap. Institute on Assets and
Social Policy, Heller School for Social Policy and Management at
Brandeis University. Retrieved from: https://heller.brandeis.edu/iere/
pdfs/racial-wealth-equity/racial-wealth-gap/stallingdreams-how-student-
debt-is-disrupting-lifechances.pdf.
\19\ Wilcox, M.M., Barbaro-Kukade, L., Pietrantonio, K.R., Franks,
D.N., and Davis, B.L. (2021). It takes money to make money: Inequity in
psychology graduate student borrowing and financial stressors. Training
and Education in Professional Psychology, 15(1), 2-17, https://doi.org/
10.1037/tep0000294.
\20\ Choi, Y. (2014). Debt and college students' life transitions:
The effect of educational debt on career choice in America. Journal of
Student Financial Aid, 44(1), 3. Retrieved from: https://
ir.library.louisville.edu/cgi/
viewcontent.cgi?article=1050&context=jsfa.
Accordingly, APA calls for the expeditious reauthorization of the
following programs, which are set to expire at the end of Fiscal Year
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(FY) 2022:
The Graduate Psychology Education Program (GPE) is the nation's primary
federal program dedicated solely to the education and training of
doctoral-level psychologists. GPE provides grants to accredited
psychology doctoral, internship, and postdoctoral training programs to
support the interprofessional training of psychology graduate students
while also providing behavioral health services to underserved
populations in rural and urban communities. APA urges reauthorization
of this vitally important program at $50 million per year.
The Minority Fellowship Program (MFP) serves a dual purpose: to both
increase the number of mental health professionals of color and
increase access to mental health services in underserved areas. Decades
of psychological research has shown that youth of color report less use
of behavioral health services than non-Hispanic white youth,\21\ in
part due to the lack of bilingual and culturally competent providers.
MFP provides funding for the training, career development, and
mentoring of behavioral health professionals--including trainees in
psychology, nursing, social work, psychiatry, addiction counseling,
professional counseling, and marriage and family therapy--to work in
ethnically diverse communities and provide culturally and
linguistically competent services to meet the needs of individuals in
underserved areas.
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\21\ Marrast, L., Himmelstein, D.U., and Woolhandler, S. (2016).
Racial and ethnic disparities in mental health care for children and
young adults: A national study. International Journal of Health
Services, 46(4), 810-824.
The Behavioral Health Workforce Education and Training (BHWET) Program
supports pre-degree clinical internships and field placements for a
broad array of behavioral health professionals, including doctoral-
level psychology students, master's-level social workers, school social
workers, professional and school counselors, psychiatric mental health
nurse practitioners, marriage and family therapists, and occupational
therapists. The program is also a key source of support for other
behavioral health training programs and substance use disorder
prevention efforts. Preserving this program is key to reaching
underserved populations, as well as meeting the needs of patients
wherever they are on the spectrum of mental health needs, from early
screening and prevention services for those who may be experiencing
symptoms of a behavioral health disorder to mobile crisis services for
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those in need of immediate intervention.
The Integrated Substance Use Disorder Training Program (ISTP) expands
the number of nurse practitioners, physician assistants, health service
psychologists, and/or social workers trained to provide mental health
and substance use disorder (SUD) services, including opioid use
disorder (OUD) services, in underserved community-based settings that
integrate primary care, mental health, and SUD services.
Improve Medicaid Coverage Policies and Payment Rates
Medicaid is the largest payer of behavioral health services in the
U.S., and yet many patients cannot access quality, affordable care in
their communities, instead seeking care in emergency rooms or facing
interminable wait lists for services. Despite their status as
``essential health benefits'' that many private plans must cover under
the Affordable Care Act, mental health and substance use services are
not mandatory benefits under state Medicaid programs. Accordingly, APA
urges enactment of Senator Smith's Medicaid Bump Act (S. 1727), which
incentivizes state Medicaid programs to increase their coverage of
mental and behavioral health services. Without access to crisis
services, patients often find themselves languishing in emergency rooms
or seeking treatment in other inappropriate settings. We strongly
support the inclusion of Chairman Wyden's CAHOOTS Act (S. 764) to
incentivize state Medicaid coverage of services provided by round-the-
clock mobile crisis teams.
Research consistently demonstrates connections between low Medicaid
reimbursement rates and low rates of provider participation in the
program.\22\, \23\, \24\, \25\
Psychologists and other providers often accept Medicaid patients as a
public service, but low reimbursement rates can be a barrier to
participation. In surveys we have conducted, psychologists who have
chosen not to participate in Medicare cite the program's low
reimbursement rates as the primary reason for their decision.
Similarly, a recent report issued at the request of the Oregon
Legislature documented behavioral health providers' significant concern
over low Medicaid reimbursement rates, and the authors' conclusion that
``wage increases are a necessary but insufficient component to
improving behavioral health workforce shortages'' (p. 5).\26\
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\22\ Holgash, K., and Heberlein, M. (2019). Physician acceptance of
new Medicaid patients. Medicaid and CHIP Payment and Access Commission,
January, 24.
\23\ Candon, M., Zuckerman, S., Wissoker, D., Saloner, B., Kenney,
G.M., Rhodes, K., and Polsky, D. (2018). Declining Medicaid fees and
primary care appointment availability for new Medicaid patients. JAMA
Internal Medicine, 178(1), 145-146.
\24\ Chatterji, P., Decker, S.L., and Huh, J. (2021). Medicaid
physician fees and access to care among children with special health
care needs. Review of Economics of the Household, 1-33.
\25\ Alexander, D., and Schnell, M. (2019). The impacts of
physician payments on patient access, use, and health (No. w26095).
National Bureau of Economic Research.
\26\ Zhu, J.M., Howington, D., Hallett, E., Simeon, E., Amba, V.,
Deshmukh, A., and McConnell, K.J. (2022). Behavioral Health Workforce
Report to the Oregon Health Authority and State Legislature.
Medicaid provider payment rates remain substantially below Medicare
reimbursement rates.\27\ Given the dire need to increase access to
behavioral health services for children and youth, we urge Congress to
consider assisting states in raising Medicaid reimbursement rates to
match Medicare reimbursement rates for behavioral health services for
this population.
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\27\ Zuckerman, S., Skopec, L., and Aarons, J. (2021). Medicaid
Physician Fees Remained Substantially Below Fees Paid by Medicare in
2019: Study compares Medicaid physicians fees to Medicare physician
fees. Health Affairs, 40(2), 343-348.
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Increase Access to School-based Behavioral Health Services
Meeting the need for behavioral health services for children and youth
will only be possible if all available venues are utilized effectively
for reaching those in need of help, so that there is ``no wrong door''
for obtaining care. Schools are an essential component of such an
approach. In fact, in many communities, they are an essential--and
often the only--source of meeting the physical and mental health needs
of students and families. While some school districts leverage Medicaid
funds to stretch scarce resources and create school-based behavioral
health programs, shortages of school-based behavioral health
professionals continue to persist.\28\
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\28\ National Association of School Psychologists. (2017).
Shortages in school psychology: Challenges to meeting the growing needs
of U.S. students and schools. Retrieved from: https://www.
nasponline.org/resources-and-publications/resources-and-podcasts/
school-psychology/shortages-in-school-psychology-resource-guide.
Improving the behavioral health and emotional well-being of all
students, including by instituting evidence-based comprehensive
behavioral health systems in schools, can help mitigate the impacts of
pandemic-related learning loss,\29\ and reduce the frequency and
severity of mental health and substance use disorders.\30\ Such a
holistic approach provides a full complement of supports and services
that establish multi-tier interventions and promotes positive school
environments. They are built on collaborations between students,
parents, families, community health partners, school districts, and
school professionals, such as administrators, educators, and
specialized instructional support personnel, including school
psychologists.
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\29\ Dorn, E., Hancock, B., Sarakatsannis, J., and Viruleg, E.
(2020, December 8). COVID-19 and learning loss--Disparities grow and
students need help. McKinsey and Company, https://www.mckinsey.com/
industries/public-and-social-sector/our-insights/covid-19-and-learning-
loss-disparities-grow-and-students-need-help.
\30\ American Psychological Association. (2020). APA's Guide to
Schooling and Distance Learning During COVID-19. Retrieved from:
https://www.apa.org/ed/schools/teaching-learning/recommendations-
starting-school-covid-19.pdf.
As the third-largest stream of federal funding for school-based health
care services, Medicaid remains a critical mechanism for meeting many
of these needs among our most vulnerable students by broadening access
to physical and mental health care available through school-based
health centers. School districts can use Medicaid reimbursement to fund
health professionals and specialized instructional support personnel,
including school psychologists,\31\ purchase and update specialized
equipment and connect eligible students with providers outside of
school settings. Medicaid can also be used to pay for services
described in a Medicaid-enrolled student's individual education plan
(IEP) under the Individuals with Disabilities in Education Act.
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\31\ Pudelski, S. (2017). Cutting Medicaid: A Prescription to Hurt
the Neediest Kids. AASA, The School Superintendent's Association,
https://www.aasa.org/uploadedFiles/Policy_and_Advocacy
/Resources/CuttingMedicaid2018Addendum.pdf.
To meet the growing need for child and adolescent behavioral health
care and increase access to school-based behavioral health services,
APA urges the Committee to strengthen Medicaid-funded services in
schools by directing CMS to update its guidelines on Medicaid in
schools to ensure that Medicaid reimbursement can be utilized for
school-based physical and behavioral health care. CMS must also
periodically review Medicaid's early and periodic screening,
diagnostic, and treatment (EPSDT) requirements to determine whether
they are being implemented successfully in support of access to
prevention, early intervention, and developmentally appropriate
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services.
Additionally, we strongly oppose restrictions on Medicaid payments to
schools for necessary services, as well as the implementation of per-
capita caps or block grant funding for Medicaid programs. Finally, we
urge the Committee to support a permanent extension of the Children's
Health Insurance Program (CHIP) as a stable source of coverage for low-
income children.
Further, we urge Congress to pass legislation that increases access to
behavioral health services in schools and addresses disparities in
behavioral health care among Black youth, including:
The Mental Health Services for Students Act (S. 1841), to build
partnerships among local educational agencies, tribal schools, and
community-based organizations;
The Comprehensive Mental Health in Schools Pilot Program Act (S.
2730), to provide resources for low-income schools to develop a
holistic approach to student well-being;
The Increasing Access to Mental Health in Schools Act (S. 1811),
to expand the school-based mental health professional workforce; and
The Pursuing Equity in Mental Health Act (S.1795), to authorize
funding for research on Black youth suicide and improve the pipeline of
culturally competent providers.
Promote Integration of Pediatric Primary Care and Behavioral Health
Increasing implementation of evidence-based integrated pediatric
primary and behavioral healthcare could significantly increase access
to care, improve treatment outcomes, promote healthy development, and
aid in addressing social determinants of health.\32\ A substantial
percentage of patients visiting primary care practices are experiencing
behavioral health issues affecting their well-being, including both
mental health and substance use disorders or difficulties, and
behavioral factors associated with physical conditions or chronic
disease management.\33\
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\32\ McCabe, M.A., Leslie, L., Counts, N., and Tynan, W.D. (2020).
Pediatric integrated primary care as the foundation for healthy
development across the lifespan. Clinical Practice in Pediatric
Psychology, 8(3), 278.
\33\ Crowley, R.A., Kirschner, N., and Health and Public Policy
Committee of the American College of Physicians. (2015). The
integration of care for mental health, substance abuse, and other
behavioral health conditions into primary care: Executive summary of an
American College of Physicians position paper. Annals of Internal
Medicine, 163(4), 298-299.
More than a decade of research has documented the effectiveness of
programs implementing the primary care behavioral health (PCBH) model,
the collaborative care model (CoCM), and blended models of integrated
care. One of the leading models of integrated care is the Primary Care
Behavioral Health Model (PCBH), in which primary care providers,
behavioral health consultants (BHCs), and care managers work as a team,
sharing the same health record systems, administrative support staff,
and waiting areas, and collaborate in monitoring and managing patient
progress in order to improve the management of behavioral health
problems and conditions. In the PCBH model, the behavioral health
consultant role is often, but not always, filled by a clinical
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psychologist.
The PCBH model is a truly population-based approach to integrated care,
in which the goal is to improve both mental and physical health
outcomes for the clinic's patients of every age and condition by
managing behavioral health problems and bio-psychosocially influenced
health conditions.\34\ Generally, the BHC strives to see patients on
the same day the primary care provider (PCP) requests help, ideally
through a ``warm hand-off,'' and works with the PCP to implement
clinical pathways for treatment. An integrated care psychologist's day
may include meeting with a parent of a child exhibiting behavioral
difficulties or hyperactivity, seeing a new mother experiencing
symptoms of depression, helping another patient manage chronic pain or
diabetes, and working with another patient who has recently
discontinued using psychotropic medication. Both patients and providers
have reported high levels of satisfaction with PCBH model
services.\35\, \36\ From the patient's perspective,
behavioral health services are seamlessly interwoven with medical care,
mitigating the stigma often associated with behavioral health services.
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\34\ Reiter, J.T., Dobmeyer, A.C., and Hunter, C.L. (2018). The
primary care behavioral health (PCBH) model: An overview and
operational definition. Journal of Clinical Psychology in Medical
Settings, 25(2), 109-126.
\35\ Petts, R.A., Lewis, R.K., Brooks, K., McGill, S., Lovelady,
T., Galvez, M., and Davis, E. (2021). Examining patient and provider
experiences with integrated care at a community health clinic. The
Journal of Behavioral Health Services and Research, 1-18.
\36\ Angantyr, K., Rimner, A., Norden, T., and Norlander, T.
(2015). Primary care behavioral health model: Perspectives of outcome,
client satisfaction, and gender. Social Behavior and Personality: An
International Journal, 43(2), 287-301.
The PCBH model is particularly well-suited for use in pediatric care.
Interventions and supports to promote children's physical, behavioral,
and emotional health can positively influence the long-term trajectory
of their health and well-being into adulthood. Almost all children are
seen in primary care, and it is estimated that one in four pediatric
primary care office visits involves behavioral health problems.
Psychologists can be especially helpful in pediatric care because
assessing behavioral and emotional issues in children is generally more
difficult than in adults, and pediatric education traditionally focuses
on children's physical health. In addition to improving treatment in
this area, early childhood behavioral health services can help mitigate
the effect of adverse social determinants of health. Ideally,
integrated pediatric primary care includes a whole-family approach to
services that encompasses screening and services for perinatal and
maternal depression, domestic violence, and adverse childhood
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experiences.
Investing in evidence-based integrated primary and behavioral health
care across multiple delivery models would help us meet the current
crisis, as more than a decade of research has shown that programs
implementing the PCBH model, the collaborative care model (CoCM), and
blended models of integrated care can increase access to care and
achieve the health care triple aim of improving patient outcomes,
increasing satisfaction with care, and reducing overall treatment
costs.
Adoption of PCBH and other integrated care models is often challenging
for primary care providers, as they face barriers related to physical
office space, the need for improved information technology systems,
management procedures, clinical staffing and policies, health records
and data tracking practices, and provider education and training.
APA supports the provision of federal financial and technical
assistance to aid in the expansion of integrated care, whether provided
through partnerships (including state agencies) or through direct aid
to primary care providers. Initiatives and incentives to promote
integrated care should support implementation of not just PCBH
programs, but all evidence-based models of integrated care. Because of
differences in providers' patient populations and access to behavioral
health providers, there is no ``one-size-fits-all'' approach to
effective integrated primary care. APA urges Congress to continue
giving primary care practices the flexibility to choose the model of
integrated care that works best for their community.
Maintain and Extend Access to Behavioral Health Services Provided via
Telehealth
The decisions by Congress and CMS to expand access to tele-mental
health services represented a rare positive outcome of the COVID-19
pandemic, as it extended evidence-based mental behavioral health care
to many individuals in areas and communities that traditionally lacked
access to these services and made access to care easier and/or safer
for many others. There is ample evidence demonstrating that mental and
behavioral health services delivered via telehealth can be at least
equally effective as services delivered in person.\37\ Audio-only
telehealth is an especially important treatment modality for those
residing in areas lacking accessible or affordable broadband Internet
services, as well as individuals who lack the technological familiarity
with video conferencing platforms. Telehealth will remain in use long
after the pandemic ends; According to a recent survey of practicing
psychologists, 93% of respondents said that they intend to continue
offering telehealth as an option in their practice after the
pandemic.\38\
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\37\ See, e.g., Turgoose, D., et al., (2018) Journal of
Telemedicine and Telecare, Vol. 24, No. 9, https://doi.org/10.1177/
1357633X17730443; Varker, T., et al. (2019), Psychological Services,
Vol. 16, No. 4, https://doi.org/10.1037/ser0000239; Slone, N.C., et al.
(2012) Psychological Services, Vol. 9, No. 3, https://doi.org/10.1037/
a0027607.
\38\ American Psychological Association (October 19, 2021),
Worsening Mental Health Crisis Pressures Psychologist Workforce: 2021
COVID-19 Practitioner Survey, https://www.apa.org/pubs/reports/
practitioner/covid-19-2021.
APA urges enactment of the bipartisan Telehealth Improvement for Kids'
Essential Services (TIKES) Act (S. 1798) introduced by Senator Carper
and Senator Cornyn to provide guidance to states on increasing coverage
of telehealth services through state Medicaid and CHIP programs. APA
also supports several other bills before Congress to cement the gains
in access achieved under recent improvements in telehealth and audio-
only services coverage, including the Telemental Health Care Access Act
(S. 2061), introduced by Senators Cassidy, Smith, Cardin, and Thune,
which would eliminate a new Medicare telehealth coverage requirement
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that unnecessarily requires patients to be periodically seen in person.
To incentivize providers to continue offering telehealth services,
coverage of and reimbursement for telehealth services should be
equivalent to their in-person counterparts. Reimbursing at a lower rate
and requiring coverage on more stringent terms would drive providers to
offer more in-person services, making it more difficult for the many
patients who rely on services delivered via telehealth to access care.
APA recommends that Congress enact the Telehealth Coverage and Payment
Parity Act (H.R. 4480), which requires private insurance plans to cover
telehealth services on equal terms and equal rates as their in-person
counterparts.
APA is heartened by the focus on mental health in Congress, and eager
to work with this Committee and its members to develop legislation to
carry out these and other initiatives. We urge Congress to regard the
COVID-19 pandemic as an opportunity to address the longstanding
shortcomings of our behavioral health treatment system.
1____
American Therapeutic Recreation Association
25 Century Blvd., Suite 505
Nashville, TN 37214
D: +1.703-234-4140
F: +1.781-623-8103
https://www.atra-online.com/
U.S. Senate
Committee on Finance
RE: COVID-19, Mental Health Care in Adolescents and Young People, and
the Role of Recreational Therapists
Dear Chairman Wyden, Ranking Member Crapo, and Members of the Senate
Finance Committee,
On behalf of the American Therapeutic Recreation Association (ATRA), we
appreciate the opportunity to submit this statement for the record
regarding the Committee's hearing on ``Protecting Youth Mental Health:
Part II--Identifying and Addressing Barriers to Care.'' The hearing
highlights the pressing issues facing today's youth and the gaps in
mental health treatment in our current healthcare system. We look
forward to working with you to develop solutions to address America's
mental health crisis.
ATRA is committed to advancing access to recreational therapy and
ensuring that individuals, in particular adolescents, are able to
receive care that suits their interests and needs and supports the
development of functional skills for daily living and stress release.
ATRA is the largest professional association representing recreational
therapy. Recreational therapists are nationally certified, and where
applicable, state-licensed to provide evidence-based treatment services
for individuals with a range of disabling conditions across the
lifespan. Recreational therapy is active treatment, medically
necessary, and can be prescribed by a physician as part of a client's
plan of care.\1\
ATRA has watched with interest and concern as new data has highlighted
the significant impact COVID-19 has had on adolescents and young
people's mental health outcomes. As recreational therapists, we are
trained to use a variety of interventions to help clients address
mental health challenges, as well as other areas like physical health
and emotional/social well-being. Therefore, we recognize the critical
need to ensure that resources are in place following the public health
emergency to ensure that young people are able to successfully manage
the stress and anxiety associated with COVID-19.
In mental health care, recreational therapists support clients with
cognitive, social, leisure, and physical interventions, as well as
stress management techniques, to improve a client's overall health.
Recreation therapy (RT) for mental health incorporates activities
including music, sports, dance, art, and outdoor activities to help a
client find strategies that work for them to manage stress and ensure
they have a healthy outcome for managing their mental health. RT also
uses meaningful engagement in life activities or leisure as a means to
increase coping and therefore reduce depression and anxiety. This type
of therapy can be particularly helpful and attractive to individuals,
including adolescents, as an alternative, non-pharmacological outlet.
As illustrated during the hearing, the impact of the COVID-19 pandemic
highlights the next public health emergency: stress, depression, and
anxiety among young people and adolescents. To respond to this, serious
steps must be taken to support young people as they cope and adjust to
different normalcy with resiliency. The use of interdisciplinary health
teams that include recreational therapy is required to ensure that
young people have the necessary skills and resources to improve their
mental health. We urge Congress to include recreational therapists in
any legislation addressing youth mental health.
The Important Role that Recreational Therapists Play
Recreational Therapy (RT) embraces a definition of ``health'' which
includes not only the absence of ``illness,'' but extends to the
enhancement of physical, cognitive, emotional, social, and leisure
development so individuals may participate fully and independently in
chosen life pursuits. Recreational therapists address assessed client
needs related to behavior, cognition, function, pain management,
physical activity level, socialization, recreation, and leisure.\2\
Recreational therapists have the competencies to assess and implement
interventions necessary to promote improved mental health, quality of
life, and prevent secondary conditions \3\, \4\ by reducing
depression, stress, and anxiety in their clients and helping build
confidence to socialize in their community. Recreational therapists
work in a variety of settings that promote youth and adolescent mental
health including community mental health centers, public and
alternative schools, co-occurring disorder programs, day hospitals for
outpatient treatment, inpatient psychiatric hospitals, inclusive
recreation programs, residential living facilities, nature-based
recreation programs, and addiction recovery centers.
In the United States, recreational therapists at a minimum must have a
bachelor's degree in recreational therapy (or therapeutic recreation)
or a related field.\5\ Anatomy and physiology, assessment, salient
characteristics of illness and disabilities, medical terminology, the
therapeutic process, and 560 hours of fieldwork are required
courses.\6\ The Certified Therapeutic Recreation Specialist (CTRS) is
the required certification for recreational therapists by NCTRC and
shows that the recreational therapist has passed an all-encompassing
national certification exam demonstrating extensive knowledge and
skill-based training in core therapy skills (assessment, planning,
implementation, documentation, and evaluation), a team-oriented
approach to care delivery, and training in group processes.\5\ The CTRS
credential is required for practice as a recreational therapist in
Veterans Affairs \7\ and designated as the accepted certification for
recreational therapists by the Centers for Medicare and Medicaid
Services federal guidelines for skilled nursing facilities. Ethical
conduct is mandated by the professional organization, the American
Therapeutic Recreation Association (ATRA)'s code of ethics, and quality
indicators of RT practice are supported by the ATRA Standards of
Practice.\1\
Research has shown the effectiveness of recreational therapy services
for young people's mental health outcomes. Through recreational therapy
interventions, youth with mental health challenges saw increases in
health-related quality of life,\8\ positive changes in their perceived
self-esteem,\9\ and decreases in feelings of social isolation and
loneliness.\10\ Through outdoor adventure interventions, recreational
therapists also helped some young people with substance abuse disorder
and post-
traumatic stress disorder to learn effective strategies for their
personal recovery.\11\
To better explain the role of RT, we have provided some examples of
recreational therapy services specific to adolescents with mental
health conditions:
A recreational therapist in Virginia works at a residential
treatment center for adolescents with mental health diagnoses.
Utilizing stress management interventions like guided imagery,
progressive muscle relaxation, Tai Chi, and yoga, recreational therapy
services help adolescents reach goals like decreasing symptoms of
depression and anxiety while increasing self-confidence and personal
grounding.
Another recreational therapist works in a school in New Mexico
with high school students with intellectual and developmental
disabilities (IDD) who are experiencing increased anxiety during COVID-
19. Recreational therapy services help the students cope with feelings
of fear, worry, and hopelessness through after-school, group therapy
sessions for teaching emotional identification, coping skills, and
adjustment strategies to navigate their ever-changing daily schedules.
Lastly, a recreation therapist in Colorado utilizes nature-
based, adventure therapy interventions for adolescents with mental
health diagnoses. Goals of improving adolescents' self-confidence,
problem-solving skills, and sense of community are achieved through
outcomes-based, recreational therapy modalities that include kayaking,
rock climbing, high and low ropes courses, and wilderness hiking.
Conclusion
As Congress considers new legislative efforts to improve youth mental
health, we ask that recreational therapy services be considered
essential to addressing the mental health crisis for youth and
adolescents as a result of the COVID-19 pandemic. Specifically, we urge
Congress to include recreational therapists in any legislative language
dedicated to reducing stress, anxiety, and depression among youth and
adolescents. We welcome the opportunity to speak with you more about
what RT is, and how it can help in responding to the mental health
emergency as a result of COVID-19. Please do not hesitate to reach out
to the American Therapeutic Recreation Association (ATRA) directly,
please contact Brent Wolfe, ATRA Executive Director, at brent@atra-
online.com or by phone at (703) 234-4140.
Sincerely,
Brent Wolfe
End Notes
[1] Kemeny B, Fawber H, Finegan J, Marcinko D. Recreational therapy:
Implications for life care planning. J Life Care Plan.
2020;18(4):35-58.
[2] Commission on Accreditation of Rehabilitation Facilities. 2020
Medical Rehabilitation Standards Manual. 2020.
[3] Hawkins B, Kemeny B, Porter H. Recreational therapy competencies,
Part 2: Findings from the ATRA competencies study. Ther
Recreation J. 2020;54(4). doi:10.18666/trj-2020-v54-i4-
10238.
[4] Kinney J. Analysis of services performed by recreational
therapists. Ther Recreation J. 2020;54(3):227-243.
doi:10.18666/trj-2020-v54-i3-10248.
[5] National Council for Therapeutic Recreation Certification. The CTRS
is the qualified provider of Recreational Therapy Services.
2020.
[6] Bureau of Labor Statistics U.S. Department of Labor. Occupational
Outlook Handbook, Recreational Therapists. 2020.
[7] U.S. Department of Veterans Affairs. VA Handbook 5005, Part II,
Appendix G60. The Recreation and Creative Arts Therapist.
[8] Bennett JR, Negley SK, Wells MS, Connolly P. Addressing well-being
in early and middle childhood: Recreation therapy
interventions aimed to develop skills that create a healthy
life. Spec Issue Strengths-based Pract--Part 1. 2016;50(1):
unpaginated. http://js.sagamorepub.com/trj/article/view/
6782.
[9] Concepcion H. Video game therapy as an intervention for children
With disabilities. Ther Recreation J. 2017;(3):221-228.
[10] Luchies LB, Barbour AL, Anderson SR. Children's Healing Center
involvement reduces social isolation and loneliness among
immunocompromised children and their family members. Am J
Recreat Ther. 2019;18(3):37-47.
[11] Leighton J, Lopez KJ, Johnson CW. ``There is Always Progress to Be
Made'': Reflective Narratives on Outdoor Therapeutic
Recreation for Mental Health Support. Ther Recreation J.
2021;55(2):185-203.
______
Letter Submitted by Stephanie Barrett
U.S. Senate
Committee on Finance
To the honorable members of the Senate Finance Committee:
I've worked on the social service delivery and government sides of the
system of care for youth with mental health challenges over the last 27
years, in direct service to teens facing adversity, sexual assault
services (including child sexual abuse), and child protective field
work before moving to the bureaucratic role. There are numerous
challenges in accessing effective mental health services for children
and youth.
Most recently, the Private Equity Stakeholder Project released a report
on the rising impact of private equity in children's mental health
services. This is a concerning trend, as equity has turned an eye to
extracting profits from an industry with slim margins. Whatever
approaches to this problem are taken must account for the vultures,
circling what is an apparent cash cow in the birthing, as attention
(and as it follows, money) is turned toward this vital sector. See
report: ``The Kids Are Not Alright: How Private Equity Profits Off of
Behavioral Health Services for Vulnerable and At-Risk Youth,'' Eileen
O'Grady, February 2022, https://pestakeholder.org/wp-content/uploads/
2022/02/PESP_Youth_BH_Report_2022.pdf.
Having been elbows deep in treatment programs for the last 14 years, I
can share some essential observations regarding factors that affect
quality services to children and youth:
- Bureaucratic focus on Evidence-Based Practices (EBPs): I have
repeatedly seen EBPs embraced, at considerable expense, then delivered
to those outside the basis of the evidence. There are good EBPs and
there are bad EBPs. At the end of the day, no EBP will be effective if
safety, both physical and emotional in a way the nervous system can
perceive it, is not established.
- The longest-running, most well-established factor (evidence
base) that predicts success of treatment is the quality of the
relationship with the clinician.
- Mental health treatment for children and youth is delivered,
broadly, by the least qualified and capable clinicians in the field,
typically the new grads and those with ``conditional'' licenses.
- Children's program clinicians experience low wages for the field
and poor supervision.
- As conditional clinicians gain any skill and experience, and
their full licensure, they often move on to work outside of residential
programs and beyond, to private practice.
- With the turnover in children's clinicians, it's difficult to
establish a trustworthy relationship. Oftentimes, the broken
relationships just reinforce the relational trauma of those in
services.
My suggestions for improvement include:
Wage standards, identified in rate, to increase starting pay for
clinicians in children's treatment settings with the aim of attracting
and retaining high-quality, capable clinicians.
Enforceable standards for quality clinical supervision of
conditional licensees, and accounted for within the rates.
Enforceable standards for clinical quality--I have read
terrible, terrible work, over and over, with few to no teeth to force a
change.
Standards for providers that emphasize safety at all levels, and
freedom from intrusive behavioral interventions. The Qualified
Residential Provider language under FFPSA takes a huge stride in the
right direction.
Statute that obligates investigation of ANY allegation of sexual
abuse or impropriety by a clinician or residential program staff
against any child or youth receiving services.
Enforceability. Not just through cost recovery, but through
public information and a clearly delineated quality and corrections
process that is uniform regardless of the state or entity providing
oversight and that is impervious to swings in policy that is common at
the state level with changes in administration.
This last suggestion will also give bones and hope to dedicated public
servants who are trying to fulfill their duties in the public trust. I
have stories I can tell about how administrations can quickly dismantle
oversight structures and how hard it is to recover. Meanwhile, children
and youths suffer with their struggles and poor quality services.
Meanwhile, the child welfare system has a role to play as well. I once
evaluated a number of youth suicides occurring in our state and nearly
all had or should have had effective child welfare involvement. Those
youths (age 8-17) were living in dangerous homes and several had taken
their own lives after yet again meeting a child welfare worker who
unsubstantiated the allegations of abuse. When the worker walked out
the door, that kid had no hope that anyone would be able to help them.
Meanwhile, the 8-year-old's family didn't have a CPS record, but should
have. Sadly, the most challenging cases I handled as a CPS worker were
intergenerational trauma and when I knocked on the door, with the tools
I had, I was failing the fourth generation.
I'm happy to provide any additional info or context as requested. With
respect,
Stephanie Barrett
Quality Assurance and Training Manager
Disability and Brain Injury Services
Office of Aging and Disability Services
41 Anthony Avenue, SHS 11
Augusta, ME 04333
Desk: (207) 287-7048
To access the CDS Amin and Trainers list self-service, please use this
link: https://forms.office.com/g/TDA1A8p9zU.
DirectCourse ON-DEMAND ADMINISTRATOR TRAINING:
Select ``Resource Center'' from bottom of DirectCourse landing page.
Then select ``DirectCourse'' from second page and ``Training'' from top
of final landing page.
______
California Youth Connection et al.
March 1, 2022
U.S. Senate
Committee on Finance
Dirksen Senate Office Bldg.
Washington, DC 20510-6200
Dear Chairman Wyden, Ranking Member Crapo, and members of the Senate
Finance Committee:
Thank you for your interest and focus on improving access to mental
health services and supports for children and youth. The testimony
provided at the hearings on February 8th and February 15th was
insightful, sobering, and provided many helpful recommendations on how
to address the mental health crisis that children, youth and families
are confronting across the country. We write to add our voice and the
voices of young people with experience in foster care for your
consideration as you begin to develop solutions that will improve
access to and the quality of mental health care for children, youth,
and families.
Young people in and leaving foster care are at the center of the mental
health crisis. The removal and separation of children from their
families in and of itself can be a traumatic experience requiring
mental health treatment. Many young people have entered the child
welfare system because of unmet mental health needs. Their family
members may also be experiencing mental health challenges as well. Once
in the foster care system, young people often experience additional
trauma and mental health challenges which frequently last long beyond
their time in care. Failing to address the needs of these young people
has dire consequences for their health and well-being as youth and as
adults, yet large numbers of youth report that their needs are not met
and that their healing is not a priority in the child welfare and
mental health systems. We hope that designing a better approach to
providing mental health services, addressing the impact of trauma, and
centering healing will be a priority for both mental health and child
welfare reform and improvements.
We agree with Trace Terrell from Youth Line in Oregon who testified on
February 15th; it is critical to hear from young people and families
who are impacted by the mental health system. We're grateful to the
members of the Senate Finance Committee and the Committee's commitment
to listening to young people and families. With this in mind, our
recommendations were developed in collaboration with young people with
experience in foster care and the organizations that serve them.
Young people who have been in foster care have consistently called for
mental and behavioral health reforms that are youth-driven, supportive,
gender-affirming, and culturally responsive. Our suggested reforms
follow their lead because the first step in healing is establishing an
environment where young people feel safe to develop trusting
relationships with those who are helping them on their journey.
Services and treatment must be trauma-informed, constructive, and
healing. Even more importantly, we have to base our reforms in an anti-
racist framework. Healing is thwarted when the behavioral health care
system ignores the historical harms, present realities, unique needs,
and cultural strengths of young people of color. Changes to the
behavioral health care system must work against the pathologizing of
non-white cultural practices, values, and familial norms. Reforms must
be sensitive to the systemic oppressions that have harmed the mental
and behavioral health of youth who have experienced foster care and
actively remove barriers to equity at the intrapersonal, interpersonal,
community, and system levels.
We have submitted detailed recommendations in response to the
Committee's Request for Information in the Fall of 2021, which are
attached. Below we summarize our key recommendations.
RECOMMENDATION 1:
Connect young people with behavioral and mental health care providers
in their communities and ensure that healing is at the center of case
planning and service delivery in the child welfare system.
RECOMMENDATION 2:
Ensure that young people have education, agency, and access to
available behavioral and mental health services in their communities.
RECOMMENDATION 3:
End systemic racism and all forms of oppression in mental health
systems by requiring training, ensuring and enforcing anti-
discrimination provisions, requiring affirming practices, and
supporting the provisions of services in the communities of youth and
their families.
RECOMMENDATION 4:
Radically reduce the use of psychotropic medications and enhance
federal and state oversight of their use for youth in the foster care
system.
RECOMMENDATION 5:
Ensure that young people in and leaving foster care have access to--and
that Medicaid can fund--holistic and alternative treatment other than
medication and talk therapy, including specialized treatments and
enrichment activities.
RECOMMENDATION 6:
Ensure that young people in and leaving foster care have access to the
effective intervention of peer support as a part of the behavioral
health array of services in every state.
RECOMMENDATION 7:
Ensure that behavioral health providers serving youth with experience
in foster care have a caseload, the training, and expertise that allows
them to provide excellent and age-appropriate services.
RECOMMENDATION 8:
Ensure and enhance the EPSDT guarantee to better promote the health and
well-being of young people in and leaving foster care by (1) providing
presumptive eligibility for Medicaid to all youth in foster care for
all available mental health services that a youth elects to receive,
(2) improving and enhancing planning and support for mental health care
and Medicaid coverage when youth leave the child welfare system due to
permanency or age, and (3) incentivizing specialized care coordination
through the development of a national foster care enhanced case
management definition that is Medicaid reimbursable.
Submitted by:
California Youth Connection
Children's Law Center of California
Children's Rights
First Focus Campaign for Children
FosterClub
Juvenile Law Center
National Foster Youth Institute
Think of Us
Youth Law Center
Youth Villages
______
November 1, 2021
RE: Request for Proposals to Address Unmet Mental Health Needs
Dear Chairman Wyden, Ranking Member Crapo, and members of the Senate
Finance Committee:
The undersigned organizations are writing to submit a joint response to
the Committee's September 21, 2021 request for proposals from the
public about how Congress can make data-driven policy to improve
health-care access for ``Americans with mental health and substance use
disorders.'' We comprise the Mental and Behavioral Health Subgroup of
the Federal Older Youth Coalition, which advocates for services and
support for older and former youth in foster care. We have collaborated
with young people with experience in foster care and the organizations
that serve them to identify federal legislative and administrative
reforms.
Young people who have been in foster care have consistently called for
behavioral health reforms that are youth-driven, supportive, gender-
affirming, and culturally responsive. Our suggested reforms follow
their lead because the first step in healing is establishing an
environment where young people feel safe to develop trusting
relationships with those who are helping them on their journey. Through
policy papers, presentations and reports, young people with foster care
experience have told us what they need from the behavioral health
system and so we are proposing reforms that facilitate youth's
connection to services and treatment that are trauma-informed,
constructive and healing.
Comprehensive reform in the area of behavioral health care is needed to
ensure that young people with experience in foster care receive the
services and support they need to heal and thrive. ``Comprehensive
reform'' means we need to change what services and supports are offered
and the frequency and timing that they are offered. Even more
importantly, we have to base our reforms in an anti-racist framework.
Changes to the behavioral health-care system must work against the
pathologizing of non-white cultural practices, values, and familial
norms. Healing is thwarted when the behavioral health-care system
ignores the historical harms, present realities, unique needs, and
cultural strengths of young people of color. Therefore, these reforms
have to be driven by an anti-racist approach that is sensitive to the
systemic oppressions that have harmed the mental and behavioral health
of youth who have experienced foster care and that actively removes
barriers to equity at the intrapersonal, interpersonal, community and
system levels.
We believe that comprehensive reform, which is detailed in our
recommendations below, must achieve the following:
Educate young people about the impact of trauma and the range of
treatment, supports, and activities that are available to them to help
them cope and heal;
Make improvements to screening and assessment that are informed
by knowledge of the impact of trauma on behavior, acknowledges the
trauma of removal from family, and does not result in anthologizing and
labeling expected reactions to trauma;
Provide timely connection to treatment;
Provide timely connection with the supports that young people
identify, including alternatives to traditional forms of clinical care,
supports, and activities that center healing and the development of
well-being; and
Make high quality, effective treatment, supports, and
interventions available at multiple intervals.
Under each of our recommendations, we have highlighted their overlap
with the five areas referenced in the Request for Information: (1)
Strengthening the workforce; (2) Increasing integration, coordination
and access to care; (3) Ensuring parity between behavioral and physical
health care; (4) Expanding the use of telehealth; (5) Improving access
to behavioral health care for children and young people.\1\ We have
also addressed Funding, Cultural Humility, Racial Equity, and Research
within several of our recommendations. We urge the Committee to ensure
that all reforms advance racial equity and to elevate policies aiming
to eliminate racism in the mental and behavioral health arena.
---------------------------------------------------------------------------
\1\ While some of our recommendations may fall into a few of the
categories in area (5), we noted the category that seemed most
relevant.
---------------------------------------------------------------------------
RECOMMENDATION 1:
Congress should take the following actions to connect young people with
behavioral and mental health-care providers authentically and ensure
that healing is at the center of case planning and service delivery.
Strengthening the Workforce
Provide funding for grants and technical assistance to build
state and local agencies' psychosocial services capacity to ensure that
transition-age youth and their parents or caregivers have access to
mental health screenings and comprehensive, trauma-informed, evidence-
based psychosocial services.
Increasing Integration, Coordination, and Access to Care
Develop a plan to improve coordination among maternal and child,
youth, and family programs (HRSA, ACF, etc.) and plans to integrate
trauma-informed and resilience training and programming on a systematic
basis.
Develop standards of practice and highlight models of service
delivery that are most effective for expectant and parenting youth.
Calls for Research
Establish a demonstration program within the Centers on Medicaid
and Medicare Services (CMS) that: Reviews research and makes
recommendations on the use of non medical interventions for the
treatment of trauma, the current availability of those treatments, and
how they are funded.
RECOMMENDATION 2:
Congress should take the following action to ensure that young people
have education, agency, and access to available behavioral and mental
health services in their communities.
Strengthening the Workforce
Adjust reimbursement rates to better compensate and attract
mental and behavioral health-care providers.
Increasing Integration, Coordination, and Access to Care
Congress should require coordination between HHS and CMS to
improve the availability of trauma-informed, evidence-based
psychosocial services to
transition-age youth via additional grants and technical assistance.
This should include additional funding for wrap-around services to
facilitate access to and receipt of behavioral health services for
transition-age youth, including transportation costs, child care costs,
and reimbursement for lost wages.
Congress should ensure the availability of and accessibility to
comprehensive preventative health-care services guaranteed in federal
law through EPSDT for children younger than 21.
Improving Access for Children and Young People
Congress should amend Title IV-B, Subpart 2 to include more
explicit requirements around post permanency supports, including
additional funding for post-adoption, guardianship and reunification
services that are available until the age of 26.
Congress should take action to allow youth exiting Adoption
Assistance to apply early for SSI as an adult so that their Medicaid
coverage continues during the determination period.
Calls for Research
Congress should authorize a study on transition-age youth access
to mental health services and outstanding providers that work with
transition age youth that show positive outcomes on mental health
services. The study should also include how youth are provided the
following: information about the terms of their health insurance
coverage, coverage for behavioral health services, information about
how to renew their coverage, and a listing of available health-care
providers in their area who will accept their coverage prior to their
discharge from care.
RECOMMENDATION 3:
Congress should take the following action to end systemic racism and
all forms of oppression in mental health systems.
Strengthening the Workforce by Promoting an Anti-Racist Approach
Require that providers of behavioral health services participate
in pre-service and ongoing anti-racism and trauma-informed training and
collect data on the receipt of training.
As a condition of receiving federal funds, require that all
service providers follow non-discrimination policies and provide
services that are culturally competent and developmentally appropriate.
Require child welfare agencies contract with medical and
behavioral health providers in sufficient numbers to reflect the racial
and cultural diversity of children and youth in care, and with medical
and behavioral health providers that can support transgender and gender
nonconforming children and their caregivers.
Funding Reforms and Cultural Humility
Fund research on culturally responsive evidence based mental
health prevention and treatment services for children and families of
color. Allow for the cultural adaptation of existing evidence based
mental health service models to address the disparities and inequities
for children and families of color, especially those who are Indigenous
and Alaska Native, LGBTQ+ or Two-Spirit, and those that are
intersectional.
RECOMMENDATION 4:
Congress should take the following actions to radically reduce the use
of psychotropic medications and enhance federal and state oversight of
their use for youth in the foster care system.
Increasing Integration, Coordination, and Access to Care
Congress should increase federal oversight of states'
prescription and use of psychotropic medications among children and
young people in foster care and require that states' health-care
coordination and oversight plans are included in a state's Title IV-E
plan. States should have the following in place:
Policies to ensure meaningful informed consent
and assent to psychotropic medication are obtained for each new or
continuing psychotropic medication prescription, including
documentation that the youth has been offered other evidence-based
interventions besides psychotropic medication;
Clear guidance to caseworkers, prescribers,
caregivers, biological parents, and youth on which individuals are
responsible for the informed consent and assent decisions, including:
the role(s) of a protective adult and pre-TPR biological parent in a
informed consent; youth-friendly process(es) for refusal, complaints,
and grievances by the youth; and process(es) to be heard by a neutral
decision-maker in the event of conflict;
Best practices around metabolic baseline
screening and monitoring prior to psychotropic medication authorization
and continuance;
Access to a secondary medical review by a
licensed child and/or adolescent psychiatrist for outlier or off-label
prescriptions with known risks, such as those above the maximum adult
dosage, prescription of multiple medications in the same class and
across classes, prescription of psychotropics to children under the age
of 6, and others;
An oversight process to routinely assess the
safety of prescribed psychotropic medications, including an analysis of
appropriate dosages, strength, necessity, generics and substitutions,
and contraindications of combined medications;
A red flag or independent second opinion system
with a licensed child psychiatrist;
An up-to-date medical passport containing
essential information on the child, including health history,
diagnoses, medications, dosages, potential side effects, and observed
side effects, is delivered with the child upon placement and moves with
the child from placement to placement;
Details regarding how the state will provide
first-line psychosocial services, reducing over-reliance on
psychotropic medications, and how it will help young people that may
develop an addiction.
Congress should also:
Ensure that states are incorporating professional
practice guidelines and that the prescription of and monitoring of
psychotropic medications is done in compliance with professional
practice guidelines for the state;
Ensure that states provide an opportunity for
young people to voice their wishes on whether they are prescribed
psychotropic medication.
RECOMMENDATION 5:
Congress should take the following actions to ensure that young people
have access to holistic and alternative treatment other than medication
and talk therapy, including specialized treatments that are currently
not billable to Medicaid.
Increasing Access for Children and Young People
Develop a national peer certification protocol that will enable
the expansion of peer support programs.
Ensure that holistic and alternative treatments can be funded
through Medicaid and other federal funding streams.
Funding Proposals
Establish a demonstration program within the Centers on Medicaid
and Medicare Services (CMS) that reviews research and makes
recommendations on the use of non- medical interventions for the
treatment of trauma, the current availability of those treatments and
how they are funded.
RECOMMENDATION 6:
Congress should take the following actions to ensure that young people
have access to the effective intervention of peer support as a part of
the behavioral health array of services in every state.
Increasing Access for Children and Young People
Develop a national peer certification protocol that will enable
the expansion of peer support programs.
Ensure that Medicaid and other funding streams support the
delivery of outreach, treatment and ancillary support services that
improve mental health and well-being by individuals with lived
experience, including federal protocols for peer certification that
streamline the process in the states.
RECOMMENDATION 7:
Congress should take action to ensure that behavioral health providers
serving youth with experience in foster care have a caseload, the
training, and expertise that allows them to provide excellent and age-
appropriate services.
Funding Reforms
Increase funding for statewide family networks currently
administered through SAMHSA discretionary funds and set aside for child
welfare and juvenile justice involved children.
Increase the Medicaid reimbursement rate for behavioral health
providers that are effectively able to respond to the treatment needs
of young people in foster care by delivering treatments that have been
identified as effective through research, are trauma sensitive,
informed by a racial equity approach, and informed by the feedback of
young people.
RECOMMENDATION 8:
Congress should take the following actions to preserve and enforce the
EPSDT guarantee to better promote the health and well-being of young
people.
Increasing Integration, Coordination, and Access to Care
Provide presumptive eligibility for Medicaid to all youth in
foster care for all available behavioral health services that a youth
elects to receive.
Congress should require all states to provide a final needs
assessment if a youth wishes, to assess the mental and emotional well-
being of all youth achieving permanency and/or when their case closes
and ensure an adequate plan for services, including for young people
who are transitioning to adulthood. In the assessment, youth should be
evaluated for their mental and emotional well being to determine a plan
of recommended service(s) to ensure a successful healing and growth
process for youth beyond placement. States will also benefit from this
assessment, as it will be a tool to address the gap in services
specific to their population.
For young people who are transitioning out of foster care to
adulthood, amend the transition planning requirement of the Social
Security Act to ensure that there is documentation of the following:
That the young person's Medicaid eligibility as a
former foster youth has been established, that eligibility under
another category has been established, or other health insurance
coverage if the young person is not eligible for Medicaid;
The transition plan includes a list of behavioral
health or mental health treatment providers if the young person wanted
continued treatment and services.
That the young person with a disability or
special need has been assisted in applying for any federal and state
benefits that will support their care and well-being, including, but
not limited to SSI, SSDI, and Home and Community Based Waivers.
Increasing Access for Children and Young People
Develop a national foster care enhanced case management
definition that is Medicaid reimbursable so that children and youth in
foster care can receive improved care coordination. Conduct a study on
evidence-based case management services (i.e., Motivational
Interviewing, Solution-Based) and provide Medicaid reimbursement.
Mandate Medicaid coverage for all children and youth in foster
care regardless of their in-state or out of state status,\2\ receipt of
a foster care maintenance payment or their immigration status.
---------------------------------------------------------------------------
\2\ Effective January 2023, The Substance Use-Disorder Prevention
that Promotes Opioid Recovery and Treatment for Patients and
Communities Act (Pub. L. 115-271) will expand Medicaid coverage for
former foster youth so that all states will cover youth regardless of
the state in which they were in foster care. We propose that the
effective date of this vital reform be moved up to 2022.
---------------------------------------------------------------------------
Strengthen the Workforce
Increase the Federal Match Assistance Percentage (FMAP) to 90%
for all children's mental health and supportive services provided under
the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT)
entitlement, covering all children under the age of 21 in all states
and territories.
Apply the 90% FMAP to Medicaid Administrative Activities (MAA)
related to youth behavioral health including workforce training,
technical assistance, outreach and education. Gradually reduce the 90%
FMAP over a 5-year period to 80%.
Submitted by:
California Youth Connection
Children's Rights
First Focus Campaign for Children
FosterClub
Juvenile Law Center
National Foster Care Institute
Think of Us
Youth Law Center
Youth Villages
For more information, please contact:
Aubrey Edwards-Luce, First Focus Campaign for Children,
aubreyel@firstfocus.
org Tony Parsons, Youth Villages,
[email protected].
______
Children Now (California) et al.
Elissa Hyne
On behalf of the undersigned organizational members of
the State Policy Advocacy and Reform Center (SPARC)
c/o Partnership for America's Children
5335 Wisconsin Ave., NW, Suite 440
Washington, DC, 20015
March 14, 2022
Chairman Ron Wyden
U.S. Senate
221 Dirksen Senate Office Building
Washington, DC 20510
Ranking Member Mike Crapo
239 Dirksen Senate Office Building
Washington, DC 20510
RE: Testimony regarding the mental health of children and youth in the
foster care system for the ``Protecting Youth Mental Health: Part II--
Identifying and Addressing Barriers to Care'' hearing held on Tuesday,
February 15, 2022
Dear Chairman Wyden and Ranking Member Crapo:
The undersigned organizations are members of the State Policy Advocacy
and Reform Center (SPARC), a network of state multi-issue child
advocacy organizations, legal advocates, and organizations focused on
children and families involved with the child welfare system. We submit
testimony to the Senate Committee on Finance regarding the hearing that
took place on February 15, 2022, entitled ``Protecting Youth Mental
Health: Part II--Identifying and Addressing Barriers to Care.'' SPARC
commends the Committee for its continued attention to the mental health
needs of children and youth. Children and youth involved with the child
welfare system are a particularly vulnerable population and the systems
and processes meant to address their mental health needs require
special consideration and improvement.
On any given day there are over 400,000 children in foster care in the
United States, and an estimated 80 percent of those children have
significant mental health issues.\1\ That is four times the incidence
found in the general population (approximately 18 to 22 percent).\2\ In
fact, children in foster care and those who have aged out of foster
care experience Post-Traumatic Stress Disorder (PTSD) at a rate that is
double that of war veterans.\3\ Children in foster care have a history
of complex trauma, have experienced frequent home and life changes,
have suffered the loss of family relationships, and have had
inconsistent and inadequate access to mental health services. The very
act of the child welfare agency removing a child from their family and
home and placing them in foster care is a traumatizing experience.
Given the prevalence of mental health issues in the foster care
population, providing quality mental health services and care
coordination is essential.
---------------------------------------------------------------------------
\1\ Dore, M. (2005). ``Child and adolescent mental health.'' In G.
Mallon and P. Hess (eds.), Child Welfare for the Twenty-first Century:
A Handbook of Practices, Policies and Programs (148-172). New York:
Columbia University Press.
\2\ Dore, M. (2005). ``Child and adolescent mental health.'' In G.
Mallon and P. Hess (eds.), Child Welfare for the Twenty-first Century:
A Handbook of Practices, Policies and Programs (148-172). New York:
Columbia University Press.
\3\ Casey Family Programs, Assessing the Effects of Foster Care:
Mental Health Outcomes from the Casey National Alumni Study. Retrieved
March 4, 2022 from: http://www.casey.org/media/
AlumniStudy_US_Report_MentalHealth.pdf.
Despite the prevalence of mental health issues among the child welfare
population, there is an overall lack of adequate access to mental
health services. In fact, the American Academy of Pediatrics has
identified mental and behavioral health as the ``greatest unmet health
need for children and teens in foster care.'' Without appropriate
mental health care, children in foster care are prescribed psychotropic
medications at a much higher rate than children in the general
population. Some studies have found that children in foster care are
prescribed psychotropic medications at a rate 3 times that of other
children enrolled in Medicaid and have higher rates of polypharmacy.\4\
Not only is this practice incredibly harmful to the children
themselves, it costs states millions each year.
---------------------------------------------------------------------------
\4\ Zito, J.M., Safer, D.J., Said, D., et al. (2008).
``Psychotropic medication patterns among youth in foster care.''
Pediatrics, 121 (1). Available at: www.pediatrics.org/cgi/content/full/
121/1/e157[PubMed].
Notwithstanding the clear and compelling evidence that children and
youth in foster care experience a wide array of mental health issues,
the processes and systems created to meet those needs are falling
short. There are multiple barriers to providing adequate and
appropriate mental health care to children in foster care: incomplete
or unavailable health information, difficulty identifying who has the
authority to consent for health care on behalf of the child, deficient
care coordination between agencies, and inadequate resources for
evaluation and treatment. For example, although most children in foster
care are eligible for Medicaid, many pediatric mental health care
providers are unwilling to accept Medicaid patients--only approximately
one third of psychiatrists accepted new Medicaid patients.\5\
---------------------------------------------------------------------------
\5\ Holgash, K., and Heberlein, M. (2019). ``Physician acceptance
of new Medicaid patients: What matters and what doesn't.'' Retrieved
March 4, 2022 from https://www.healthaffairs.org/do/10.1377/
forefront.20190401.678690/full/.
The situation for children and youth in foster care has only worsened
during the COVID-19 pandemic as providers have witnessed an alarming
number of children and adolescents with severe mental health issues.
During the hearing held on February 15, Senator Wyden stated that
America's children are ``on a path to crisis.'' In fact, children and
youth in the foster care system are already experiencing that mental
---------------------------------------------------------------------------
health crisis.
There is general acceptance that there needs to be cross-system
collaboration and care coordination to ensure that behavioral health
care is coordinated between Medicaid and other child-serving systems,
including the child welfare system. There must be more effective
psychotropic medication management for children in the foster care
system, including red-flag systems and consent processes. Children in
foster care need more access to appropriate and effective mental health
services for children and youth up to age 26, including using Medicaid
to support intensive care coordination, wraparound services, family and
youth peer support, in-home services, treatment foster care, and other
home and community-based services and supports. Child welfare systems
must provide the required, but not always administered, periodic
thorough mental health assessments and screenings for all children and
youth in their care. And there must be systems in place to ensure
continuity of mental health care at all points throughout the child's
life: at entry into care, between placements while in care, and at exit
from care (whether that be reunification, adoption, or aging out).
We commend the Senate Committee on Finance's willingness to focus on
this mental health crisis for children and youth in foster care and we
thank you for your consideration of our views. If you have any
questions, please feel free to contact SPARC's Senior Child Welfare
Policy Manager, Elissa Hyne at (203) 561-7212 or ehyne@
foramericaschildren.org.
Sincerely,
Children Now (California) Michigan's Children
Children's Action Alliance
(Arizona) Nebraska Appleseed
Children's Trust of South Carolina Our Children Oregon
Florida's Children First Partners for Our Children
(Washington)
Foster Success (Indiana) Pennsylvania Partnerships for
Children
FosterAdopt Connect (Missouri and
Kansas) Rhode Island KIDS COUNT
Hawai'i Children's Action Network Tennessee Voices for Children
Juvenile Law Center (Pennsylvania) TexProtects (Texas)
Kansas Appleseed Texans Care for Children
Kentucky Youth Advocates Voices for Utah Children
Maine Children's Alliance Voices for Vermont's Children
Marion County Commission on Youth
(MCCOY) (Indiana) Voices for Virginia's Children
______
Children's Health
1935 Medical District Drive
Dallas, Texas 75235
214-456-7000
www.childrens.com
Statement of Jeanne Nightingale, MS, BSN, R.N.,
Senior Director for Psychiatry Services
Chairman Wyden, Ranking Member Crapo, and members of the committee,
thank you for convening two hearings on youth mental health and for the
opportunity to submit a statement for the record.
As Senior Director for Psychiatry Services at Children's Health in
Dallas, Texas, I oversee clinical operations related to pediatric
psychiatry programs at Children's Health--including inpatient services,
partial hospitalization, intensive outpatient, outpatient, consultative
and research services--as well as the embedded psychological services
for patients who are being treated throughout the hospital for a
chronic or acute medical diagnosis. Children's Health has seen
firsthand the growing crisis in pediatric mental health, which has only
been compounded by COVID-19.
The pandemic has taken a toll on children, whose lives were disrupted
at a critical time in their development. Children and families--
especially those in underserved communities disproportionately impacted
by the virus--have experienced significant social isolation, economic
stress, fear and grief. These challenges have contributed to a sharp
increase in the number of children with mental health concerns,
including depression, anxiety, suicidal ideation, disordered eating,
anger and substance use. As a result, more children and families in
crisis are presenting to pediatric emergency departments without
anywhere else to turn.
The Pediatric Mental Health Crisis at Children's Health
Since the start of the pandemic, Children's Health has seen a larger
percentage of children in the emergency department (ED) with mental
health needs than ever before. In 2021, more than 5,400 children
presented to our Dallas and Plano EDs in need of mental health
evaluations and services. This is a 43% increase from 2020 and a 273%
increase in the past five years. Often, these children are presenting
with acute mental and behavioral health needs--including aggression,
intentional self-harm and suicidal ideation--that require significant
resources to keep patients and staff physically safe.
In addition to the increasing number and acuity of behavioral health
patients, we are also seeing these children stay in the ED longer due
limited alternative placement options such as available inpatient
psychiatric hospitalization and outpatient psychiatric treatment
programs. North Texas lacks sufficient pediatric inpatient psychiatric
beds and facilities to meet the growing need in our community. In 2021,
49% of children (1,787) seen for mental health concerns at Children's
Medical Center Dallas waited in the ED for more than 8 hours, and 16%
of children (583) waited for more than 24 hours. Inpatient psychiatric
beds are increasingly hard to find and wait times for outpatient
psychiatric programs can be weeks or months long. These children have
no better option but to board in our ED for extended periods of time
while they wait for space to become available in an appropriate
pediatric mental health care setting. Not only does ED boarding delay
appropriate treatment and recovery for the child, but it also drains
staff and resources.
Psychiatry Programs at Children's Health
Despite this broken system and limited resources, Children's Health is
implementing strategies to mitigate ED volumes and ensure more children
can access appropriate mental health care. Last year we launched a
multifaceted response that included integrating an electronic bed
search tool for inpatient placement to psychiatric facilities, as well
as the launch of a mental health coordinator program to increase
efficiencies in transferring patients from direct patient care to
inpatient psychiatric care. Together, these initiatives decreased ED
throughput times for patients with mental health chief complaints by
29% from January 2021 to year end and reduced the percentage of
patients in the ED for more than 24 hours from 24% in April 2021 to 12%
by year end.
Children's Health has also developed and grown unique programs and
strategies to address pediatric mental health needs, including:
Suicide Prevention and Resilience at Children's Health (SPARC),
an innovative, nationally renowned teen suicide prevention program that
aims to help teens manage intense emotions and reduce risk for self-
harm and suicidal behaviors. Suicide is the second leading cause of
death in adolescents. The SPARC program was developed to help
adolescents who have had a recent suicidal event and need intensive
care and support. It is the only program in Texas that uses a
combination of teen skills group therapy, multifamily therapy,
individual therapy and family therapy and is specifically designed to
target the risk and protective factors associated with suicidality.
The Center for Pediatric Eating Disorders at Children's Health,
the nation's only pediatric program that has earned the Joint
Commission's Disease-Specific Certification for eating disorders
treatment. The program is a part of the Psychiatry Department, and our
highly trained psychologists and psychiatrists have decades of
experience treating eating disorders and other mental health issues
that may play a role in a child's overall well-being. The program
includes an inpatient program as well as a partial hospitalization and
intensive outpatient program, designed to support the child and family
throughout their journey towards recovery.
The Teen Recovery Program, the only program in North Texas
offering intensive outpatient care--designed just for teens--to address
substance use and mental health conditions at the same time.
The Center for Autism and Developmental Disabilities, which
brings together experts in different specialties to provide care to
children living with autism and developmental disabilities. This
includes psychiatry services that help children cope with anxiety,
aggression and other emotional or behavioral disorders.
The Children's Health School-Based Tele-Behavioral Health
Program, which connects students with licensed behavioral health
specialists via telemedicine and is currently available to students in
more than 250 schools across North Texas. The program expands access to
behavioral health services for students experiencing common behavioral
health issues such as depression, anxiety and self-esteem. Last year,
Children's Health launched a new virtual reality technology that is
being successfully used with students to treat their anxiety and
depression in telehealth visits. Virtually reality can help teach
positive coping skills and self-management techniques, such as muscle
relaxation and deep breathing, to manage behavioral health issues.
Strengthening our relationship with community behavioral health
providers. Improving access to pediatric behavioral health requires
hospitals and community providers work together. In 2021, Children's
Health established an agreement with a community-based behavioral
health care provider to reserve 40 beds for Children's Health patients.
Ten of these beds are intensive beds for children who require more
oversight, which is especially important as these children are often
the hardest to find community placements and treatment for. Since
September 1, 59% of behavioral health patients in our ED requiring
inpatient psychiatric treatment have been admitted to this community
provider, allowing more children to access care in an appropriate
mental health setting.
Request for Robust Support to Enhance Access to Pediatric Mental
Health Care
While our current programs help us meet the needs of community,
Congress must act to bolster the pediatric mental health care
infrastructure. Simply put, the behavioral health needs of our children
will not go away, and we must invest in services and supports that
promote access to pediatric mental health care. The solution must have
two parts:
1. Address the immediate need for more beds and acute care
services by investing in pediatric mental health infrastructure to
build capacity, and
2. Strengthen the continuum of care by increasing access to
community-based services and intermediate levels of care, such as
partial hospitalization, intensive outpatient and residential treatment
programs.
Specifically, Children's Health encourages Congress to consider
bipartisan policy solutions like the Children's Mental Health
Infrastructure Act (H.R. 4943, https://www.congress.gov/117/bills/
hr4943/BILLS-117hr4943ih.pdf), which would establish a grant program
for children's hospitals to expand mental health capacity, ranging from
construction or modernization of facilities to other additional
pediatric behavioral health services. This investment would help
regions like North Texas reallocate existing resources and create new
capacity to accommodate more pediatric behavioral health patients.
Further, resources would be leveraged in a way that allows communities
to come up with localized, flexible solutions to address shortages of
beds and acute care services.
Children's Health also supports the Helping Kids Cope Act (H.R. 4944,
https://www.congress.gov/117/bills/hr4944/BILLS-117hr4944ih.pdf), which
would provide flexible funding to support a range of community-based
activities including community health navigators, pediatric practice
integration, telehealth, crisis response services, school-based
partnerships, and workforce development. More community resources will
go a long way to decompress emergency departments, address gaps in
``in-between'' care, and ensure children and families receive support
beyond the hospital. With earlier support and improved resources,
children can better avoid, navigate and recover from mental health
crises.
Children's Health sincerely appreciates the committee's attention to
this pressing issue. The impact of the COVID-19 pandemic on children's
mental health will be felt for years to come, and it is imperative that
we make the right investments now to ensure the right level of care is
available for children with immediate and future behavioral health
needs. This includes providing more resources for early identification
and preventative care, a full continuum of acute care and stepdown
services, and long-term care services with improved care coordination
for our most seriously ill children. Building capacity and addressing
profound gaps in the care continuum will take collaboration, and
children's hospitals are ready to be a part of the solution.
About Children's Health
Children's Health is the leading pediatric health care system in North
Texas and one of the largest pediatric health care providers in the
nation. A private, not-for-profit organization, Children's Health is
anchored by two full-service hospitals and one specialty hospital. The
system includes an extensive network offering specialty, urgent,
primary, virtual care and more to the children of North Texas and
beyond. In addition, Children's Health is affiliated with UT
Southwestern as the official pediatric teaching hospital for the
medical school. This provides families with access to a world-renowned
medical faculty and transformative biomedical research. For more
information about Children's Health, visit www.childrens.com.
For more information, contact Matt Moore, Senior Vice President,
Government and Community Relations, Children's Health at 214-456-1971
or Matt.Moore@
childrens.com.
______
Children's Hospital Association
600 13th St., NW, Suite 500
Washington, DC 20005
202-753-5500
https://www.childrenshospitals.org/
The Children's Hospital Association (CHA), representing over 220
children's hospitals, thanks the Senate Finance Committee for holding
this hearing, ``Protecting Youth Mental Health: Part II--Identifying
and Addressing Barriers to Care,'' focused on this critical issue for
children, families, the pediatric health care workforce and our entire
nation. We call on this committee to join us in recognizing the
magnitude of the situation and advancing meaningful and
transformational solutions to address it.
Children's hospitals serve as a vital safety net for all children
across the country, regardless of insurance status, including those
that are uninsured, underinsured and enrolled in Medicaid. Medicaid is
the single largest health insurer for children in the U.S. and serves
as the backbone of children's health coverage. Children account for
over 40% of Medicaid enrollees, and a large portion of children served
by children's hospitals are covered by the program.
The challenges facing children's mental, emotional and behavioral
health are so dire that we joined the American Academy of Pediatrics
and American Academy of Child and Adolescent Psychiatry in declaring a
national emergency (https://www.aap.
org/en/advocacy/child-and-adolescent-healthy-mental-development/aap-
aacap-cha-declaration-of-a-national-emergency-in-child-and-adolescent-
mental-health/) in child and adolescent mental health last fall. On the
same day that we declared a national emergency, we launched the Sound
the Alarm for Kids initiative (https://www.soundthealarmforkids.org/)
to raise the visibility of the children's mental health crisis and
build momentum for action. The emergency for our children is broadly
recognized--now we need to work together on immediate action.
We strongly encourage the committee to put forward tailored and
dedicated policies and support for children to better address their
emotional, mental and behavioral health needs. The current mental
health system for children has been under-resourced for years and now
requires significant attention by this committee. It is an historic
opportunity to make a national impact for children and prevent larger
and more costly problems in the long term. As the single largest payer
for children, Medicaid investment, through better support for services,
integrated care and consistent implementation of the Early and Periodic
Screening, Diagnostic and Treatment (EPSDT) benefit, is critical to
supporting children's mental health needs across the continuum and
before diagnosis to prevent future and more serious problems. We ask
the committee to remember that broader supports and those provided
through Medicare do not reach children. There is a need in your work
for focus on children's unique needs and the major programs, like
Medicaid, that support much of the pediatric mental health services
provided in our country.
The statistics illustrate an alarming picture for our children. Prior
to the pandemic, almost half of children with mental health disorders
did not receive care they needed.\1\ This is not limited to one state
or one community--children in states across the country face the same
challenges accessing the necessary mental health care to address their
needs.\2\ Children's mental health conditions are common. One in five
children and adolescents experience a mental health disorder in a given
year,\3\ and 50% of all mental illness begins before age 14.\4\ For
children needing treatment, it takes 11 years on average after the
first symptoms appear before getting that treatment.\5\ Significant
investments are needed now to better support and sustain the full
continuum of care needed for children's mental health. These
investments will significantly impact our children and our country for
the better as we avoid more serious and costly outcomes later--such as
suicidal ideation and death by suicide.
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\1\ Daniel G. Whitney and Mark D. Peterson, ``US National and
State-Level Prevalence of Mental Health Disorders and Disparities of
Mental Health Care Use in Children,'' JAMA Pediatrics 173, no. 4
(2019): 389-391, doi:10.1001/jamapediatrics.2018.5399, https://
jamanetwork.com/journals/jamapediatrics/fullarticle/2724377.
\2\ Ibid.
\3\ Centers for Disease Control and Prevention (CDC), ``Key
Findings: Children's Mental Health Report,'' March 22, 2021, https://
www.cdc.gov/childrensmentalhealth/features/kf-childrens-mental-health-
report.html.
\4\ Substance Abuse and Mental Health Services Administration
(SAMHSA), ``Adolescent Mental Health Service Use and Reasons for Using
Services in Specialty, Educational, and General Medicaid Settings,''
March 5, 2016, https://www.samhsa.gov/data/sites/default/files/
report_1973/ShortReport-1973.html.
\5\ National Alliance on Mental Illness, ``Mental Health
Screening,'' accessed on November 10, 2021, https://www.nami.org/
Advocacy/Policy-Priorities/Improving-Health/Mental-Health-Screening.
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As reported from children's hospitals:
Between March and October of 2020, the percentage of emergency
department visits for children with mental health emergencies rose by
24% for children ages 5-11 and 31% for children ages 12-17.\6\
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\6\ CDC, ``Mental Health-Related Emergency Department Visits Among
Children Aged <18 Years During the COVID-19 Pandemic--United States,
January 1-October 17, 2020,'' https://www.cdc.gov/mmwr/volumes/69/wr/
mm6945a3.htm, November 13, 2020 .
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In 2021, children's hospitals reported emergency room visits for
self-injury and suicide attempts or ideation in children ages 5-18 at a
44% higher rate than during 2019.\7\
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\7\ Children's Hospital Association (CHA), analysis of CHA PHIS
database, n=38 children's hospitals.
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There was also a more than 50% increase in emergency department
visits for suspected suicide attempts among girls ages 12-17 in early
2021 as compared to the same period in 2019.\8\
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\8\ CDC, ``Emergency Department Visits for Suspected Suicide
Attempts Among Persons Aged 12-25 Years Before and During the COVID-19
Pandemic--United States, January 2019-May 2021,'' https://www.cdc.gov/
mmwr/volumes/70/wr/mm7024e1.htm, June 18, 2021.
Demand is outstripping supply causing kids in crisis to wait in
children's hospital EDs for long periods of time, otherwise known as
boarding. Medicaid investments in the full spectrum of pediatric mental
health services are critical in making immediate strides to address the
crisis end of the continuum, which is overstretched right now, and
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prevent emergencies in the future.
The challenges and limitations of the current mental health care system
are affecting all children, but the pandemic has exacerbated and
highlighted existing disparities for children of color in mental health
outcomes and access to high-quality mental health care services. In
2019, the Congressional Black Caucus found that the rate of death by
suicide was growing at a faster rate among black children and
adolescents, and that black children were more than twice as likely to
die by suicide before age 13 than their white peers.\9\ Studies of
Latino communities have found higher reported rates of depression
symptoms and thoughts of suicide among Latino youth, but comparatively
lower rates of mental health care utilization. As the Senate Finance
Committee weighs recommendations to promote children's mental health
and strengthen access to care, the needs of children from racial and
ethnic minority communities and the added barriers they frequently face
must be addressed.
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\9\ Congressional Black Caucus, ``Ring the Alarm: The Crisis of
Black Youth Suicide in America,'' December 17, 2019, https://
watsoncoleman.house.gov/imo/media/doc/full_taskforce_
report.pdf.
Military and veteran families are also affected. Military and veteran
families face additional challenges with separation from parents and
caregivers, frequent moves and caregivers or parents with their own
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trauma and mental health pressures.
We appreciate the Senate Finance Committee's recognition of the
children's mental health emergency and continuing focus on this
specific population and their unique needs. As you work to develop
legislative solutions, we ask you to advance the following policy
priorities, which will result in improved access to mental health
services for children, from promotion and prevention through needed
treatments:
Increase Medicaid investments in pediatric mental health
services to address the current crisis and better support coordination
and integration of care. Medicaid is the largest payer for behavioral
health services, but there continue to be access issues. In 2018, only
54% of non-institutionalized children on Medicaid and CHIP who
experienced a major depressive episode received mental health
treatment.\10\ According to MACPAC, ``Just 35 percent of psychiatrists
accepted new patients enrolled in Medicaid in 2014-2015, in contrast
with 62 percent accepting new patients covered by Medicare and private
insurance (Heberlein and Holgash 2019).''\11\ We believe creating
equity between what Medicaid and Medicare pay for similar services will
improve access for the millions of children who rely on this program
for care. Low payment rates weaken provider engagement and
participation in the Medicaid program and directly relate to the mental
health workforce shortages and access challenges for children. The
primary care payment bump passed in 2010 was found to increase access
to these services and to support continued engagement of primary care
physicians.\12\
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\10\ MACPAC, Response to Senate Finance RFI on behavioral health,
November 15, 2021, https://www.macpac.gov/wp-content/uploads/2021/11/
MACPAC-response-to-Senate-Finance-RFI-on-behavioral-health.pdf.
\11\ Ibid.
\12\ Laura Tollen, ``Health Policy Brief: Medicaid Primary Care
Parity,'' Health Affairs, May 15, 2015, https://www.healthaffairs.org/
do/10.1377/hpb20150511.588737/full/healthpolicybrief_
137.pdf.
Direct CMS to review how EPSDT is implemented in the states to
support access to prevention and early intervention services, as well
as developmentally appropriate mental health services across the
continuum of care, and provide guidance to states on Medicaid payment
for
evidence-based mental health services for children that promotes
integrated care. The EPSDT benefit is tailored to children's unique
needs and provides an important opportunity to support early
identification even before diagnosis. Children's hospitals report that
there are significant gaps in the intermediate level of care, including
intensive outpatient services and day programs, which can prevent
hospitalizations and help transition children back to their homes and
community after a hospitalization. We can do a better job of
implementing and supporting this benefit more consistently for children
to ensure they receive care as early as possible and at every point
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along the continuum when needed.
Facilitate access to mental health services through telehealth.
Throughout the COVID-19 pandemic, greater state and federal regulatory
flexibilities have increased the availability and convenience of
telehealth services for children and families. Psychiatry continues to
rely on telehealth at a far greater rate than any other physician
specialty. Congress should extend these flexibilities past the COVID-19
public health emergency, including covering audio-only services,
lifting originating site restrictions and geographic limitations, and
encouraging state Medicaid programs to continue telehealth coverage and
payment. For children, Medicaid and private insurance are major
insurers, and we ask the committee to ensure that telehealth support
and flexibilities are supported across payers, in addition to Medicare,
to give everyone the opportunity that telehealth provides.
Ensure strong implementation, oversight and proactive
enforcement of the Mental Health Parity and Addiction Equity Act. It is
unacceptable that payers and plan administrators are failing to cover
needed mental health and substance use disorder care by creating
barriers to in-network mental health care, limited provider networks
and establishing non-qualitative treatment limits not otherwise seen in
medical and surgical benefits. In addition, public and private payers
routinely exclude payment for mental health services provided by a
primary care provider. Congress should work to remove payment barriers
that hinder access to mental health services in the primary care
setting.
Increase investments to support the recruitment, training,
mentorship, retention and professional development of a diverse
clinical and non-clinical pediatric workforce. Currently, there are
dire shortages of minority mental health providers, which represents an
added burden on racial and ethnic minority communities who already face
inequitable access to care. More dedicated support for a larger and
more diverse pediatric workforce is critical to addressing children's
mental health needs now and in the future. Stronger Medicaid
investments supporting children's mental health services will improve
engagement in the program and encourage more people to enter these
fields.
At the core of a strong pediatric mental health care delivery
system is a strong, interconnected network of pediatric mental health
providers and supportive services that are available to deliver high-
quality developmentally appropriate care. To expand and strengthen
these networks at the community level, the Senate should consider H.R.
4944, the Helping Kids Cope Act of 2021 (https://www.congress.gov/bill/
117th-congress/house-bill/4944), bipartisan legislation that provides
flexible funding for communities to support a range of child and
adolescent-centered community-based services, as well as efforts to
better integrate and coordinate across the continuum of care. It also
invests in pediatric mental health workforce development for a wide
array of physician and non-physician mental health professions, to
ensure children's long-term access to providers and services across the
continuum of care.
Dedicate support for the pediatric mental health system and
infrastructure, which is currently woefully underfunded. Children's
hospitals recommend that lawmakers take additional actions this year to
strengthen pediatric behavioral health infrastructure and improve
access to care, both immediately and long term. We urge Congress to
provide resources to support efforts to scale up inpatient care
capacity, including costs associated with the conversion of general
beds to accommodate mental health patients. There is also a vital need
to increase access to alternatives to inpatient and emergency
department care including step-down, partial hospitalization, intensive
outpatient services and day programs. These types of programs ensure
that children and adolescents continue to receive intensive services
and supports they need while alleviating pressure on acute care
settings. We note that bipartisan legislation has been introduced in
the House, H.R. 4943, the Children's Mental Health Infrastructure Act
of 2021 (https://www.congress.gov/bill/117th-congress/house-bill/4943),
which would provide grants to children's hospitals to increase their
capacity to provide pediatric mental health services such as those
described above.
Children's hospitals are eager to partner with you to advance policies
that can make measurable improvements in children's lives. Please call
on us and our members as you develop these important policy
improvements to stem the tide of the national emergency for children's
mental health. Children need your help now.
______
Children's Trust Fund Alliance
P.O. Box 15206
Seattle, WA 98115
Generations United
80 F St., NW, 8th floor
Washington, DC 20001
FosterClub
620 S. Holladay Drive, Suite 1
Seaside, OR 97138
March 1, 2022
U.S. Senate
Committee on Finance
Dirksen Senate Office Bldg.
Washington, DC 20510-6200
RE: Testimony Submitted for ``Protecting Youth Mental Health: Part
II--Identifying and Addressing Barriers to Care,'' Hearing
Held on February 15, 2022
Dear Chairman Wyden, Ranking Member Crapo, and Members of the Senate
Committee on Finance,
Thank you for your interest in improving access to mental and
behavioral health services for children, young people, and their
families. Testimony provided during the hearings on February 8th and
15th demonstrated the urgent need to improve these services, the
importance of involving young people and included ideas for
improvement.
We write to you as add our voices organizations with networks of
individuals with lived experience in foster care and kinship care and
elevate the voices of those lived experience leaders.
The Children's Trust Fund Alliance is a national leader in promoting
and supporting the voices of parents in policy and practice areas, in
helping families build protective factors to gain capacity for life-
long changes and in preventing parental and societal neglect of
children. Its national network of state children's trust funds invests
almost $300 million annually in statewide and community-based
initiatives to strengthen families and protect children.
Generations United's mission is to improve the lives of children,
youth, and older people through intergenerational collaboration, public
policies, and programs for the enduring benefit of all. We are home to
the National Center on Grandfamilies, and our work is informed and
driven by a national network of grandparents and other relatives
raising children.
FosterClub is the national network for young people who experience
foster care. FosterClub believes when young people have the support
they need and opportunity to drive change in their life, they become
self-determined and do better. We also believe when the system listens
to young people, it does better.
We bring together young people, birth parents and relative caregivers
to drive change within foster care. Collectively, these voices are
referred to as lived experience leaders--each bringing their own
experience engaging with the child welfare system.
During the February 15th hearing, Mr. Trace Terrell stated: ``My peers
and I believe we deserve a seat at the table. While there are many ways
we can do this, it starts by ensuring young people can meaningfully
contribute to and be involved with legislative work on the local, state
and federal level.'' Our organizations agree fully and we are thankful
for Chairman Wyden's, Ranking Member Crapo and the Committee Members'
commitment to ensuring young people have a seat at the table as work on
this critical issue continues. In addition to young people, we are
asking that parents and kinship caregivers be included at the table
when identifying challenges and solutions.
While the February 8th and 15th hearings were focused on protecting
youth mental health, we know providing mental health support to parents
and caregivers, along with young people, leads to better outcomes.
Robust, quality and accessible mental and behavioral health services
can lead to children and youth staying safely together with their
family, rather than experiencing the trauma of entering the foster care
system.
In April 2021, we asked young people, parents and relative caregivers
about the support services for families that are facing mental or
behavioral health challenges (including addiction). We received 80
total responses that came through with 5 key themes of recommendations.
Lived experience leaders discussed the types of support services and
resources that will help families who are facing mental, behavioral
health and/or addiction challenges receive support, build on their
strengths and stay safely out of the foster care system, wherever
possible.
It is clear from the responses, that the whole family must be able to
access and engage in mental and behavioral health services and
supports.
The recommendations from young people, parents and caregivers are
below:
1. Provide us with timely, unbiased, culturally relevant, and
evidence-based prevention services that center family engagement.
2. We need rehabilitation and treatment programs that serve and
support the entire family, to include caregivers, and children, when
providing treatment services for mental health or substance use.
3. Create space for individuals with lived experience to serve as
peer mentors and work to deliver treatment programming and services to
families.
4. Connect us with trauma-informed mental health and family
engagement services that address the root and systemic challenges and
reasons for addiction including adverse childhood experiences and
trauma.
5. Address and support our basic needs by providing services such
as: housing, transportation, food, education, employment, and child
care assistance.
We've selected perspectives and quotes from lived experience leaders to
further demonstrate the above recommendations.
1. Provide us with timely, unbiased, culturally relevant, and
evidence-based prevention services that center family engagement.
Having equitable mental health services like being able to do
therapy through the phone, having a daycare connected, every
insurance covered or no cost at all to get help. Teaching
children and parents and adults about boundaries, and how to
communicate when they are disrespected.
-- Grace Gold, Former Foster Youth from New York with New York
State Youth Advisory Board and BraveHearts MOVE
Culturally appropriate services.
-- Robyn Wind-Tiger, Kinship caregiver from Oklahoma
A parent's mental health and or behavioral health is often
thought of as a weakness because of the parent's inability to
receive the appropriate care. The child welfare system and or
child protection does not realize the difficulty that families
have to try to receive the health care benefits to begin to
access services. In addition, are the services located in the
community in which they live? Are the services family-friendly
allowing for the consideration of holistic treatment which
considers the entire family and is culturally sensitive? Child
welfare/child protection [can] help expedite services with the
family without judgment and when parent/parents cannot do
homework with the family to establish a care plan specifically
for their family. It's important for the caseworker, child
welfare/child protection to know what's available in the
community and how to tap into those resources in a way that
families that may not have access to. Understanding the wait
list and the lack of appropriate services in all communities.
Most importantly acknowledge the strength of the family that
may not be like your family or any other family but unique
family strengths to their culture and environment.
-- Sandra Killett from New York with We All Rise and The
Alliance
2. We need rehabilitation and treatment programs that serve and
support the entire family, to include caregivers, and children, when
providing treatment services for mental health or substance use.
Preventative resources that could support families staying
together could be youth and parent peers and mentors with lived
experience who can illuminate hope, offer support and connect a
parent or youth to other resources and model recovery. Also,
support groups and community volunteer programs that focus on
prevention and support keeping families together. One example
of a good model is Safe Families whose focus is to prevent
children from entering into the foster care system and another
great model program for support is the Parents Anonymous
support groups.
-- Leanne Walsh, Birth parent from Oregon with Oregon Parent
Advisory Council
As a former foster child of a mother who struggled with
substance addiction, my siblings and I were separated and
placed in different foster homes at an early age. This was
devastating for the entire family. I believe it could have been
avoided if support services would have included rehabilitation
services for my mother and an in-home caregiver (with temporary
conservatorship) for my siblings and me vs. foster care.
Perhaps counseling services for the entire family as well.''
-- Lorna Jackie Wilson, Former Foster Youth from Michigan
From my personal experience, I didn't have enough support and
that is why some of my children went into foster care and some
went to kinship care. I truly believe that if we had more
facilities that welcome both mom and dad to get treatment while
children remain with them in the facility would help with the
prevention of going into care, but the root is truly more
support. Some families don't have relatives or people that
would want to help out during a crisis and the unfortunate
event is entering foster care.
-- Pasqueal Nguyen, Birth parent from Louisiana with The Extra
Mile and Youth Law Center
3. Create space for individuals with lived experience to serve as
peer mentors and work to deliver treatment programming and services to
families.
Working with a Certified Peer Support Specialist (someone with
lived experience with addiction/mental health) or a Family
Partner (someone with lived experience in child welfare).
Access to MAT-Medication-Assisted Treatment for Substance
Misuse.
-- Kelly Kirk, Birth parent from North Carolina with Sandhills
Opioid Response Consortium, NC DHHS Child Welfare Family
Advisory Council, Drug Free Moore County, Richmond County DSS,
Richmond County--DEFT (Drug Endangered Families Task Force)
I think support groups would help a parent's mental health, I
think that if they had a group they would be able to share
their thoughts vs. having to go through struggling with inside
problems alone.
-- Former Foster Youth from South Carolina
For African American families, education and awareness
campaigns run by grassroots trustworthy organizations to
decrease the stigma of mental health and provide resources,[
including] access to culturally relevant mental health
services. Anything that encourages early awareness of problems
and a safe place for caregivers to share and explore options
would help. This is such a HUGE problem in communities of color
and progress in this area would definitely benefit the welfare
of our families.
-- Melodye James, Kinship caregiver from Ohio with Restored
Vision
4. Connect us with trauma-informed mental health and family
engagement services that address the root and systemic challenges and
reasons for addiction including adverse childhood experiences and
trauma.
A trauma-informed therapist would have helped me process what I
went through and aided my dad's understanding of my behavior
and how to properly support me.
-- Zoe Jones-Walton, former foster youth, Texas, FosterClub
When there are not affordable centers to treat and give mental
therapy, people don't go. We all know addiction and mental
health issues go hand in hand, but when there is no access . .
. they continue on their journey with drugs.
-- Terri, Kinship caregiver from Alabama
As a former foster youth who aged out of care and as a parent
who returned to the system and accused of having undiagnosed
mental health issues, and the biases that it brings is
heartbreaking. It would have been helpful to receive
dialectical behavioral therapy or cognitive processing therapy
as a mechanism to help revert the issues they were bringing me
in for and remove my children as a consequence of something I
didn't have.
-- Ashley Alber, current foster youth from Washington with
Washington State Parent Ally Committee
5. Address and support our basic needs by providing services such
as: housing, transportation, food, education, employment, and child
care assistance.
Extended family and friends should be considered as resources
with funding being provided to aid them in keeping the family
together.
-- Marquetta King, foster/adoptive parent, Maryland, Treatment
Foster Care Parent Advisory Board, Arc Northern Chesapeake;
Together as Adoptive Parents
Such resources as therapy, skills training, transportation
assistance, food assistance, housing assistance can make a big
change in a family's life. Prevention and Education are key to
helping families stay out of the system.
-- Isabel, Birth parent from Arizona
I went into foster care for the first time when I was 11, it
was due to my mother's addiction to methamphetamine. I think
being able to provide an adequate amount of support for the
parent, whether it be resources in the community or even a
government stipend for the right treatment would help
immensely. Most parents feel as if they are fighting this
battle on their own and I think helping them realize they
aren't would be incredible for them and the reunification
process.
-- Charles Lewis, Former Foster Youth from Indiana
Our organizations are pleased to share these priorities with the
Committee as you continue looking at how to improve mental health
supports for young people and their families. If you would like to
discuss further, please contact Binley Taylor, System Change Director
at FosterClub, 503-717-1552 or [email protected], Jaia Lent,
Deputy Executive Director at Generations United, 202-777-0115 or
[email protected] and Teresa Rafael, Executive Director at Children's Trust
Fund Alliance, 206-650-5317 or [email protected].
Sincerely,
Children's Trust Fund Alliance
Generations United
FosterClub
______
Citizens Commission on Human Rights
1701 20th Street, NW
Washington, DC 20009
Statement of Anne Goedeke, Executive Director
The Citizens Commission on Human Rights (CCHR) recognizes that children
have faced unprecedented and stressful disruptions in their lives
during the pandemic. However, we have a serious concern, supported by
substantial research, that increased screening of children and at
earlier ages, as now called for by mental health providers, will result
in many more children being inaccurately diagnosed with mental
disorders and further escalate the number of American children
prescribed powerful psychotropic drugs, putting them at risk of serious
physical and psychological side effects.
Research studies have found mental health screening is ineffective and
potentially harmful to children.
Allen Frances, M.D., a psychiatrist and Professor and Chairman Emeritus
of the Department of Psychiatry and Behavioral Sciences at Duke
University School of Medicine, chaired the task force on the 4th
edition of the American Psychiatric Association's Diagnostic and
Statistical Manual of Mental Disorders.
Writing in The Wall Street Journal in 2016, Dr. Frances stated:
``Screening for depression is one of those ideas that is terrific in
theory but terrible in practice. Proponents see only the potential
benefits and remain blind to the many risks. They imagine an ideal
world in which troubled teens are accurately identified as depressed or
pre-depressed and receive just-in-time care that reduces the burden of
illness and the risk of suicide. They fail to imagine the many
limitations and unintended consequences that make testing much more
harmful than helpful.''
Dr. Frances stated that no screening method can differentiate between
the sadness which is very common in teens, and clinical depression
requiring treatment. He says that teens are ``especially tough to
diagnose'' because their symptoms are fluid and highly responsive in
the short run to pressure from family, friends and school. He warns
that ``mislabeling a teen as mentally ill changes the way they see
themselves and can ruin their lives.'' He further notes that ``medical
efficacy in adolescence is questionable and medications may increase
the risk of agitation, impulsivity, suicide and/or violent behavior.''
The late Karen Effrem, M.D., a well-known pediatrician and researcher,
found that increased screening results in the increased psychiatric
drugging of children and adolescents, with significant evidence of
harmful, even life-threatening side effects, including suicide,
violence, psychosis, hallucinations, diabetes, and movement disorders.
A study by researchers at McGill University, published in 2016 in the
Canadian Journal of Psychiatry, found after an exhaustive search of
medical literature that there was not a single screening tool with even
moderate evidence of sufficient accuracy to effectively identify
depressed children and adolescents without also mistakenly identifying
many non-depressed children and adolescents. They noted that screening
leads to the unnecessary prescribing of potentially harmful psychiatric
drugs, as well as giving negative messages about their mental health to
children who do not have mental health disorders.
That was precisely the case from 1999 to 2012, when an untold number of
adolescents were screened for depression using the TeenScreen
questionnaire. The screening tool was widely promoted and utilized,
even though psychiatrist David Shaffer, M.D., who led the Columbia
University team that developed TeenScreen, admitted the screening tool
would result in 84 non-suicidal teens being referred for further
psychiatric evaluation for every 16 youths correctly identified--a
staggering number of false positives. CCHR was instrumental in ending
the use of TeenScreen.
Further confirming the lack of evidence of effectiveness in screening,
research published in 2017 in BMC Medicine found there have been no
randomized, controlled trials, considered the gold standard for
research, with any direct evidence of improved health or other
beneficial outcomes from depression screening.
The United Kingdom National Screening Committee and the Canadian Task
Force on Preventive Health Care recommended against all questionnaire-
based screening because of the lack of direct evidence of benefit and
the potential harm to patients and waste of resources. The U.S.
Preventive Services Task Force did recommend screening of adolescents
ages 12 and older, but ``with adequate systems in place to ensure
accurate diagnosis.''
However, accuracy in psychiatric diagnoses cannot be ensured. A
fundamental flaw in the present-day field of mental health is that
there are no objective, scientific diagnoses of psychiatric conditions,
as there are in physical medicine, a fact which was acknowledged by the
former director of the National Institute of Mental Health, Thomas
Insel, M.D.
Therefore, what constitutes a child's ``elevated symptoms'' requiring
treatment is entirely subjective--and can vary from one provider to the
next. There is no consistency and no valid standards in the
determination of a psychiatric diagnosis and, therefore, no accuracy.
The result of this subjectivity in diagnosing is reflected in the ever-
growing number of children and adolescents estimated by mental health
providers to need mental health treatment.
CCHR has long recommended that before any rush to judgment about a
child having a mental disorder, the child should receive a complete
physical exam with laboratory tests to discover any undiagnosed
physical condition--illness, infection, injury or other condition--that
could account for the child's behavioral symptoms. If found and
corrected, this spares the child from being inappropriately labeled and
treated for a psychiatric condition the child does not have.
CCHR further recommends the child should be checked for allergies, food
intolerances, nutritional deficiencies, and environmental toxins, which
are all known to cause behavioral symptoms. A recent study published in
JAMA Pediatrics found that of the 1.1 million American children tested
for lead, 50.5% have detectable levels of lead in their blood. Even the
lowest levels of lead in children can cause irritability and nervous
system damage.
The diagnosis of a psychiatric condition in a child with a behavioral
problem in school often overlooks the fact that the child's educational
needs are not being met, resulting in unwanted classroom behavior. This
applies both to children falling behind in their studies and children
bored because they are not sufficiently challenged. Screening the child
for a mental disorder is the wrong approach. Applying correct
educational solutions would prevent children from being diagnosed with
ADHD and prescribed stimulant drugs.
As Mary Ann Block, M.D., author of No More ADHD, has stated, ``By
taking a thorough history and giving these children a complete physical
exam as well as doing lab tests and allergy testing, I have
consistently found that these children do not have ADHD, but instead
have allergies, dietary problems, nutritional deficiencies, thyroid
problems and learning difficulties that are causing their symptoms. All
of these medical and educational problems can be treated, allowing the
child to be successful, without being drugged.''
In 2020, some 6.2 million American children ages 0 to 17--roughly one
in 12--were prescribed psychiatric drugs, including antidepressants,
antipsychotics, antianxiety drugs and ADHD drugs, according to IQVia, a
healthcare data source. This includes 418,000 youngsters 0 to 5 years
old. These troubling numbers of drugged youth could dramatically
increase with even more widespread screening.
Of note, the number of children and adolescents taking psychiatric
drugs has decreased by 8% since 2017. This may reflect a growing
awareness on the part of parents and others of both the ineffectiveness
and the unwanted side effects of these drugs, which may have led to
their refusal to consider giving them to children. The CCHR psychiatric
drugs side effect search engine currently lists some 300 warnings from
international drug regulatory agencies and research studies on the
adverse effects of psychiatric drugs for children 0 to 17 years old.
Half of these warnings pertain to antidepressants' adverse effects on
children, especially suicide and aggressive behavior. The FDA's most
serious black box warning is required on the labels of antidepressants,
advising they can cause suicidal thoughts and actions in children and
young adults. Nearly 2.2 million children and adolescents ages 0 to 17
are currently taking antidepressants, 35,000 of them during the tender
ages of 0 to 5.
Researchers led by professor of psychology Glen I. Spielmans, Ph.D.,
analyzed data from antidepressant clinical trials for a study,
published in Frontiers in Psychiatry in 2020, that concluded,
``Increasing antidepressant prescriptions are related to more youth
suicide attempts and more completed suicides among American children
and adolescents.''
In 2017, researchers Martin Ploderl, Ph.D., a clinical psychologist,
and Michael P. Hengartner, Ph.D., a senior researcher and lecturer in
clinical psychology and psychopathology, concluded: ``If you look at
the past 10 years, antidepressant rates are associated with increased
suicide rates,'' adding that antidepressants ``most likely cause
suicidal behavior in young people'' and that the ``data strongly
suggest that antidepressants can cause suicides and aggressive
behavior.''
A study from the Nordic Cochrane Centre and the University of
Copenhagen published in the British medical journal, The BMJ, in 2016
also concluded that antidepressants are linked to suicide and
aggression in teens and that ``children and young people are more
likely to think about or attempt suicide while taking
antidepressants.''
Peter Breggin, M.D., a Harvard-trained psychiatrist and former
consultant to the National Institute of Mental Health, describes
antidepressants as neurotoxins because they harm and disrupt the
functions of the brain, causing abnormal thinking and behaviors that
include anxiety, irritability, hostility, aggressiveness, loss of
judgment, impulsivity and mania, which can lead to violence and
suicide. He says that the harmful mental and behavioral effects of
antidepressants are especially prevalent and severe in children and
adolescents.
In draft guidance published in November, the London-based National
Institute for Health and Care Excellence advised that antidepressant
drugs should not be considered first-line treatment for any patients.
Instead, those with depression should be offered and able to choose
from a variety of treatment options, including non-drug options. CCHR
supports this shift in thinking to non-drug solutions to children's
emotional problems.
Another 829,000 children ages 0 to 17 are prescribed antipsychotic
drugs, 31,000 of them age 0 to 5 years, for ADHD, aggression, mood
swings, and conduct problems. The CCHR psychiatric drugs side effect
search engine currently lists 42 research studies and 13 drug
regulatory agency warnings about adverse effects of antipsychotic drugs
for children and adolescents. Among the many adverse effects, the drugs
are widely known to cause weight gain, diabetes, cardiovascular
problems, and the risk of sudden death.
A study published in JAMA Psychiatry in 2018 found that children and
teens taking higher doses of antipsychotics were 1.8 times more likely
to die for any reason, 3.5 times more likely to die unexpectedly
(excluding overdose), and 4.29 times more likely to die from
cardiovascular or metabolic problems.
Antipsychotic drugs have long been linked with akathisia, a state of
restlessness and agitation that can induce suicidality or violence in
children. David Healy, M.D., a psychiatrist and professor of
psychopharmacology, stated in a 2009 interview for a blog on the
Psychology Today website that antipsychotics are universally recognized
as causing akathisia and that akathisia is recognized as increasing the
risk of suicidality and violence. He stated that since the introduction
of antipsychotics, the rates of suicide have risen 10- or 20-fold.
The drugs are also known to cause the devastating neurological damage
called tardive dyskinesia, an involuntary jerkiness of the face,
tongue, torso and limbs that can be disabling and permanent and may
also lead to suicide.
An analysis of those aged 10-18 found that antipsychotic drug use was
associated with a 50% increase in the risk of developing type 2
diabetes. This was higher for youth who used antidepressants and
antipsychotics concurrently.
For all the risk to children of psychiatric drugs, research studies
show the drugs may be largely ineffective and do more harm than good.
In a study recently published in The BMJ Drug and Therapeutics
Bulletin, researchers reviewed meta-analyses of studies of newer
generation SSRI and SNRI antidepressants. They found no clinically
significant difference in measures of depression symptoms between
children and adolescents treated and not treated with antidepressants.
They noted that published accounts of clinical studies involving
adolescents exaggerated benefits and understated adverse events, such
as by coding suicide attempts as ``mood swings.''
In a 2018 study published in Frontiers in Psychiatry, Michael P.
Hengartner, Ph.D., a senior researcher and lecturer in clinical
psychology and psychopathology, concluded after thoroughly examining
the medical literature that antidepressants are largely ineffective and
potentially harmful.
Researchers led by Paul W. Andrews, Ph.D., a professor psychology and
evolutionary biologist, analyzed previous studies to determine the
overall physical impact on the human body of antidepressants that
target serotonin. Serotonin regulates emotion, development, nerve
cells, attention, electrolyte balance and reproduction. The study,
published in Frontiers in Psychology in 2012 found that antidepressants
generally do more harm than good by disrupting a number of adaptive
processes regulated by serotonin.
Jose Luis Turabian, M.D., Ph.D., reviewed the medical literature and
concluded in a study, published in 2021 in the Journal of Addictive
Disorders and Mental Health, that psychiatric drugs can lead to a
structural remodeling of the brain that adversely affects emotions and
other aspects of mental function and may become irreversible. He says
that the drugs block the expression of feelings, affect the problem-
solving process, and make the person passive.
Decades of increasing mental health screening and the drugging of
children with mind-altering psychotropic drugs has done nothing to
reduce the rate of child and adolescent suicide, reduce school
violence, or improve students' educational performance, but has exposed
children to substantial harm.
There are global concerns about a growing dependency upon a biological
approach to treating mental health issues. In 2017, Dainius Puras, the
United Nations Special Rapporteur on the right to physical and mental
health, reported: ``There is now unequivocal evidence of the failures
of a system that relies too heavily on the biomedical model of mental
health services, including the front-line and excessive use of
psychotropic medicines, and yet these models persist.''
A 2020 report from the World Health Organization (WHO) criticizes the
mental health field's ``entrenched overreliance on the biomedical model
in which the predominant focus of care is on diagnosis, medication and
symptom reduction while the full range of social determinants that
impact people's mental health are overlooked, all of which hinder
progress toward full realization of a human rights-based approach.''
The WHO calls for holistic mental health services to replace today's
narrow focus on the diagnosis and drugging of individuals to suppress
symptoms, a mental health approach that results in ``an over-diagnosis
of human distress and over-reliance on psychotropic drugs.''
CCHR's co-founder, the late Thomas M. Szasz, M.D., a professor of
psychiatry and humanitarian recognized by many academics as modern
psychiatry's most authoritative critic, wrote: ``Labeling a child as
mentally ill is stigmatization, not diagnosis. Giving a child a
psychiatric drug is poisoning, not treatment.''
CCHR advocates against mental health screening, which experts have
proven does not reduce the burden of mental health issues or the risk
of suicide in children and teens, but does lead to mislabeling normal
children and prescribing them psychiatric drugs that are harmful to
them.
CCHR advocates that children experiencing emotional difficulties should
be given a complete physical exam with lab tests to discover any
underlying physical cause for their behavioral symptoms, and that
parents be made aware of the importance of proper sleep, nutrition, and
exercise for their children's mental health. It advocates for proper
educational solutions to be used for children's problems in school. It
advocates for the full disclosure of the risks of serious side effects
when taking and withdrawing from psychiatric drugs, so that parents can
make fully informed decisions about the use of these drugs for their
children.
CCHR supports evidence-based, non-drug and educational solutions for
youth mental health issues and public funding directed to programs
utilizing those solutions, handling the underlying causes of children's
behavioral problems instead of compounding their problems with
psychiatric labels and drugs that are proving to do more harm than
good.
______
Driscoll Health System
Driscoll Children's Hospital
3533 S. Alameda Street
Corpus Christi, Texas 78411
(361) 694-5000
Statement of Dr. Mary Dale Peterson
Chairman Wyden, Ranking member Crapo and members of the Senate Finance
Committee, my name is Dr. Mary Dale Peterson and I am the Executive
Vice President and Chief Operating Officer for the Driscoll Health
System (Driscoll), which comprises Driscoll Children's Hospital,
Driscoll Health Plan (DHP), physician practices, clinics, and specialty
centers. We serve over 31 counties in South Texas, which is roughly the
size of Senator Scott's State of South Carolina. We would like to thank
Senator Cornyn for his continued leadership in South Texas. He visited
our hospital back in February 2020 to promote his vaping legislation
and we support his and the Committee's commitment to strengthen
pediatric behavioral health's infrastructure, personnel, and services.
He also cosponsored legislation (S. 1798, called the TIKES Act)
allowing the pediatric workforce to identify and break down barriers in
using telemedicine and telehealth, so we understand and support his
passion for the issue. Driscoll welcomes working with the Committee in
addressing complex behavioral and mental health issues that impact
service delivery in our service region. We submit comments in support
of the Committee identifying critical issues, but more importantly, we
respectfully request a commitment in funding to address barriers of
care for children's hospitals.
The Driscoll Way
Historically, the inequalities along the Texas-Mexico border in
healthcare are prevalent and COVID-19 exposed new challenges. Poverty
in South Texas exacerbates healthcare inequities by limiting access to
transportation, Internet, and food. Additionally, retention and
recruitment of pediatric physicians, nurses and medical support
personnel is challenging. Despite these barriers to care, in 2020
Driscoll provided $126.6 million in community benefits for South Texas
and provided 93% of pediatric, in-patient care in the Rio Grande
Valley, the most southern portion of our services area. Additionally,
our health plan, a Medicaid Care Organization, covers over 220,000
children and families with many value added services.
Our commitment to our service area is so strong that Driscoll is
building the only designated, freestanding children's hospital in the
Rio Grande Valley and want to invite the Senate Finance Committee to
visit the new hospital when completed. Without Driscoll's commitment to
the US-Mexico border, the region would experience significant delays in
preventative pediatric care that would cost the State of Texas
massively. In 2020, Driscoll flew over 600 flights to the region with
pediatric subspecialists who provided over 40,000 clinic visits. If
Driscoll did not transport this care or build infrastructure and cover
these costs, pediatric services would be limited or unavailable in
these communities. We call our commitment to ensure all children remain
well the ``Driscoll Way.''
Pandemic's Impact on Behavior Health in South Texas
From Driscoll's perspective, evaluation, stabilization, case
management, inpatient discharge, and transport process is complicated
further by COVID-19. Our Emergency Department (ED) requires more space
capacity to ensure that injured and sick children do not impede
children presenting with mental health issues. Additionally, children
and adolescents with mental health issues require additional separate,
safe spaces that are age appropriate. As experienced before and during
the COVID-19 pandemic, recruiting and retaining mental health
professionals continues to be an issue in South Texas. These
professionals are needed to ensure adequate staffing for children
suffering from extreme emotional or mental distress. When Driscoll
completes its assessment and medical clearance approved, locating safe
transport for a child to a local mental health facility from our
facility is currently not available in South Texas. It is important to
note a child may have to travel hundreds of miles to an inpatient
behavioral health facility in South Texas, further complicating the
needed family interactions in the care plan and discharge.
Driscoll Mental and Behavioral Health Data
In 2021, Driscoll had 652 ED visits, 100 observations, and 43
admissions (including 20 in the ICU) for medical stabilization of
behavioral health patients.We have transferred 428 patients to
psychiatric facilities, about 155 of those hundreds of miles away.
Average length of stay in the ED is about 7 hours with some difficult
placements up to 26 hrs. Most of these patients require a 1:1 staffing
ratio throughout their stays, which is quite challenging in our current
labor shortage environment. When looking at year over year data, the ED
visits are slightly down but the acuity is significantly up, as
evidenced by the 80 patient increase in transfers to psychiatric
facilities.
Additionally, mental health cases grew at Driscoll by 48% from FY2019
thru FY2021. FY 2022 is on target to increase another 51% over FY2020.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
In just the first two months of FY2022, Driscoll already
accumulated 73% of the suicide attempts experienced in FY2021, and on
track for a 70% increase in suicidal ideation for the same period.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mental health patients ED length of stay times are increasing.
THE PRESIDENT OF THE UNITED STATES
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Recommendations
Driscoll recommends the Committee study the feasibility and funding for
the following items:
Additional funding for children's hospitals for construction and
expansion of sites for pediatric mental health services, digital
infrastructure such as telehealth, and conversion of existing beds used
for non-mental health care.
We recommend continuing to fund Internet
infrastructure development in rural and economically disadvantaged
areas, similar to South Texas, is critical to improve children's access
to telehealth and mental health professionals.
Additional funding to support workforce initiatives for
children's hospitals to support and improve training, retention, and
recruiting their mental health workforce.
We recommend incentivizing community partnerships
between children's hospitals and higher education programs that improve
the number of pediatric and family counselors, pediatric social
workers, care coordinators, child and adolescent psychiatrists, and
other support professionals.
Full and rapid tuition reimbursement for programs
that place professionals directly in communities of need like South
Texas. Develop stipends that children's hospitals can utilize for
relocation costs, continued education and training.
Additional funding to fill in the gaps in the continuum of care
which include early intervention, detention through crisis intervention
and stabilization, safe transportation between facilities, and improved
case management that follows the child to adolescent to adulthood.
We recommend funding transportation partnerships
in rural communities. In many communities with limited resources, a
child and their family have no support after discharge.
Long distances between a child's home and
facilities prevents the child from seeking care if reliable transport
is not available. COVID complicates this transport further.
Additional funding for mobile mental health clinics that travel
to rural areas so that professionals and support personnel can go out
to the community.
Conclusion
The COVID-19 pandemic's impact on the mental health of children is
difficult to assess. The pandemic compromised children's mental health
as they lost loved ones suddenly, were forced into isolation as schools
went virtual, and ongoing family violence and abuse went unreported.
Further, before the pandemic, modern anxieties such as social media
bullying and school violence plagued children and adolescents. Now add
the complexities and awkwardness of simply growing up, the need to
assist children's mental health is overdue. Because of these external
factors, children's hospitals require adequate funding and resources to
support early intervention, physical and IT infrastructure capacity,
and filling in the gaps of the continuum of care to ensure children do
not fall through the cracks. As illustrated in the data provided from
Driscoll in my testimony, we have cause for concern.
The U.S. Senate now has the opportunity to develop a solution that
assists all partners of care--children's hospitals, mental and behavior
health professionals, school districts, juvenile services, and other
community stakeholders. It is unfortunate that it took a pandemic to
shed light on the long-standing void in youth mental health services,
but getting it right now is critical and COVID-19 offers us an
opportunity to reset. The fact is we may never know the impact COVID-19
has on our children's mental health, but they were struggling well
before the pandemic. We need to act quickly to alleviate this mental
health crisis in children. Driscoll is ready to work with the Senate
Finance Committee on solutions to erode barriers and improve how
children's hospitals around the nation can better serve the communities
they call home.
______
First Focus on Children
1400 Eye Street, NW, Suite 650
Washington, DC 20005
t: 202-657-0670
f: 202-657-0671
https://firstfocus.org/
Chairman Wyden, Ranking Member Crapo, and Members of the Senate
Committee on Finance, we thank you for the opportunity to submit this
statement for the record. First Focus on Children is a bipartisan
children's advocacy organization dedicated to making children and
families a priority in federal policy and budget decisions.
Our country is facing a youth mental health crisis, and the COVID-19
pandemic has only sharpened the lens on an existing issue. Even before
the pandemic, 13-20% of children under the age of 18 \1\ experienced a
mental disorder, and the suicide rate among youth aged 10 to 24 has
increased nearly 60% \2\ since 2007. The issue has only worsened due to
the pandemic. In the first 6 months of 2021, children's hospitals
reported a 45% increase \3\ in the number of cases of self-injury and
suicide in children ages 5 to 17 compared to the first 6 months of
2019. While children from all backgrounds have been impacted by mental
health challenges during the pandemic, children of racial and ethnic
minorities are disproportionately impacted.
---------------------------------------------------------------------------
\1\ https://www.cdc.gov/childrensmentalhealth/basics.html.
\2\ https://www.cdc.gov/nchs/data/nvsr/nvsr69/nvsr-69-11-508.pdf.
\3\ https://www.soundthealarmforkids.org/a-national-emergency/.
Unfortunately, demand for services has gone up, but there is a severe
lack of resources available to children and teens. Currently, there are
10 child psychiatrists per 100,000 kids; it is estimated that we need
47 per 100,000 \4\ to address the current crisis. Many parents,
regardless of whether they have private insurance or are covered
through Medicaid, are not able to find providers for their children
because insurance networks are limited and there is a severe workforce
shortage. These issues must be addressed to get our children the care
they need.
---------------------------------------------------------------------------
\4\ https://pubmed.ncbi.nlm.nih.gov/31685696/.
In addition to school closures and isolation, the COVID-19 pandemic has
caused 175,000 children and youth \5\ in this country to lose a primary
caregiver, exacerbating the mental health crisis even further and
disproportionately impacting children of racial and ethnic minorities.
---------------------------------------------------------------------------
\5\ https://publications.aap.org/pediatrics/article/148/6/
e2021053760/183446/COVID-19-Associated-Orphanhood-and-Caregiver-
Death?autologincheck=redirected?nfToken=00000000-0000-0000-0000-
000000000000.
In December 2021, the Surgeon General issued a report \6\ on youth
mental health, citing the alarming increases in the prevalence of
mental health challenges. We appreciated his powerful testimony at the
February 2022 hearing before this Committee, in which he outlined what
steps need to be taken to address this crisis for our children.
---------------------------------------------------------------------------
\6\ https://www.hhs.gov/sites/default/files/surgeon-general-youth-
mental-health-advisory.pdf.
Below are a few of our recommendations to address the youth mental
health crisis in America.
Expand and Improve the Mental Health Workforce
Demand for mental health services has gone up dramatically, but there
is a severe lack of providers to meet this increased need. The federal
government should bolster training programs for providers in children's
mental health. Currently, the government spends $15 billion \7\ on
health care workforce development but only 1% of that is spent on
children's mental health workforce development.
---------------------------------------------------------------------------
\7\ https://www.gao.gov/products/gao-18-
240#::text=Federal%20agencies%20and%20state%20
Medicaid,Medicaid%20agencies%20spent%20%252$15%20billion%20annually.
---------------------------------------------------------------------------
Some ideas to address the workforce shortage include:
Expand loan repayment programs, access to scholarships, and
training programs for mental health professionals committed to
practicing in rural and other underserved communities.
Raise the Medicaid reimbursement rate for mental health
providers.
Integrate mental health services with primary care.
Encourage young people to consider the mental health profession
as a career to expand the pipeline of behavioral health providers.
Invest in Community-Based Mental Health Services
Children need improved and increased access to community-based mental
health services. These are often more appropriate and effective for
children and youth than in-patient care, and they are less expensive.
The Certified Community Behavioral Health Clinics (CCBHCs) model is an
example of a program that increases access to comprehensive mental
health and substance use disorder services for populations including
children. This model encourages collaboration between social service
systems and school-based settings, reaching children where they are.
Making mental health services as accessible as possible is vital to
decreasing the stigma attached to these services and allowing children
to continue living their lives in their communities, with their
families.
Invest in School-Based Mental Health Models to Meet Children Where
They Are
School-based mental health models are an extremely effective way to
deliver mental health services to children. However, such programs vary
across states and many schools are underfunded and understaffed. These
programs need additional investments and support to ensure they are
reaching all children who need help.
Schools should provide a continuum of supports to meet student mental
health needs, including evidence based prevention practices and trauma-
informed mental health care. Tiered supports should include
coordination mechanisms to ensure students get the right care at the
right time.
The school-based mental health workforce needs to be expanded. This can
be done through the sustained use of local, state, and federal funds to
hire and train additional staff, such as school counselors, nurses,
social workers, and school psychologists, including dedicated staff to
support students with disabilities.
School districts should be encouraged to access Medicaid funding for
health and mental health services. The Centers for Medicare and
Medicaid should update guidance to states that will enable them to
equitably access Medicaid reimbursement and require Medicaid to
simplify the billing process for schools to ensure access and decrease
the money spent on administration expenses.
Mental health needs to be fully integrated into our education system.
Social and emotional learning should be integrated into K-12
curriculums, and discussions on mental health should be included in
health discussions the way schools currently do for nutrition,
exercise, cancer prevention, and other physical health topics.
Ensure All Children Have Access to High-Quality and Affordable Mental
Health Care by Addressing Parity
By law, children (whether on Medicaid or covered by private insurance)
are entitled to preventive services which include mental health
diagnosis, prevention and treatment but they are often not receiving
services because these laws are not being strongly enforced. Therefore,
millions of children are falling through the cracks and unable to
receive the care they need. On average, nearly 11 years lapse between
the presentation of mental health disorders and the professional
diagnosis of symptoms. We are failing our children when we force them
to wait on average 11 years for treatment.
Three laws are important to the improvement of our mental health system
for children. The Social Security Amendments of 1967 included
provisions to ensure that early and periodic screening, diagnostic, and
treatment services (EPSDT) are available to children in Medicaid. Over
forty years later, the Affordable Care Act (ACA) defined ``essential
health benefits'' for children as mental health, preventive care and
pediatric care, as well as requirements to ensure the adequacy of
provider networks to offer those services. For children covered by
private health insurance, these provisions guarantee access to a
relatively similar scope of preventive services as EPSDT under
Medicaid. Finally, the passage of the Mental Health Parity and
Addiction Equity Act of 2008 (MHPAEA) promotes equal access to
treatment for mental health and substance abuse disorders by
prohibiting coverage limitations that apply more restrictively for
mental health and substance abuse than for medical and surgical
benefits.
The high rates of depression, anxiety and suicides are a result of
these laws not being enforced, a lack of investment in the mental
health workforce and the failure of our school systems to provide more
support to children with mental health needs. Together, these laws
provide the framework for a more comprehensive and equitable system. We
have the right laws, we simply need to implement and enforce them.
Network adequacy is a critical piece to the mental health continuum of
care. It is important to all children to have access to a range of
services from qualified providers in a geographic area--whether the
children are on Medicaid or have private health insurance. Without
adequate networks, parents may not be able to find providers who accept
Medicaid or their particular type of private insurance. Oftentimes,
once a provider is identified, wait lists can be one to four months
which is not acceptable when a crisis occurs for a child, teen or
adolescent. Or, parents with Medicaid may only be able to find in-
patient care for their children when research suggests that in most
cases, community-based care delivers better outcomes. Those parents
with private insurance might find a ``provider network list'' but
cannot find anyone in their geographic area, or the list might only
have a few names on it, or the providers may not be taking new
patients, or lists may be outdated--all of which can lead to roadblocks
and barriers to finding viable provider options for their children.
Improve Crisis Response Services
We have seen the numbers of children in mental health crises increase
dramatically in recent years, and we must ensure that these children
and youth are able to access services when and where they need them.
This year, states must implement the new 988 behavioral health crisis
response system. This should be a more responsive crisis system that
avoids unnecessary and often harmful interventions such as a police
presence and visits to emergency rooms. This approach is especially
important for children and youth and for achieving equity in mental
health. These crisis systems must address the special needs of
children, youth, and young adults as well as be culturally competent
and able to help populations including LBGTQ youth.
One helpful tool in responding to mental health crises for children and
youth in appropriate and accessible ways is the mobile crisis response
unit. Several states, including Oregon,\8\ are implementing mobile
crisis response systems that increase equity and accessibility for
children and youth in addressing their mental health needs, and these
should be incorporated into states' implementation of the new 988
number.
---------------------------------------------------------------------------
\8\ https://www.clasp.org/publications/report/brief/youth-mobile-
response-services-investment-decriminalize-mental-health/.
---------------------------------------------------------------------------
Address the Needs of Children Who Have Lost Caregivers Due to
COVID-19
In October 2021, even prior to the arrival of the Omicron variant, the
number of children who had lost a parent or grandparent primary
caregiver due to COVID-19 was 175,000,\9\ a staggering statistic. And
over five million children worldwide \10\ have lost a parent or primary
caregiver. Children of racial and ethnic minorities accounted for 65%
of those who lost a primary caregiver,\11\ while making up only about
50 percent of the child population. These children currently have great
needs and will continue to have many into the future.
---------------------------------------------------------------------------
\9\ https://www.npr.org/sections/health-shots/2021/10/07/
1043881136/covid-deaths-leave-thousands-of-u-s-kids-grieving-parents-
or-primary-caregivers.
\10\ https://www.nytimes.com/live/2022/02/24/world/covid-19-tests-
cases-vaccine#children-parents-caregiver-covid-deaths.
\11\ https://spectrumlocalnews.com/tx/south-texas-el-paso/news/
2021/10/25/175-000-children-parentless-due-to-covid-deaths.
The needs of this population of children should be met in a
comprehensive way after identifying who they are. These children should
have expanded access to mental health services, including in schools,
regardless of their insurance coverage (public or private.) We must
ensure that children who have lost caregivers during the COVID-19
pandemic receive the benefits that they are entitled to under current
law and make them categorically eligible for other public programs and
economic aid including early learning programs like the Child Care and
Development Block Grant and Head Start, the Temporary Assistance for
Needy Families, the Supplemental Nutrition Assistance Program,
Medicaid, the Child Tax Credit, and others.
Conclusion
We appreciate the Committee's focus on the mental health crisis of our
country's children and youth and the two valuable and impactful
hearings that the Committee hosted in February 2022. First Focus on
Children commends the Committee's bipartisan approach to this topic and
we look forward to seeing the proposals that emerge from the five work
groups that the Committee has established. We share your concern for
the mental health of America's children and youth and we look forward
to continuing to work with you as you craft legislation and funding
proposals.
For questions or comments, please reach out to Averi Pakulis, Vice
President of Early Childhood and Public Health Policy
([email protected]), Elaine Dalpiaz, Vice President of Health
Systems and Strategic Partnerships (ElaineD@firstfocus.
org) or Olivia Gomez, Director of Health and Nutrition Policy
(OliviaG@firstfocus.
org).
______
FosterClub
620 South Holladay #1
Seaside, OR 97138
PH: 503-717-1552
FAX: 503-717-1702
WEB: https://www.fosterclub.com/
EIN: 93-1287234
CFC: 76187
March 1, 2022
U.S. Senate
Committee on Finance
Dirksen Senate Office Bldg.
Washington, DC 20510-6200
RE: Testimony Submitted for ``Protecting Youth Mental Health: Part
II--Identifying and Addressing Barriers to Care,'' Hearing Held on
February 15, 2022
Dear Chairman Wyden, Ranking Member Crapo, and Members of the Senate
Committee on Finance,
Thank you for your interest in improving access to mental and
behavioral health services for children, young people, and their
families. Testimony provided during the hearings on February 8th and
15th demonstrated the urgent need to improve these services and the
importance of engaging young people. During the February 15th hearing,
Mr. Trace Terrell stated: ``My peers and I believe we deserve a seat at
the table. While there are many ways we can do this, it starts by
ensuring young people can meaningfully contribute to and be involved
with legislative work on the local, state and federal level.'' We agree
fully and we are thankful for Chairman Wyden's, Ranking Member Crapo
and the Committee Members' commitment to ensuring young people have a
seat at the table as work on this critical issue continues.
FosterClub is writing to ask for assistance in adding the voices of
young people who have lived experience in the foster care system who
face unique challenges in accessing and receiving mental and behavioral
services and support.
FosterClub is the national network for young people who experience
foster care. While foster care provides a critical safety net in our
society for children and youth, we know that being in foster care can
be a very difficult experience for a young person. FosterClub believes
that when young people have the support they need and the opportunity
to drive change in their life, they are able to develop into self-
determined individuals. We also believe that when the system listens to
young people, it develops a better understanding of how best to support
them.
For the past two decades, FosterClub has worked with young people about
the need for mental and behavioral health support in child welfare.
We've heard from young people about the diverse challenges they face.
These include but are not limited to: a lack of awareness about
available health care and services; difficulty getting to the resources
that will help their needs; changes in services available from
jurisdiction to jurisdiction and state to state; and difficulty forming
close relationships with peers while in foster care.
The challenges young people elevated inspired them to find creative
solutions to the problems they and their peers are facing. The
continued meaningful engagement of young people is critical to solving
both these and future challenges to improve the well-being of young
people in and from foster care. The involvement of young people in
service delivery should extend beyond their role as recipients of
services. Young people should be involved in every aspect of the
design, implementation, delivery and evaluation process.
Increase awareness of health care eligibility.
Although states have been enrolling former foster youth in Medicaid for
several years, implementation varies. Some states automatically enroll
young people and some states ask young people to complete a several-
page application. Some states cover young people who relocate to a new
state and some do not.
States need to improve outreach to young people, simplify the
enrollment process and cover young people who experienced foster care
in another state.
I think that the need to do outreach is so important. Had it
not been for some former foster youth campaigning and doing
outreach I would not have found out that I could get insurance
and I honestly don't know if I would have still been here
today. I didn't know I could still get insurance and because of
that I failed to go to the hospital and get the help I needed
and that made things worse in the long run.
-- Dashun Jackson, FosterClub Lived Experience Leader who spent
4 years in Nevada's foster care system.
I could have lost my health care if I had left New York to go
to Texas for a surgery that I needed. Losing my health care
could have jeopardized all of my hard work and progress toward
earning my college degree.
-- Cody Rivera, FosterClub Lived Experience Leader who spent 12
years in New York's foster care system
Facilitate improved navigation to services.
Young people need support in navigating the services that can meet
their unique needs. FosterClub frequently receives calls from young
people and professionals who are trying to support young people to
connect with services. Currently, the resources that exist to provide
these services are not accessible for young people, and frequently,
they are not accessible for professionals.
We need dedicated foster care navigators who can support connection to
the right mental health resources and understand what foster youth are
eligible for. Navigators can be young people with lived experience who
are trained and equitably compensated.
Streamline services young people are eligible for.
When young people come together from across the country, they report
vastly different services that they are eligible for. Large disparities
exist in the quality of services available to young people across the
country.
Regardless of their location, young people should have access to and be
eligible for a core set of services. We must ensure diverse communities
have equitable access to both services and supports.
Increase Access to Peer Support
Young people who are in foster care often feel isolated, as they know
few other young people who are also in foster care. Young people are
often more likely to listen to and accept information from their peers
than they are from professionals.
We must ensure young people have access to peer-delivered services and
peer support groups, including those with the expertise to conduct
initial conversations on the importance of health and well-being,
provide accurate information on the benefits of regular health care
coverage. Peer support can occur in structured, ongoing opportunities
for youth in foster care to gather in person or virtually to connect
with one another. Youth should be supported by trained facilitators who
are themselves foster youth. There are strong examples of successful
peer support implementation including in Oregon where FosterClub has
hosted teams of Peer Navigators who are providing support to fellow
foster youth during the pandemic.
In summary, FosterClub recommends the following considerations from
young people with lived experience in foster care in order to improve
mental and behavioral health supports:
1. Meaningfully engage young people in the design, implementation,
delivery and evaluation process.
2. Increase awareness of health care eligibility.
3. Facilitate improved navigation to services.
4. Streamline services young people are eligible for.
5. Provide regular access to peer support.
FosterClub is pleased to share these priorities with the Committee as
it continues discussions about how to improve mental health supports
for young people in and from foster care. If you would like to discuss
further, please contact Celeste Bodner, FosterClub, 503-717-1552 or
[email protected].
Sincerely,
Celeste Bodner
Executive Director
______
FosterClub
620 S. Holladay Drive, Suite 1
Seaside, OR 97138
Foster Care Alumni of America
5810 Kingstowne Center Dr., Suite 120-730
Alexandria, VA 22315
March 1, 2022
U.S. Senate
Committee on Finance
Dirksen Senate Office Bldg.
Washington, DC 20510-6200
RE: Testimony Submitted for ``Protecting Youth Mental Health: Part
II--Identifying and Addressing Barriers to Care,'' Hearing Held on
February 15, 2022
Dear Chairman Wyden, Ranking Member Crapo, and Members of the Senate
Committee on Finance,
Thank you for investing in improving the access and resources children,
young people and their families have to mental and behavioral health
supports. Testimony given during the hearings on February 8th and 15th
revealed the urgency of improving these services and the importance of
engaging young people in these improvements.
FosterClub is the national network for young people who experience
foster care. FosterClub believes when young people have the support
they need and opportunity to drive change in their life, they become
self-determined and do better. We also believe when the system listens
to young people, it does better.
Foster Care Alumni of America's vision is that all people in and from
foster care are connected, empowered, and flourishing.
During the February 15th hearing, Mr. Trace Terrell stated: ``My peers
and I believe we deserve a seat at the table. While there are many ways
we can do this, it starts by ensuring young people can meaningfully
contribute to and be involved with legislative work on the local, state
and federal level.'' FosterClub and Foster Care Alumni of America agree
with Mr. Terrell fully. We are writing to elevate the recommendations
that we've received from members of our networks regarding mental
health services and supports that can improve the well-being of young
people in and from foster care. We are thankful for Chairman Wyden's,
Ranking Member Crapo and the Committee Members' commitment to ensuring
young people have a seat at the table as work on this critical issue
continues.
Young people and alumni in our networks consistently share challenges
they encounter in accessing and engaging in high-quality mental and
behavioral health services. Our networks haven't stopped at raising
challenges; they've developed solutions. We've included several key
solutions that we have heard from young people in our networks below.
Much of the information we are outlining can be viewed in further
detail in the referenced published documents.
(1) Educate and inform us of our choices regarding treatment
and medication.\1\ This includes education for our families
before reaching a crisis point and grief services. Young people
must be provided with youth-friendly information regarding the
medications they receive.
---------------------------------------------------------------------------
\1\ See Older Youth Successful Transition to Adulthood (December
2020, https://nationalpolicy
council.org/sites/default/files/docs/blogs/
_Older%20Youth%20Successful%20Transition%20to%
20Adulthood.pdf); Quality Residential Services (February 2020, https://
nationalpolicycoun
cil.org/sites/default/files/docs/blogs/
Quality%20Residential%20Services_Feb.%202020_Final%
20.pdf); and Improving Youth Engagement and Access to Mental Health
Services, (April 2013, https://nationalpolicycouncil.org/sites/default/
files/docs/landingpage/Mental%20Health%20
Priorities.pdf).
Mental health services offered to me never felt like they were
presented as a choice. It was as if my trauma and the
subsequent behavior challenges that came with it was a burden
and something to be fixed. I almost always felt like my
autonomy was denied
-- Brittney Lee, experienced foster care in Washington State
People think that, because you've been removed from your home
of origin, you've been ``saved.'' Youth are rarely provided
with support to grieve. Unresolved loss can prevent us in
moving forward in finding and retaining permanence.
-- Youth Voice
(2) Provide us with peer support and peer navigation.\2\ Build
opportunities for youth to have access to peer groups
throughout their transitions into adulthood as young people
tend to turn to peers for support. Youth organizations have had
youth and alumni speak out about mental health challenges and
witnessed attitudes among youth in care shift instantly.
---------------------------------------------------------------------------
\2\ See Older Youth Successful Transition to Adulthood (December
2020, https://nationalpolicy
council.org/sites/default/files/docs/blogs/
_Older%20Youth%20Successful%20Transition%20to%
20Adulthood.pdf); and Improving Youth Engagement and Access to Mental
Health Services (April 2013, https://nationalpolicycouncil.org/sites/
default/files/docs/landingpage/Mental%20
Health%20Priorities.pdf).
(3) Curb over-reliance on medication.\3\ Based on personal
experiences, medication is often offered as the ``first fix''
when we start to exhibit issues due to trauma. Part of curbing
the over-reliance of medication is to ensure informed consent
and have an established and independent appeal process
available to us if we have a medication regimen (especially
while the regimen is being considered regardless of whether the
medication is over the counter or prescribed including off
label use).
---------------------------------------------------------------------------
\3\ See Quality Residential Services (February 2020, https://
nationalpolicycouncil.org/sites/default/files/docs/blogs/
Quality%20Residential%20Services_Feb.%202020_Final%20.pdf); and
Improving Youth Engagement and Access to Mental Health Services (April
2013, https://nationalpolicycouncil.org/sites/default/files/docs/
landingpage/Mental%20Health%20Priorities.
pdf).
When I was thirteen I was given 7 medications at one time and
later came to find out two of those medications were found to
be dangerous when used together and one of those medications
was not even approved for use for anyone under the age of 18.
-- Former Foster Youth from Iowa
(4) Prevent ``diagnosis-for-dollars.''\4\ We've heard anecdotal
stories from young people who portray a diagnosis being made in
their case to bump-up the reimbursement rate for caregivers. In
some states, caregivers receive triple or quadruple
reimbursement rates for youth with a mental health diagnosis.
Placement in foster care should be sufficient for our
eligibility for Medicaid services.
---------------------------------------------------------------------------
\4\ See Improving Youth Engagement and Access to Mental Health
Services (April 2013, https://nationalpolicycouncil.org/sites/default/
files/docs/landingpage/Mental%20Health%20
Priorities.pdf).
(5) Guide us so we are adequately prepared to transition to
adult mental health services.\5\ Ensure we are aware of how to
access mental health support after we transition out of foster
care to permanency or to adulthood. Peer navigators and
opportunities for group therapy are valuable supports.
---------------------------------------------------------------------------
\5\ See Older Youth Successful Transition to Adulthood (December
2020, https://nationalpolicy
council.org/sites/default/files/docs/blogs/
_Older%20Youth%20Successful%20Transition%20to%
20Adulthood.pdf).
(6) Ensure special populations, including those of us who are
LGBTQ2S+,\6\ can access specific and inclusive services to
bolster our health and well-being foundations.\7\ This can be
accomplished through training for caregivers and child welfare
professionals.
---------------------------------------------------------------------------
\6\ When we use the acronym LGBTQ2S+, we are referring to members
of the LGBTQ community, Two-Spirit youth and queer-identifying youth.
\7\ See Improving Youth Engagement and Access to Mental Health
Services (April 2013, https://nationalpolicycouncil.org/sites/default/
files/docs/landingpage/Mental%20Health%20
Priorities.pdf).
(7) Ensure we know our rights.\8\ Ensure we have access to and
are educated on our rights; we must be able to report
violations of our rights.
---------------------------------------------------------------------------
\8\ See Older Youth Successful Transition to Adulthood (December
2020, https://nationalpolicy
council.org/sites/default/files/docs/blogs/--
Older%20Youth%20Successful%20Transition%20to
%20Adulthood.pdf); Quality Residential Services (February 2020, https:/
/nationalpolicycoun
cil.org/sites/default/files/docs/blogs/
Quality%20Residential%20Services_Feb.%202020_Final%2
0.pdf); and Improving Youth Engagement and Access to Mental Health
Services (April 2013, https://nationalpolicycouncil.org/sites/default/
files/docs/landingpage/Mental%20Health%20
Priorities.pdf).
Mental health professionals were talking to others involved
with my case. There was a sense of violation and
disempowerment. I knew that information I shared could be used
against me.
-- Youth Voice
We are pleased to share these priorities with the Committee as you
continue looking at ways to improve mental health outcomes for young
people. If you would like to discuss further, please contact Angel
Petite, Senior Policy Manager at FosterClub, 503-717-1552 ext. 105 or
[email protected] or Kodi Baughman, Lived Expertise Policy
Director at Foster Care Alumni of America, (515) 402-2238, or
[email protected].
Sincerely,
Angel Petite
Senior Policy Manager
FosterClub
Kodi Baughman
Lived Expertise Policy Director
Foster Care Alumni of America
______
Healthy Schools Campaign
2545 Diversey Ave., Suite 214
Chicago, IL 60647
312-419-1810
https://healthyschoolscampaign.org/
Dear Chairman Wyden and Ranking Member Crapo:
On behalf of Healthy Schools Campaign, thank you for the opportunity to
submit a statement for the record for the hearing, ``Protecting Youth
Mental Health: Part II--Identifying and Addressing Barriers to Care.''
We commend the U.S. Senate Committee on Finance for developing
bipartisan legislation to address the challenges facing the United
States' mental health care system. Schools play a critical role in
meeting the behavioral health care needs of children and young people
across the country and strengthening and supporting schools and school-
based providers is a critical component of any policy solution.
The COVID-19 pandemic has impacted the behavioral health and emotional
well-being of students across the country. Mental Health America
reported that in 2020, 14% of youth suffered from at least one major
depressive episode in the past year. Data from the Centers for Disease
Control and Prevention (CDC) indicates that mental health-related
emergency department visits are up 24% for children (age 5-11) and 31%
for youth (age 12-17). While schools serve as a key source of mental
health programs and supports for children and youth, 68% of principals
report having insufficient school-based mental health professionals to
meet student needs.
While student and staff mental health issues are increasing as a result
of the pandemic, this problem is not new. Mental health issues present
a major challenge for students. Prior to the pandemic, it was estimated
that as many as one in five children living in the United States
experience a mental disorder in a given year, and approximately 40% of
adolescents experience a mental health condition each year. Three
quarters of all students receiving mental health services receive those
services in schools.
Through Healthy Schools Campaign's work at the national, state and
local levels, we have seen the critical role schools play in supporting
coordinated, comprehensive and equitable access to behavioral health
care. Healthy Schools Campaign leads the Healthy Students, Promising
Futures Learning Collaborative which was launched by the U.S.
Department of Education and U.S. Department of Health and Human
Services in July 2016 and brings together 15 state teams focused on
expanding Medicaid funded school health services. Core to the learning
collaborative's work is identifying policy solutions that support
expanded access to and resources for school-based behavioral health
services. In addition, Healthy Schools Campaign has over two decades of
experience providing on the ground support to school stakeholders,
including families, school staff, youth and community members to
advance healthy school environments, including access to behavioral
health services and supports.
Through this work, Healthy Schools Campaign has identified a number of
federal and state policy solutions that, if implemented, can ensure
schools are supported as key providers of behavioral health services
and programs.
1. Strengthen school-based Medicaid programs.
A key strategy for improving access to behavioral health care for
children and young people is ensuring school districts are able to
receive Medicaid reimbursement for behavioral health services delivered
in schools. While Medicaid has a 30-year history of reimbursing for
school-based health services, that reimbursement has primarily been
limited to eligible services included in students' Individualized
Education Programs or Individualized Family Service Plans. This means
that the majority of behavioral health services delivered to Medicaid
enrolled students in school settings are not Medicaid eligible.
In 2014, the Centers for Medicare and Medicaid Services (CMS) issued a
state Medicaid director letter allowing states more flexibility in
their school-based Medicaid programs by permitting school districts to
bill Medicaid for health services delivered to all Medicaid-enrolled
children, not just those with a special education plan documented by an
Individualized Education Program (IEP). In order to implement this
change, some states need to submit a state plan amendment (SPA) to CMS;
other states are able to implement this change administratively without
a SPA. This policy change presents a critical opportunity to expand
access to and resources for school-based behavioral health services and
yet, only 16 states have leveraged the opportunity to expand their
school-based Medicaid programs. Federal support and guidance are needed
to ensure the remaining states leverage this opportunity
Solutions to strengthen school Medicaid programs across the country
include:
Require that all states implement the free care policy to expand
their school Medicaid programs to cover all medically necessary
services--including prevention and early intervention--delivered to all
Medicaid eligible students in a school setting.
Require Centers for Medicare and Medicaid Services to update
both the Medicaid School Health Technical Assistance Guide and the
Administrative Claiming Guide to better support states in designing and
implementing their school-based Medicaid programs, including how to
address significant implementation barriers faced by schools. The last
federal guidance on school Medicaid programs was issued in 2003 and the
lack of updated guidance presents a significant challenge to states and
school districts seeking to strengthen and expand their school Medicaid
programs. The guidance should be updated with significant input from
states and stakeholders.
Provide an increased Federal Medical Assistance Percentage
(FMAP) for health services provided in a school-based setting,
including behavioral health services. An increased FMAP would both
incentivize states and school districts to expand their school Medicaid
programs and ensure school districts had access to sustainable funding
to deliver behavioral health services to Medicaid enrolled students.
Deepen funding for technical assistance (TA) to schools and
state Medicaid programs by establishing a national Medicaid technical
assistance center to support states and school districts in operating
their school Medicaid programs. This could be modeled after the Mental
Health Technology Transfer Center Network (https://mhttcnetwork.org/).
Provide states with funding to support small and rural school
districts implement and/or expand school mental health Medicaid
programs--and provide ongoing technical assistance. This could include
funds to train school health providers, educate school district billing
departments, and provide dedicated state staff to coordinate between
state Medicaid and Education departments. Initial funding can help
ensure states and school districts are able to serve the most students
possible.
Issue a Request for Information on school-based Medicaid
programs to better understand the challenges and opportunities facing
school districts in billing Medicaid for school health services,
including behavioral health services.
2. Support the delivery of school-based telehealth services.
During the COVID-19 pandemic, students have faced disruptions in access
to school-based physical and behavioral health services as schools
shifted from in-
person to virtual learning. Many schools adapted by delivering services
through telehealth and states leveraged federal flexibilities to
implement policies that allow Medicaid to reimburse for school-based
telehealth services to support the health needs of students. These
policies promote access to critical health services for students and
support schools in meeting federal requirements to provide services to
students with disabilities while reducing risk of COVID-19
transmission. Supporting states in continuing to maximize the use of
telehealth to deliver school-based behavioral health services is a key
strategy to meeting student behavioral health care needs.
Solutions to strengthen the use of telehealth to deliver school-based
behavioral health services include reimbursing behavioral telehealth
services at the same rate as in-person services. Given the significant
investments required of school districts to offer and maintain
telehealth services, it is critical to ensure school districts are able
to maximize resources for school-based telehealth services to support
ongoing access for students.
3. Address shortages of school-based behavioral health providers.
School districts across the country are facing workforce shortages of
school-based health providers, particularly school-based behavioral
health providers. This issue is particularly critical as school
districts develop and implement plans to spend American Rescue Plan
funding. Many school districts have prioritized spending COVID-19
relief funding on expanding access to school-based behavioral health
providers and yet, they are unable to find enough providers to meet
students' behavioral health care needs.
Solutions to strengthen the school-based behavioral health workforce
include:
Create and expand loan forgiveness, repayment and scholarships
for healthcare students and professionals who pledge to work within
school settings.
Develop a National School Health Services Corp under the
National Health Service Corp.
Simplify the Public Service Loan Forgiveness program (PSLF) to
make it easier for individuals who commit to serving as health
professionals in schools to qualify for loan forgiveness. This could
include partial, up-front loan forgiveness, as an alternative to the
all-or-nothing back-end loan forgiveness currently provided by the PSLF
program as well as forgiving a portion of the borrower's eligible loans
every two years.
Expand Health Resources and Services Administration's (HRSA)
State Loan Repayment program to include school health professionals as
eligible members of the healthcare workforce.
HHS and ED should establish national certifications for all
school health providers, such as the National Certified School
Psychologist credential and grant state reciprocity for all school
healthcare workers to remedy the shortages in rural and other
underserved communities.
Thank you for considering our feedback on this important issue. We care
deeply about the ability to meet the behavioral healthcare needs of
students and believe strengthening the delivery of school-based
behavioral health services is a key strategy to improve access to
behavioral health care for children and young people.
Sincerely,
Rochelle Davis
President and CEO
______
Juvenile Law Center
1800 JFK Boulevard, Suite 1900B
Philadelphia, PA 19103
215-628-0551
800-875-8887
215-625-2808 fax
https://www.jlc.org/
Hello, my name is Alexis Andino; I go by Lexi. I am 24 years old, and I
have been working with the Juvenile Law Center's Youth Advocacy Program
as part of their Youth Fostering Change program for 4 years.
I was 10 years old when I first went into foster care. They picked us
up from lunch, and I never got to go back home. I was scared, I was
frustrated, being with a whole bunch of people I didn't know. We waited
in one of the rooms in the DHS building for hours. I was in care for
the whole time until I was about 17. I got discharged, because I got
approved for Kinship care. I thought I could be with my great
grandmother, but I had to move, and I had to find a place to go because
shortly after I got out of care she passed away, and then I was
homeless again.
It was hard to get in contact with people. When I was 18 and 19, they
told me it would be hard to reenter, and that I'd be in a shelter for
over a year before I got housing. They basically told me I would have
to go back to a shelter, and that basically was my only option. I was
hopping around from home to home. I tried to go back into foster care
at age 19 and I didn't get help with anything until after I was 20.
It wasn't until a few months after I was 20 that I got help through AIC
(The Achieving Independence Center). I wound up still staying with a
family friend. I kept trying to get connected to Valley Youth House
though AIC. AIC finally got me connected to Valley Youth House after I
was 20. I only got about 10 months of support. The system is messed up.
It shouldn't be like that. There's no reason that they can say that we
can come back and get help and that we're able to get help until we're
21 but when you try to get help, they literally deny you and tell you
no and that you'll be in a shelter for over a year. They were basically
telling me don't get back in the system because you're basically not
going to get any help. They kept denying me services and resources
until it was kind of too late. I ended up only getting services for
less than a year when I should have been able to get it for that whole
3 or 4 years, when I really needed it. Someone just told me that they
think that AIC was extended until 23, and there are all of these other
things like this Ombudsman hearing, and all of these other services--
nobody tried to contact me or help me with anything. And of course, all
of that stuff changed and extended because of COVID but I already
turned 23 so I couldn't receive those extra services.
Every time I tried to get connected to services, they acted like I
should know who my family is, like I haven't been in the system for 10
years. They separate you from your family, don't let you communicate,
don't use to not let them come and see me or vice versa, sometimes for
a punishment, that's not right. Literally restricted phone calls and
you're supposed to magically know your family and have somewhere to
live with when you age out. It doesn't make any sense, it's so dumb.
They wonder why we age out of the system and don't have a support
system or family. It's ridiculous.
Being in foster care growing up, I did go through a lot of things
related to race. I was always in other people's homes--foster homes and
group homes, of people I didn't relate to. They would look at me as if
I was different. There was a lot of time I was the only white person in
the home, or school, I got picked on a lot. Staff would be talking at
youth instead of talking with youth. They wouldn't give you a chance to
speak. This was the rule and that's it. You can't say how you feel, and
you have to follow it or you're getting punished. I never had a sense
of normalcy or a good childhood. They would take away stuff. I didn't
have a cell phone until I was like 15. I was coming in and out of the
city at the age of 13 on the buses with no phone. I was making my own
doctor's appointments, I did almost everything on my own. Every time I
asked for help, they would look at me like ``what do you need help
for?, you can do it yourself.''
I felt like every time I asked for help they would give me the run
around--``you gotta contact this person'', ``I don't know, you gotta go
to this person'', ``I can't help you with this, go to this agency''. I
didn't get help until I was going to everyone's supervisor and telling
people in court that I was trying to get help, and nobody wanted to
help me. I didn't get help with getting back into therapy until after I
got discharged from DHS. I asked for help getting services and it was
so much of a process that took forever. I didn't know if it was the
process or if they weren't trying to help me in the beginning.
Youth questions about their case can often go unanswered by attorneys
and the case workers assisting them. For example, I followed up every
time I was experiencing challenges, or had questions, or when I needed
help or wanted access to service. However, despite how many times I
reached out, I never seemed to get clear answers, the outcome remained
the same. I had no final answer, and no clear help to get answers. It
seemed like I needed to figure out how to help myself and get myself
access to services, even at such a young age. This made me feel
frustrated and like I didn't want to follow up because they would give
me general statements instead of action steps. This inconsistency
process, and lack of clear follow-up impacts youth emotional health and
well-being. For me, it made it feel alone, helpless, and truly I felt
belittled, like I didn't matter, or neither did my opinions, or my
life. I felt stuck, and like there was no value on my future- that
people didn't care about me. My case planning team should have been
honest and realistic about what was happening and what my options and
next steps were. They should have explained my case to me and got me
help and support much sooner than 3 months before I aged out. Since no
one really taught me, anything growing up, this is why I'm struggling
now. I believe if they would have been honest with me and communicated
with me about my case and what I could do to better my life, to help
myself, and directly connected me to supportive services I would have
been better. I wouldn't have just been living day to day.
I recommend that there is a requirement to ensure that it is written in
a youth case plan of which staff are required to actively engage with
youth in their case planning, the specific services needed for youth,
and who on the youth's team will connect them to these services and
supports. This needs to be completely detailed for youth and written
out more comprehensively so that it happens. I believe if this happened
for me, I would be in a better place, because all I really needed was
resources, a sense of guidance. All I needed was someone to tell me
``this is life, you need X,Y,Z'', and I will help you through it,
especially as a child and a teen. I was never able to be a child. I'm
still learning and unlearning things. If I would have been more active
in my case, I would have been engaged and have a say in my life.
Youth deserve a sense of normalcy, guidance, a good and reliable
support system, someone to show them how to navigate through life. It's
really not easy when nobody tells you or teaches you important things.
To ensure what happened to me doesn't happen to other youth, I would
also recommend incentivizing states and counties to Designate a mental
health point person who can discuss youth therapeutic options and the
benefits of therapies and work with youth and families to connect them
with community agencies that will fit their needs--whether outpatient,
partial, weekly, art therapy etc. This process must include discussing
that various types of therapy are dependent on the age of the youth,
and if there is an immediate mental health crisis taking place. I
believe if there was someone like this available in my state or county
it would have helped my case and me a lot. I still struggle every day
because I don't have any guidance, anybody to call when I have
questions. If I had someone involved in my life, I would have felt like
I would have finally had someone in my life who cared about me.
Thank you.
______
My name is Aqilah David. I am 21 years old. This is my fourth year
serving as an advocate with Juveniles for Justice at the Juvenile Law
Center.
I first entered the child welfare system at age 15. It was a long,
horrible journey. I've been bounced around through a few juvenile youth
residential treatment facilities. I've had workers assigned to me
through DHS and the courts. To this day I feel like I've encountered so
many harmful and traumatic events while in the child welfare systems. I
was expelled in the 11th grade due to truancy, ODD, and feeling
frustrated with things happening in my life. After being expelled, I
was sent to an alternative school, on probation, and later forced to go
to a juvenile placement because of a GPS violation. When I got to the
juvenile holding facility, no one notified the alternative, so they did
not know I was in placement and constantly marked me absent while I was
in the juvenile facility.
They held me at the juvenile holding facility until a placement became
available. Finally placed at an official placement I suffered from
depression, and I felt spiritless. I met with a psychiatrist there who
I explained to that I was having trouble sleeping and was always sad. I
was glad to talk to anyone, because I just wanted to express to someone
how things were making me feel while I was at a residential treatment
placement. The placement prescribed me medicine as a child, that was
too high in dosage and made me lightheaded, dizzy and made me throw up.
I told this to my Philly CUA worker who then told me the medicine was
for my own good. So, I told the psychiatrist I did not feel the
medicine was making me feel better, I made a mistake telling her
because this only led to them increasing the medication they were
giving me throughout my whole stay. I gained weight and I am scared of
medicine to this day as an effect. Congress must work with HHS to
develop policies that require first utilizing therapeutic services
first, and medication must be provided only as needed, and after
individualized assessments by qualified professionals and following
full consideration of alternatives to pharmaceuticals.
While at placement I felt I had to advocate for myself a lot, including
attending a school off-grounds from the placement; a local community
school where I had to be tested and was accepted. I was glad because
the placement school was horrible. I was discharged from the placement
at age 18. I did not leave with the documents that I needed like my
school documents, my health records, or vital docs. I had to find my
vital documents on my own. The placement or the local public school
never gave me my diploma, so I had no proof that I graduated from high
school.
There was no aftercare support after I left placement. No one talked to
me about my safety when I got home. I wish I had more support to
prepare for college or had someone who could have guaranteed my
educational transition would be successful. Also, any mental wellness
support and medications that were started in placement needed to be
continued but when youth leave, there is no person ensuring anything.
There should also be a state office, like a Youth Ombudsman office in
every state where youth could go there to file complaints and get
accurate information on who is supposed to help and report when people
are not supporting them. I could have used an Ombudsman office in my
state this office when I was over-medicated, and when I didn't receive
appropriate support in placement, and when I left. No child or youth
should have to do this alone, but I did. I was a kid, I deserved
better. To expect that youth who go to placement will experience
success and complete school is unrealistic because youth are not given
enough guidance support. We need better options.
Thank you.
______
Hello, my name is Alexandria Rivera. I am 21 years old, and I have
entered eight different placements, including Foster Care. I have been
working with the Juvenile Law Center, Youth Advocacy Program, as part
of their Juveniles for Justice program for three years, and I have been
an active alumna for one year. The reason I continue to work on issues
youth face is because I was a youth who had issues. Now, I am an adult
still trying to fix the damage the system causes. I believe that we
don't need generation after generation to fall apart due to a broken
system, so it is important for us to share our testimonies to fix the
damaged system.
Before I even walked into the courtroom, my worker told me I was not
going home. They did not tell me how long I was staying. They stated
that I wasn't going home. That was a lot for me to think about so fast,
because it happened before I even walked in and then,--when I walked
into court, I didn't even understand what they were saying. They said
that I would be with my brother at an ``on-grounds school'' because he
was placed a week before me. My mom started crying. I figured I was
being sent to placement because of the things that were going on at
school--a school I didn't even want to go to because I knew what would
happen to me if I went there. Before I entered the justice and foster
care system, I was living at home and going to Edison, my community
high school, but the school had a bad reputation. I knew that if I went
to that school things would not go well. It had a lot of police and was
a really chaotic environment with little to no structure. We didn't
have a principal for about 2 months, or any support or programs. I
didn't feel comfortable showing up to school, I felt like there was no
point in going to school because I wasn't learning. It wasn't safe and
was so unorganized in class. I remember my teacher gave me an
assignment to complete that already had all the answers filled in. I
told my mom I wanted to go to a better school that had more structure
and more after-school programs so I would have a better experience, but
I was sent to Edison instead. Instead of help, or the court asking me
why I didn't want to go to school or what was happening at school- I
was sent to placement.
When I got to the placement it was freezing, I didn't even know the
name or location, how long or where or even the real reason why I was
placed. The second day at the placement, there was a ``house meeting''
with two groups of youth housed at the placements and a big fight broke
out. I didn't know what was going on. I was supposed to be meeting a
staff member who would be assigned to me, but I didn't meet her until a
week later. I should have met her within 24-48 hours. I wanted to talk
with someone at the facility to know why I was placed, and why I did
not get a warning. I kept thinking, did I get sent to placement,
because my siblings went to placement, am I being sent here as a
warning? I couldn't understand why they sent me when I had never been
in trouble until I went to Edison.
Being in placement kind of destroyed my life. It destroyed my
education. I didn't get proper education and none of my credits
transferred. Being in placement feels like you're in a ``halfway''
house for children. Placement is what made me feel like I was a
delinquent. No one offered me support from my community to go to a good
school, the court should have given me support to stay home and offered
to help me get into the right school I wanted to get into, not sending
me to an unsafe community school. If our community had support for
youth, I wouldn't have felt like I had to make certain choices to
protect myself. I went from having to defend myself in school, to
defending myself in a placement, just to go back home on my own and
have to deal with the effects of all I went through before placement
and while I was in placement. That is too much to worry about as a
child. If I was offered support at home, I would have only had to worry
about what a child should have been worrying about: how I was going to
finish out my classes at the school.
I was a kid. I deserved better. We all deserve better. We deserve
someone really fighting for us and for all youth in placement to
require all states to have a Youth Ombudsman Office to be a place where
youth can go, to have someone on their side. Someone who we could have
gone to who worked outside of the placement, and outside of the system.
The least people can do is give youth an alternative. Congress should
also work to ensure that before a youth is placed in a group facility,
agencies exhaust all efforts to make sure youth are placed in family-
based settings. Many people don't know what it's like to feel scared
not knowing where you are going, and that you're going to be in
placement. We deserve chances to get alternatives. We deserve support.
We deserve to be offered programs, better schools, and resources. We
deserve something better than being put away.
Thank you.
______
Hi, my name is I-sha-le Watson. I first entered into placement around
15 and then entered into foster care. Being in group placements did not
help me, especially not with school. The first placement that I went to
did not have school. I did not know that I was supposed to have
educational support in placement, so I did not ask about it. If I was
never sent to placement, I would have graduated on time. While I was in
juvenile placement, I experienced discrimination because I'm a LGBTQ
youth. Discrimination and mistreatment in these facilities is a
constant problem and one no person or child should ever have. Sometimes
it happens because of our race, orientation, or sexuality and no one
ever really knows, or is held accountable for what happens to us.
Congress should work to enact legislation that would reduce the impact
of racial bias in the foster care system, including requiring that
states develop policies and protocols to ensure that all options for
support are provided in the home and with other family members before
removal.
We need an Ombudsman office, because obviously, youths are not being
cared for in these placements. Youth deserve care and respect. Adults
should have been carefully going through children's and youths'
complaints and should be evaluating these places. How can you all look
at these complaints, and cases and say to yourself, ``oh, a youth
reported that,'' and then you just throw out or ``unfound'' these
claims? That's wrong and it doesn't make any sense. The system needs to
be held accountable for what has happened to us in these facilities.
As a society we should be investing money in youth and families,
instead of the over $211,000 per kid it can costs in states like mine,
in Pennsylvania to lock youth up. The same amount of money you all
spent to incarcerate youth can be used to create many programs to keep
youth off the street and in family-based setting. Youth need more
physical activity programs, sports, like basketball, and recreational
activities that support our mental health and physical growth. Youth
and families shouldn't have their only option to be to go into foster
care or to have them put into placement when they need help. Placing a
child in a juvenile and or group facility is not helpful. It did not
help me at all, especially with school. I'm still not sure I ever got
credits while in placements. I found out because when I got home, I was
trying to get into a local community school, and they couldn't locate
any credits from the placement school I needed to transfer back to my
community school.
My experiences in placement and in foster care are why I think that it
should be a requirement to have all states have Ombudsman offices. If
we had an office like this in our state maybe a lot of youth in
placements and group homes might not be behind in their schooling,
having to graduate after 19, 20 or older because they could report that
they are not getting any education, or not getting the educational
support they're supposed to get, and get help faster. This office could
have also helped address when I was experiencing discrimination in
placement from staff. Furthermore, Congress must work to develop
policies and practices that end racism and all forms of oppression by
ensuring child welfare staff, and child welfare agencies provide
required training, and have process' to enforce all anti-discrimination
practices. It also just means a lot to me if Congress works to address
these issues and to know that someone is trying to help to make sure
that youth have what they need when they need it.
Thank you.
______
Hello, my name is Briannah Stoves. I am 17 years old. I have been in
seven different placements since I was 12 years old. This is my first
year working at the Juvenile Law Center with their Youth Advocacy
Program. I got involved with Juvenile Law Center's Youth Advocacy
Program because I heard I could verbally advocate, and I've been in the
juvenile system so I know how the system is, and if I can have a say so
in changing it, then I want to.
The very first time I was arrested for running away, I was taken to a
mental hospital. I felt safe at the hospital, but I was under
medication the whole time. If there was any sort of conflict, they
would always choose to sedate me. This was not the best method, what I
needed was therapy for me and my family, I would like there to be less
reliance on medication for children who are experiencing a crisis. We
are resilient and can heal not only from medication. I wish they first
would have provided me with another alternative before medication,
because there are sometimes harsh side effects and long-term effects.
The second time I was arrested, it was a mistake. I let my anger get
the best of me. Me and the police officer both could have done better,
but I was immediately placed from that experience. We both could have
deescalated. We both played a part in it, but I'm the only one that
paid the consequences. I was 14 years old. I feel like the cop should
have de-escalated the situation. He approached me with an angry
attitude, which wasn't helpful. You cannot approach anger with anger. I
wish the cop might have taken another second to have talked to me to
de-escalate the situation, because as a teen I was experiencing a lot
of traumas and was visibly upset. I don't think I needed to have been
arrested immediately, as the first option. More steps could have been
taken so that everything didn't have to occur the way that it occurred.
When I was placed after that experience, being in placement showed me
that nowhere was safe. Staff was allowing the other kids to bully me,
so I ran away. There was always a lot of fighting. Especially with a
lot of females in one house. My sense of safety was gone. I stayed in
my room a lot of the time and just read books.
I learned about the grievance procedures in a more disciplinary
setting. I didn't file any grievances because I didn't believe that
anything would be done. I know how long it takes to go through the
chain of command, and it would have been dismissed before anything was
one. I recommend Congress require federally funded, and state funded
facilities to develop a truly youth-friendly grievance policy and
connect youth to independent advocates who can assist youth in
navigating the process. This should include reviewing and assisting
youth with the grievance procedure. There also should be more staff
support and training for staff running not only juvenile, but
residential treatment and foster care group homes. There should not be
limited staff members who also lack skills in working with kids. I
remember the staff where I was staying didn't know how to deescalate
situations and a lot of times when the kids would get upset, the staff
would too.
Having safer environments for youth It would allow them to build
healthy relationships that are helpful for growth and healing. Thank
you for listening to my story and I hope you understand what is really
going on and that you will help make a change.
Thank you.
______
Mending Minds Village
1594 West 400 South #28
Salt Lake City, Utah 84104
Senators,
We had the privilege of listening to the hearing the U.S. Senate
held today regarding protecting youth mental health on a national
level. Mending Minds Village was created specifically to facilitate
change in the State of Utah, as well as on the national level to
provide much needed resources for our youth starting immediately. We
wanted to provide you a statement on this issue today, and provide our
stance on this issue.
Thank you to Senators Wyden and Crapo for putting bipartisan
support on this very critical issue nationwide. The youth in Utah are
having large difficulty in finding resources and treatment for their
mental health issues across the board here. We have seen a major uptick
in suicide and violence, especially across our minority groups in the
state. We have heard from families and therapists alike in the mental
health field, and what we are finding is very much equal across the
board in the needs and detriments. We have found that the programs
dedicated to providing services in this state are being highly slowed
by details such as billing and reporting requirements, and in some
cases they are not able to bill for certain services (i.e., autism
care) that is preventing them from helping the clients they care for.
My team at Mending Minds Village is dedicated to bridging the gap
between families who need support, the providers who are trying to
address those needs, and the medicaid and state/federal systems that
are preventing them from doing their jobs. In listening to the
testimony given in this hearing, we are moved to see such amazing,
bipartisan leadership being dedicated to helping our youth and creating
the changes that will help families going forward. Having recently
heard of the CCBHCs, we have done our research on the program, and we
are having the conversation with state and local leaders to bring that
movement to Utah as well. We believe strongly that this program was
dedicated to creating a better mental health system going forward, and
to have the support and funding of the federal government could
drastically change some lives of the families in our great state.
We began Mending Minds Village in January of 2022, after having
spent the last 4 years consecutively addressing the mental health needs
of our amazing 7 year old daughter. In the last 4 years, we have been
turned away, told there is no testing for her age (4-6), told that she
did not qualify for mental health treatment, and many more frustrating
and difficult things along the way. As we have delved into this
organization and tried to understand the needs of providers and
families alike, we are finding a general theme in those conversations:
the need for financial and state assistance for both. We have created
an organization (working on our 501(c)(3) status) that we feel could
help provide the assistance needed to desperate families, as well as
provide a private forum for providers and directors to create some much
needed intervention and conversation.
We come to you in support of the work that you are trying to
accomplish, and in support of the members of your committee who spoke
today regarding this issue. We applaud your work and constant attempts
at bettering life for those with mental health concerns. We plead with
you to work diligently to pass bills that will provide much needed
relief for these families who have needed it for so long, and are
losing the battle waiting on intervention. Too often we hear of
families who have lost a child or a loved one due to mental health
concerns that were not addressed by those they reached out to the most.
Too often we hear of families being torn apart due to a child's
uncontrolled behavior thanks in part to severe mental health. It is
time these families are heard and their needs are met. And we know you
are working hard to come to a resolution that will do just that.
We would love the opportunity to address the committee in person
(or on Zoom), and discuss with you the voices we are hearing in our
short time since being formed. The providers voices who are working the
frontlines and know what is so desperately needed. The families who are
begging for help before their world falls apart and being at the mercy
of the State and medicaid boards. We would love to share their stories
with you in hopes of creating another strong push for intervention and
assistance.
Thank you for your time and your work in this matter, Senators. And
thank you for your time, and allowing this statement to go on record.
Sincerely,
Kaden Mattinson
Founder and Director
______
Mental Health Liaison Group
1400 K Street, NW, Suite 400
Washington, DC 20005
https://www.mhlg.org/
February 20, 2022
The Honorable Ron Wyden The Honorable Mike Crapo
Chairman Ranking Member
U.S. Senate U.S. Senate
Committee on Finance Committee on Finance
Washington, DC Washington, DC
Re: Full Committee Hearing: ``Protecting Youth Mental Health: Part II--
Identifying and Addressing Barriers to Care''
On behalf of the Mental Health Liaison Group (MHLG), we submit this
statement for the record for the U.S. Senate Finance Committee hearing
entitled ``Youth Mental Health: Part II--Identifying and Addressing
Barriers to Care.'' MHLG is a coalition of national organizations
representing consumers, family members, mental health and addiction
providers, advocates, payers, and other stakeholders committed to
strengthening Americans' access to mental health and addiction care. We
strongly support the committee's continued attention to addressing the
needs of individuals with mental health and substance use disorders,
including among children and adolescents. We are grateful for your
leadership in convening this bipartisan hearing at a critical moment
for our nation's youth.
Significant unmet child and adolescent behavioral health needs existed
nationwide, even prior to COVID-19.\1\ Since 2007, suicide rates among
children aged 10 and older have climbed significantly each year, making
suicide the second most common cause of death among adolescents before
the pandemic.\2\ COVID-19 has only exacerbated these trends, including
among children who did not previously exhibit symptoms of a behavioral
health disorder.\3\ This led to the American Academy of Pediatrics, the
Children's Hospital Association, and the American Academy of Child and
Adolescent Psychiatry to declare a national state of emergency on
children's mental health, last fall.\4\ This was followed by a December
2021 U.S. Surgeon General advisory calling for a unified national
response to the mental health challenges young people are facing.\5\
Considering the rarity of such advisories, this further underscores the
need for action to help stem the long-term impacts of the pandemic on
the mental health and well-being of children and adolescents. We
applaud you for inviting the Surgeon General to speak before the
committee to discuss the steps which can be taken to promote child and
adolescent mental health and improve their access to care.
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\1\ Centers for Disease Control and Prevention. (2020). Youth Risk
Behavior Surveillance. Retrieved from: https://www.cdc.gov/mmwr/
volumes/69/su/pdfs/su6901-H.pdf; Substance Abuse and Mental Health
Services Administration. (2017b). Age and gender-based populations.
\2\ Centers for Disease Control and Prevention. (2020). National
Vital Statistics Reports. State Suicide Rates Among Adolescents and
Young Adults Aged 10-24: United States, 2000-2018. Retrieved from:
https://www.cdc.gov/nchs/data/nvsr/nvsr69/NVSR-69-11-508.pdf.
\3\ Osgood, K., Sheldon-Dean, H., and Kimball, H. (2021). 2021
Children's Mental Health Report: What we know about the COVID-19
pandemic's impact on children's mental health--and what we don't know.
Child Mind Institute. Retrieved from: http://wvspa.org/resources/CMHR-
2021-FINAL.pdf.
\4\ American Academy of Pediatrics. (October 2021). AAP-AACAP-CHA
Declaration of a National Emergency in Child and Adolescent Mental
Health. Retrieved from: https://www.aap.org/en/advocacy/child-and-
adolescent-healthy-mental-development/aap-aacap-cha-dec
laration-of-a-national-emergency-in-child-and-adolescent-mental-
health/.
\5\ Office of the U.S. Surgeon General. (December 2021). Protecting
Youth Mental Health: The U.S. Surgeon General's Advisory. Retrieved
from: https://www.hhs.gov/sites/default/files/surgeon-general-youth-
mental-health-advisory.pdf.
The stakes of untreated mental and behavioral health symptoms for
children and adolescents are exceptionally high, both on an individual
and societal level. Failing to detect and address early indicators of a
mental or behavioral health disorder can have profound consequences on
the overall trajectory of a child's life, including a greater
likelihood of difficulties with learning, addiction to substances,
lower employment prospects, and involvement with the criminal justice
system.\6\
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\6\ Sacks, V., and Murphey, D. (2018). The prevalence of adverse
childhood experiences, nationally, by state, and by race/ethnicity.
Bethesda, MD: Child Trends; National Collaborative on Education and
Health. (2015). Brief on chronic absenteeism and school health.
Chicago, IL: Healthy Schools Campaign.
The mental health of children is frequently tied to the overall health,
safety, and stability of their surroundings. The social isolation,
upheaval, and disrupted routines brought on by COVID-19, has placed
considerable stress on children and their families, which typically has
a downstream effect on their mental health. Ongoing national surveys of
households with young children have found high levels of childhood
hunger, emotional distress among parents, and frequent disruptions in
child-care services.\7\ Even before COVID-19, nearly 10% of U.S.
children lived with someone who was mentally ill or severely
depressed.\8\ Furthermore, since the start of the pandemic, over
167,000 children have lost a parent or caregiver to the virus.\9\ This
kind of profound loss can have significant impacts on the mental health
of many children, leading to anxiety, depression, trauma, and stress-
related conditions.
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\7\ Center for Translational Neuroscience. November 2021. Still in
Uncertain Times; Still Facing Hunger. RAPID-EC Fact Sheet. Eugene, OR:
University of Oregon; Center for Translational Neuroscience. November
2021. Emotional Distress On the Rise for Parents . . . Again. RAPID-EC
Fact Sheet. Eugene, OR: University of Oregon; Center for Translational
Neuroscience. November 2021. Child Care Shortages Weigh Heavily on
Parents and Providers. RAPID-EC Fact Sheet. Eugene, OR: University of
Oregon.
\8\ Ullmann, H., Weeks, J.D., and Madans, J.H. Disparities in
stressful life events among children aged 5-17 years: United States,
2019. NCHS Data Brief, no 416. Hyattsville, MD: National Center for
Health Statistics. 2021. DOI: https://www.cdc.gov/nchs/data/databriefs/
db416.pdf.
\9\ Treglia, D., Cutuli, J.J., Arasteh, K., J. Bridgeland, J.M.,
Edson, G., Phillips, S., and Balakrishna, A. (2021). Hidden Pain:
Children Who Lost a Parent or Caregiver to COVID-19 and What the Nation
Can Do to Help Them. COVID Collaborative.
Additionally, the COVID-19 pandemic has not been a short-term event. As
we move into the third year of this emergency, it is essential to
recognize that the pandemic has impacted children for multiple years of
their social, emotional, and cognitive development, allowing challenges
and adversities to compound. Parents continue to report being more
concerned about their children's social and emotional development and
well-being than they were prior to the pandemic,\10\ and recent data
show increased behavioral concerns among students who are having
difficulties transitioning back from remote to in-person learning.\11\
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\10\ Jung, Kwanghee, and Barnett, W. Steven. 2021. Impacts of the
Pandemic on Young Children and Their Parents: Initial Findings from
NIEER's May-June 2021 Preschool Learning Activities Survey. New
Brunswick, N.J.: National Institute for Early Education Research
\11\ Kurtz, H. (January 12, 2022). Threats of Student Violence and
Misbehavior Are Rising, Many School Leaders Report. Education Week.
Retrieved from: https://www.edweek.org/leadership/threats-of-student-
violence-and-misbehavior-are-rising-many-school-leaders-report/2022/01.
Youth within marginalized populations, including racial and ethnic
minority children and adolescents, those who identify as LGBTQ+, and
children with developmental and physical disabilities,
disproportionately have experienced some of the most severe
consequences of the pandemic. Black and Hispanic children lost a parent
or a caregiver at more than two times the rate of White children, while
American Indian, Alaska Native, and Native Hawaiian and Pacific
Islander children lost caregivers at nearly four times that rate.\12\
Two thirds of LGBTQ+ teens and young adults report that the combination
of COVID-19 and recent state actions targeting transgender youth
participation in school sports, has negatively impacted their mental
health.\13\ At the same time, young people from these communities faced
significant barriers accessing behavioral health services, even before
the pandemic.\14\
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\12\ Treglia, D., Cutuli, J.J., Arasteh, K., J. Bridgeland, J.M.,
Edson, G., Phillips, S., and Balakrishna, A. (2021). Hidden Pain:
Children Who Lost a Parent or Caregiver to COVID-19 and What the Nation
Can Do to Help Them. COVID Collaborative.
\13\ Morning Consult and the Trevor Project. (January 2021). Issues
Impacting LGBTQ Youth. Retrieved from: https://
www.thetrevorproject.org/wp-content/uploads/2021/12/TrevorProject_
Public_Final-1.pdf.
\14\ Austin, A., and Wagner, E.F. (2010). Treatment attrition among
racial and ethnic minority youth. Journal of Social Work Practice in
the Addictions, 10, 63-80.
Increases in demand for pediatric inpatient mental health services are
also a concerning indicator of the growing crisis in child and
adolescent mental health. Between April and October 2020, the
proportion of children between the ages of 5 and 11 and adolescents
ages 12 to 17 visiting an emergency room due to a mental health crisis,
increased by 24% and 31%, respectively.\15\ Moreover, due to the lack
of alternative placement options, hospitals are boarding a growing
number of children awaiting treatment in their emergency departments.
In recent months, several children's hospitals reported boarding their
highest number of children at one time and for longer stays before they
could be discharged to an appropriate alternate care setting.\16\ In
the first three quarters of 2021, children's hospitals reported a 14%
increase in mental health related emergencies and a 42% increase in
cases of self-injury and suicide, compared to the same time period in
2019.\17\ Shortages of mental and behavioral health professionals,
including those specifically trained to treat young people,\18\ further
exacerbate insufficient capacity to provide needed care and support
more effective integration of services.
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\15\ Leeb, R.T., Bitsko, R.H., Radhakrishnan, L., Martinez, P.,
Njai, R., and Holland, K.M. Mental Health--Related Emergency Department
Visits Among Children Aged <18 Years During the COVID-19 Pandemic--
United States, January 1-October 17, 2020. MMWR Morb Mortal Wkly Rep
2020;69:1675-1680. DOI: https://www.cdc.gov/mmwr/volumes/69/wr/
mm6945a3.htm.
\16\ Children's Hospital Association. Emergency Room Boarding of
Kids in Mental Health Crisis. Retrieved from: https://
www.childrenshospitals.org/-/media/Files/CHA/Main/Issues_and_Ad
vocacy/Key_Issues/Mental%20Health/2021/Boarding_fact_sheet_121421.pdf.
\17\ Children's Hospital Association (September 17, 2021). COVID-19
and Children's Mental Health. Retrieved from: https://
www.childrenshospitals.org/-/media/Files/CHA/Main/Issues
_and_Advocacy/Key_Issues/Mental-Health/2021/
covid_and_childrens_mental_health_factsheet_
091721.pdf?la=en&hash=F201013848F9B9C97FAE16A89B01A38547C7C5C7.
\18\ Ellison, K. (August 14, 2021). Children's mental health badly
harmed by the pandemic. Therapy is hard to find. The Washington Post.
Retrieved from: https://www.washington
post.com/health/child-psychiatrist-counselor-shortage-mental-health-
crisis/2021/08/13/844a036
a-f950-11eb-9c0e-97e29906a970_story.html.
Taken individually, these data are striking, but in aggregate, they
further illuminate the urgent need for action. In November, MHLG
responded to Chairman Wyden's and Ranking Member Crapo's request for
policy proposals on improving mental health outcomes and addressing
unmet needs, which included the following specific recommendations for
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improving access to coverage and care for young people and children:
Passing the permanent authorization of CHIP and the bipartisan
Stabilize Medicaid and CHIP Coverage Act (S. 646/H.R. 1738), which will
provide 12 months of continuous enrollment for Americans who are
eligible for Medicaid and CHIP.
Passing the bipartisan Helping MOMS Act (H.R. 3345) to
permanently ensure that all pregnant women on Medicaid and CHIP retain
their health coverage during the critical first year postpartum to
address serious health inequities in maternal health.
Directing the Centers for Medicare and Medicaid Services (CMS)
to review the early and periodic screening, diagnostic, and treatment
(EPSDT) requirements and whether they are being implemented
successfully at the state level to support access to prevention, early
intervention services, and developmentally appropriate services across
the continuum of care.
Directing CMS to coordinate with the U.S. Department of
Education to help the Department, states, and other stakeholders remove
barriers to full participation in school-based Medicaid programs.
Passing the bipartisan Telehealth Improvement for Kids'
Essential Services (TIKES) Act (S. 1798), which would promote access to
telehealth services for children through Medicaid and CHIP and study
children's utilization of telehealth to identify barriers,
opportunities, and outcomes.
The workforce shortage of mental and behavioral health clinicians
existed before the pandemic, but it is now a top concern throughout the
sector. The shortage of practitioners specializing in mental and
behavioral health care for infants, children, and adolescents is
particularly acute. MHLG therefore recommends that Congress increase
investments to support the recruitment, training, retention, and
professional development of a diverse clinical and non-clinical
workforce, both generally and with specialized training for child and
adolescent populations. This should include new incentives and
opportunities to practice in rural and underserved areas, additional
measures to incentivize more individuals to enter the field, and
increasing reimbursement rates. Low payment rates to providers for the
provision of behavioral health services heavily contribute to the
workforce shortage. We therefore recommend increasing payment rates for
mental and behavioral health care by passing the Medicaid Bump Act (S.
1727/H.R. 3450), which proposes to raise the federal reimbursement rate
for mental health and substance use disorder care under Medicaid.
MHLG also calls the Committee's attention to additional measures that,
while not focused specifically on children and youth, are all critical
components of a comprehensive and more effective mental health system
able to meet the increased need for services among children and
adolescents. We therefore recommend the following additional measures
be included in any forthcoming legislative package:
Ensuring parity in reimbursement for mental health and substance
use treatment, both through Medicaid and TRICARE;
Promoting the integration of primary and mental health care
through a range of measures, including by passing the Excellence in
Mental Health and Addiction Treatment Expansion Act of 2021 (S. 2069/
H.R. 4323); and
Bolstering vital crisis response systems by passing the Crisis
Assistance Helping Out On The Streets (CAHOOTS) Act (S. 764/H.R. 1914)
to expand mobile response and the bipartisan Behavioral Health Crisis
Services Expansion Act (S. 1902) to provide comprehensive support for
developing and sustaining crisis services.
As necessary as these proposals are, however, many of these actions are
long-term. The current crisis also requires a more immediate response.
To act expeditiously in addressing the current mental health needs of
young people and meet the call to action in the Surgeon General's
advisory, Congress must also pass an FY 2022 Appropriations package, as
quickly as possible. This would be the most immediate way to increase
resources for a variety of already authorized Substance Abuse and
Mental Health Services Administration (SAMHSA) and Department of
Education programs that provide mental health services for young
people. This includes Project AWARE, the National Child Traumatic
Stress Initiative, the Student Support and Academic Enrichment Grant
Program, Safe Schools National Activities, and the Community Mental
Health Services Block Grant, which provides care for children with
serious emotional disturbances and would include a set aside for
prevention and early intervention. MHLG calls on Congress to fund these
programs at the highest levels possible in a final FY 2022 omnibus
bill.
Once again, we applaud you for convening this crucial hearing, which
recognizes the challenges facing the mental health of our youth and the
potential damage that lack of action can have on an entire generation.
We thank you for your continued bipartisan leadership on issues related
to mental health and substance use disorders. MHLG and its members
stand ready and willing to work with you in your efforts to advance
policies that support the mental and behavioral health of individuals,
families, and communities.
Sincerely,
2020 Mom
American Academy of Child and Adolescent Psychiatry
American Art Therapy Association
American Association for Psychoanalysis in Clinical Social Work
American Counseling Association
American Dance Therapy Association
American Mental Health Counselors Association
American Occupational Therapy Association
American Psychological Association
American Foundation for Suicide Prevention
Anxiety and Depression Association of America
Association for Ambulatory Behavioral
Healthcare
Centerstone
Children and Adults with Attention-Deficit/Hyperactivity Disorder
Children's Hospital Association
CLASP
Clinical Social Work Association
Depression and Bipolar Support Alliance
Eating Disorders Coalition
Eating Disorders Coalition for Research, Policy and Action
Education Development Center
Global Alliance for Behavioral Health and Social Justice
International OCD Foundation
The Jed Foundation
The Jewish Federations of North America
Maternal Mental Health Leadership Alliance
Mental Health America
NAADAC, the Association for Addiction Professionals
National Alliance on Mental Illness
National Association for Behavioral Healthcare
National Association for Children's Behavioral Health
National Association of Counties
National Association of Pediatric Nurse Practitioners
National Association of School Psychologists
National Association of Social Workers
National Federation of Families
National League for Nursing
National Register of Health Service Psychologists
Nemours Children's Health
Network of Jewish Human Service Agencies
PsiAN
Psychotherapy Action Network
REDC Consortium
RI International, Inc.
Sandy Hook Promise
SMART Recovery
The Kennedy Forum
The National Alliance to Advance Adolescent Health
The Trevor Project
______
National Advocacy on Serious Neurobehavioral Illness (NASNIcares)
P.O. Box 99501
Pittsburgh, PA 15233
National Shattering Silence Coalition
P.O. Box 563
Shapleigh, ME 04076-0563
February 12, 2022
The Honorable Ron Wyden The Honorable Mike Crapo
Chairman Ranking Member
U.S. Senate U.S. Senate
Committee on Finance Committee on Finance
Washington, DC 20510 Washington, DC 20510
RE: Hearing on ``Protecting Youth Mental Health: Part II--Identifying
and Addressing Barriers to Care,'' Tuesday, February 15, 2022
Dear Chairman Wyden and Ranking Member Crapo:
We thank the Senate Finance Committee for the opportunity to share our
perspectives on the topic of mental health. We appreciate that in
holding these hearings, the Senators on this committee are
demonstrating that the mental well-being of Americans and particularly
America's youth is a matter of importance.
We must not belabor getting to the pivotal questions that underlie this
communication:
What is Mental Health?
What is Mental Illness?
What are the implications of the definitions and meanings attached to
these terms as it relates to medical care, healthcare, social services,
and the construct of parity?
The concept of parity is that mental health is as important to overall
well-being as physical health. The term mental health is a metaphor
that refers to non-medical psychosocial issues--the problems of
everyday living . . . from the relatively benign to the very serious.
Yet, in societal discourse, the term ``mental health,'' specifically
poor mental health, is conflated with ``mental illness.''
According to content on the CDC's website:
Although the terms are often used interchangeably, poor mental
health and mental illness are not the same.
We agree with this statement although we do not subscribe to other
statements on the site, such as what causes ``mental illness''--yet,
this pivots on what someone means when they use the term ``mental
illness.'' Inasmuch as the term ``mental illness'' is also a metaphor,
there is no distinction between the terms.
That is why, although we must still use the term ``mental illness'' for
the sake of clarity, stakeholders in this network of advocates strongly
object to the use of the term ``mental illness' to classify and
describe what are truly medical disorders. Segments of this advocacy
network are calling on the medical establishment to reclassify
illnesses such as ``Bipolar,'' ``Schizophrenia'' and Neurogenic
``Depression'' as the neurological conditions that they truly are, and
moreover, are calling for these medical disorders to be renamed.
There is a federal definition of Serious Mental Illness (SMI) for
administrative and regulatory purposes, but we do not subscribe to it.
It was forged by the same influences that gave rise to what NASNIcares
refers to as the crisis of conflation. The most serious ``mental
illnesses'' are in fact brain function disorders--they are medical,
they are physical in that they can involve physical anomalies of brain
structure and/or systemic bodily functions that disorder the brain's
semblance of mind. NASNIcares refers to these medical conditions as
Cerebral Illness and across our network of advocacy we refer to these
medical conditions as Serious Brain Disorders (SBD) or Brain Function
Disorders (indicating that the brain's semblance of mind can be
disordered due to systemic factors arising outside of the brain organ,
such as in an encephalopathy).
NASNIcares describes Cerebral Illness or SBDs as:
Disorders of the brain's semblance of mind and consciousness
that can involve structural anomalies of the brain organ, and
or dysfunctions of neurocircuitry involving metabolic,
hormonal, and other systemic factors that affect cognition,
metacognition, motor behaviors, volition and actualization,
perceptual processing, identity of self (ipseity) and others,
the sense of one's habitus, and other faculties and
functionalities. These disorders are predominantly hereditary,
neurodevelopmental, organic and not caused by childhood
adversity, trauma (except for physical injury--such as
traumatic brain injury--TBI), or poor mental health.
In the context of parity, we need to consider that it is not logical or
just to require one class of medical disorders to have access to
healthcare under the construct of parity while other medical disorders
are covered under regular medical benefits.
In in a 1996 Senate Hearing, Dr. E. Fuller Torrey spoke to this matter
of the illogic of parity within this context and the relevance of how
these illness are classified to the IMD Exclusion (the misguided and
tragic policy premised on the fallacious notion of ``diseases of the
mind''). Excerpting from the full text of this hearing which is
available online: https://archive.org/stream/deinstitutionali00unit/
deinstitutionali00unit_djvu.txt.
My fourth and final point is that the Senate Finance Committee
today has the opportunity to correct both of these errors.
Number one, you should ensure that health care reform covers
brain diseases such as schizophrenia and manic depressive
illness in exactly the same way it covers brain diseases such
as multiple sclerosis and Parkinsons disease and Alzheimers
disease. The brain is a single organ and it is both illogical
and discriminating to provide full coverage for some diseases
of the brain and not for other diseases of the brain. . . . It
would be exactly like covering some diseases of the heart but
not covering other diseases of the heart.
Excerpting from an article in jscimedcentral.com:
Advances in neuropsychiatry are increasing our understanding of
brain-
behavior relationships. With this knowledge, the classification
of illnesses as psychiatric and neurologic appears increasingly
outdated.
There are historical reasons for the conflation of Mental Health with
``Mental Illness'' and the demedicalization (psychologization) of
neurologic illnesses that afflict consciousness, cognition, and
mentation. These historical influences are the origin of the acute
attentions that are being paid in the present to mental health--
reaching back to the divergence of psychiatry from neurology, the rise
of psychosocial psychiatry stemming from that separation, the
subjugation of what can be called biological psychiatry, and the Mental
Hygiene Movement of the early 20th century.
Prioritization of Funding--Mental Health Versus Serious Brain Function
Disorders
On the matter of how we allocate what can be, in some circumstances,
scarce resources in terms of funding and the infrastructure of
healthcare systems as a whole, we feel that it is important to give
careful consideration to priorities when crafting programmatic
solutions under the rubric of ``mental health.'' Mental Health relates
to non-medical interventions, such as psychotherapy or CBT, peer
support programs, and other complimentary services delivered by mental
health providers.
Cerebral Illnesses or Serious Brain Function Disorders (which are not
mental health issues) relate to inpatient and outpatient medical
services--specifically pharmacological treatment, intensive case
management, and supported housing with 24/7 onsite staff for the most
severely ill individuals that cannot benefit from AOT or who cannot
live safely in the family home or independently with social service
supports. There is a paucity of these services, especially supported
housing and ideologically-driven state recovery models and the IMD
exclusion curtail services for most seriously ill.
We do not mean to devalue the importance of mental health and we
certainly do not align with dismissive judgements that tag people
struggling with mental health issues as the ``worried well.'' We do
recognize that mental health problems can be serious enough to lead to
suicide. But it is also important for policy makers to be aware that
there is what a Bipolar expert within our network describes as ``a
different type of suicide.'' This is a neurobehavioral/neurological
phenomenon that can be deemed accidental suicide in a sense because the
individual's state of consciousness is severely disordered. This is a
type of suicide that society generally does not understand. Suicide is
generally conceptualized as an act of psychological and emotional
distress. Someone in the throes of neurogenic dysmentation within a
disordered state of consciousness (psychosis) may be in a state of
repose rather than distress and unaware that they are dangerously ill
(anosognosia). Despite what professionals with a psychosocial
orientation to psychiatry believe, anosognosia is not denial.
However, we do not describe ourselves as mental health advocates and we
are aware that what underlies the intense focus on mental health in
part are ideas that informed the mental hygiene movement--the belief
that poor mental health leads to ``mental illness'' and that we must
funnel the resources of government into the cultivation of good mental
health and in doing so, work assiduously to stave off ``mental
illness.''
Excerpting from a paper published in ncbi.nln.nih.gov titled ``The
roots of the concept of mental health'':
What today is broadly understood by ``mental health'' can have
its origins tracked back to developments in public health, in
clinical psychiatry and in other branches of knowledge.
. . . more than a scientific discipline, mental health is a
political and ideological movement. . . .
Most of America's youth will be okay as mental health is concerned
despite some of the alarmist messaging that is promulgated by today's
mental health movement, unless by this intense focus on mental health
more harm is done to them than good. We want to protect children and
young people by promoting mental wellness and resilience, but we need
to be circumspect that serious brain function disorders typically
encroach upon people during adolescence when the brain is undergoing
dramatic changes. The needs of people afflicted by these
neurodevelopmental conditions are dire. Failure to identify and treat
these grave medical conditions can have catastrophic consequences. We
recommend Dr. Henry A. Nasrallah as a preeminent resource to consult on
this topic.
Sincerely,
Jennifer Bailey
Project Director
NASNIcares
Jeanne Gore
Coordinator and Co-Chair, Steering Committee
National Shattering Silence Coalition
______
National Association for Children's Behavioral Health
201 E. Main St., Suite 1405
Lexington, KY 40507
Tel: 859-402-9768
Website: https://nacbh.org/
February 22, 2022
The Honorable Ron Wyden The Honorable Mike Crapo
Chairman Ranking Member
U.S. Senate U.S. Senate
Committee on Finance Committee on Finance
Washington, DC 20510 Washington, DC 20510
Dear Chairman Wyden and Ranking Member Crapo:
The National Association for Children's Behavioral Health (NACBH)
appreciates the opportunity to provide a written statement for the
record, following up on the two excellent Finance Committee hearings on
youth mental health held on February 8 and 15.
First, we congratulate the committee for organizing such a huge topic
into five areas of inquiry and action. Focusing input from the field,
the public, and hearing witnesses in this way will allow a lot to be
accomplished in a relatively short time frame.
Hearing witnesses were particularly well-chosen, and NACBH supports the
many concrete suggestions they offered, especially around school-based
services, crisis intervention, other community-based services, and
examples of best practices that could be replicated. In addition, we
appreciate the attention called to the pending implementation of the
988 suicide prevention hotline and the need to competently respond to
young people who dial in, which includes ensuring that treatment
services are actually available and accessible to youth reaching out
for help. That is a looming challenge as the July 2022 hotline
implementation approaches, and we link it with the longstanding issue
of boarding in emergency departments to reiterate NACBH's response to
the committee's September 2021 request for information:
Please provide Medicaid funding for the full range of necessary mental
health and substance use treatment services by passing H.R. 2611, the
Increasing Behavioral Health Treatment Act. This would remove the
antiquated and discriminatory IMD exclusion for states that establish:
a full array of community-based services; assessment and oversight to
ensure treatment placements at the clinically indicated level;
engagement strategies for specific populations such as youth and young
adults; particular attention to transitions from institutional
treatment settings; and annual reporting of demographic and utilization
data for system accountability.
With the additional requirements of H.R. 2611, this approach would
bring Medicaid mental health and substance use disorder treatment into
the 21st century with guardrails to prevent unnecessary
institutionalization, and allow low-income and disabled beneficiaries
to enjoy the promise of parity offered to most privately insured
Americans. The nearly 50-year-old Institutions for Mental Diseases
exclusion is the largest violation of parity principles allowed to
stand in this country, and truly inexplicable in light of Congressional
champions' many passionate and eloquent statements on parity in the
private sector.
As Chairman Wyden said on the recent release of the tri-department
parity report, ``If given the right tools,'' he is ``confident that
true mental health parity can become a reality in the American health
care system.'' For child and adolescent services in Medicaid, those
tools could include the provisions of H.R. 2611 to fund a comprehensive
array of services, use of validated assessment instruments such as
CASII and ECSII to guide appropriate placement decisions, and federal
definitions of additional 24-hour settings (in Medicaid) and congregate
care settings (in child welfare) to ensure federal oversight of safety
and quality.
This would be a great opportunity to tackle some of the unfinished
business of the Children's Health Act of 2000 and the Family First
Prevention Services Act (FFPSA) which is also under this committee's
jurisdiction. Part I of the Children's Act has never been implemented,
leaving the use of seclusion and restraint in ``certain non-medical,
community-based facilities for children and youth'' entirely
unregulated at the federal level. Under FFPSA, four types of child
caring institutions are eligible for Title IV-E federal matching funds,
but only one is defined: Qualified Residential Treatment Programs. At a
minimum, federal definitions should be established for the other three
IV-E-eligible child caring institutions--settings specializing in
providing prenatal, post-partum, or parenting supports for youth;
supervised independent living settings; and settings providing high-
quality residential care and support services to children who have been
or are at risk of becoming sex trafficking victims--and Part I
regulations promulgated for all four. Clearly, these are all programs
serving children and youth with unique vulnerabilities and mental
health needs, and not only should there be appropriate federal
oversight of safety and quality, the Medicaid IMD exclusion should not
continue as a barrier for health services reimbursement.
Thank you again for the opportunity to provide a written statement for
the record. We will follow up with the staff identified for the five
work groups, including additional information on the IMD exclusion and
proposed cost offsets for NACBH's policy recommendations.
Sincerely,
Patricia Johnston
Director of Public Policy
[email protected]
______
Nationwide Children's Hospital
Statement of David Axelson, M.D., Medical Director of Behavioral Health
Services and Chief of Psychiatry and Behavioral Health
The crisis in pediatric behavioral health has become increasingly clear
over the last decade, and it has only been exacerbated by the COVID-19
pandemic. Before the pandemic, approximately 1 in 5 children had a
mental illness, but less than half of the estimated 7.7 million
children who needed services received them from a mental health
provider.
Physical distancing, isolation, stressful home environments, and the
loss of nutrition and other supports that youth access in schools
contribute to the growing crisis. Nationwide, mental health emergencies
among children have significantly increased during the pandemic,
including:
A 25% increase in overall mental health-related emergency
department visits for 5- to 11-year-olds from 2019 to 2020.
A 31% increase in overall mental health-related emergency
department visits for 12- to 17-year-olds from 2019 to 2020.
A 14% increase in mental health emergencies for 5- to 17-year-
olds seen at children's hospitals in the first two quarters of 2021
compared to the same time period in 2019.
Prior to the pandemic, Nationwide Children's Hospital expanded capacity
to serve children with mental and behavioral health concerns. In March
2020, at nearly the exact same time as the pandemic was closing
schools, triggering stay-at-home orders and delaying certain kinds of
medical treatment, we opened the Big Lots Behavioral Health Pavilion--a
behavioral health hospital within Nationwide Children's.
It is the largest pediatric mental health care and research facility of
its kind in the United States and a model for integrated care through
every level of acuity. The Big Lots Behavioral Health Pavilion enabled
an extraordinary expansion of our services and staff. In 2014, we had
418 staff members; today, we have more than 1,100 staff members
providing or supporting behavioral health services. With expanded
infrastructure and an incredibly dedicated team of providers, allied
health care professionals, and support staff, we have dramatically
increased the number of patients served. In 2014, Nationwide Children's
provided 128,000 outpatient visits. By 2021, this number had grown to
more than 257,000.
The Big Lots Behavioral Health Pavilion expanded services and capacity
to include a state-of-the-art Psychiatric Crisis Department for
children experiencing a mental health crisis; created a 10-bed Extended
Observation Unit, allowing for more time to observe and treat patients;
expanded from six to 16 the number of beds at the Youth Crisis
Stabilization Unit; launched a new inpatient program, which now has 36
beds; and added a Partial Hospitalization Program and two intensive
outpatient therapy programs.
Just as importantly, our Pavilion functions as a hub for a community-
wide system of pediatric behavioral health care, created with the help
of many partners. Our system ranges from prevention services in schools
through inpatient services in our Pavilion. The expertise and resources
at Nationwide Children's, working in collaboration with community
organizations and providers, serve to expand the capacity for child
behavioral health in our region.
Despite the significant expansion in infrastructure and workforce,
Nationwide Children's is struggling to serve children given the surging
demand for services. Referrals to Nationwide Children's Behavioral
Health services have continued to climb, reaching 63,000 in 2021, up
nearly 20% from 2018. Those referrals have driven growth in ambulatory
services, which have expanded significantly over the past five years,
often increasing more than 10% annually. In 2021, Nationwide Children's
experienced nearly 260,000 visits in the ambulatory setting, serving
38,751 unique children.
Additionally, patients are continuing to present to the Psychiatric
Crisis Department at record numbers, nearing 50 patients in a 24-hour
period during peak times. The Psychiatric Crisis Department topped
8,100 visits in 2021, up 35% from the prior year and more than double
the number in 2016, when Nationwide Children's Hospital began directly
seeing patients in the emergency setting with behavioral health
clinicians.
Over the last year, Nationwide Children's has experienced record
volumes and high levels of acuity, driving demand for more intensive
care, including inpatient services. That, in turn, has had an impact on
the number of patients with acute mental health needs who must be
``boarded'' at our hospital. A boarder is a person in immediate need of
inpatient-level psychiatric care, but who must be kept in a medical or
observation bed because no behavioral health-specific inpatient beds
are available. The boarder census indicates the demand for high acuity
behavioral health services in excess of capacity. In 2021, Nationwide
Children's Behavioral Health Pavilion, a facility with 56 mental health
beds, experienced a daily average of 12 boarders. During peak periods
the number was as high as 35.
Recruiting and hiring mental health providers has always been a
challenge, and Nationwide Children's continues to struggle to secure
the highly specialized workforce needed to serve our patients. In Ohio,
52 of 88 counties don't have a single practicing child and adolescent
psychiatrist, and 33 counties are in extreme shortage. That is, only
three of Ohio's 88 counties have anything approaching an appropriate
number of child and adolescent psychiatrists. Hiring psychiatric
nursing and mental health clinicians is also a challenge. For the year
ending 2021, Nationwide Children's had 209 budgeted positions unfilled,
with the largest percentage of vacancies among therapists/clinicians
(66%) and mental health technicians (21%).
Nationwide Children's is a health system committed to youth mental
health and that has made historic investments in facilities, mental
health promotion programing, and its workforce. Despite these
investments, Nationwide Children's, like children's hospitals across
the country, struggles to meet the needs of the kids we serve.
In an effort to address the challenges, Nationwide Children's
collaborated with peer hospitals in the Children's Hospital Association
to develop the Strengthening Kids' Mental Health Now proposal, a set of
recommendations focused on mitigating the negative trends in pediatric
mental health.
As the Senate Finance Committee examines the youth mental health
crisis, I respectfully request the consideration of the Strengthening
Kids' Mental Health Now proposal that addresses the needs of children,
adolescents, young adults and providers by:
Increasing investments to support the recruitment, training,
mentorship, retention and professional development of a diverse
clinical and non-clinical pediatric workforce.
Expanding pediatric mental health care infrastructure to ensure
sufficient capacity to meet the needs of children in crisis who require
higher intensity care, such as inpatient services, partial
hospitalization or step-down programs.
Ensuring payment models and reimbursement support for clinical
and non-
clinical pediatric mental health providers and workers and eliminating
implementation barriers hindering coordinated or integrated care.
Addressing existing inequities within the pediatric mental
health care system that contribute to mental health disparities in
racial and ethnic minority populations and underserved communities.
Beyond the Strengthening Kid's Mental Health Now proposal, Congress
should examine the unfulfilled promise of congressional efforts to
ensure mental health parity. Since the enactment of the Mental Health
Parity Act of 1996, Congress has pursued the policy goal that coverage
for mental health services should be equal to medical and surgical
coverage. Legal protections and oversight of mental health parity
requirements were strengthened in 2008 with the passage of the Paul
Wellstone and Pete Domenici Mental Health Parity and Addiction Equity
Act (MHPAEA), and in 2021 with the passage of the Consolidated
Appropriation Act.
The 2022 MHPAEA Report to Congress, titled Realizing Parity, Reducing
Stigma and Raising Awareness: Increasing Access to Mental Health and
Substance Use Disorder Coverage, highlights the current enforcement
challenges. With the passage of the Consolidated Appropriations Act of
2021, the Department of Labor, Department of Health and Human Services
and the Department of the Treasury for the first time are proactively
reviewing non-quantifiable treatment limitations (NQTLs).
The report indicates that very few health plans are required to
document that NQTLs comply with MHPAEA requirements. For example, of
the 2 million self-
insured health plans regulated by the Employee Benefits Service
Administration (EBSA), only 156 plans were required to submit
documentation to ESBA justifying compliance: ``ESBA concluded that many
plans and issuers were deficient in their statutory obligation to
perform and document the necessary analyses.''
Further, the report states that ``a significant number of plans sought
extensions on the grounds that the requested analyses either were not
complete, or in some cases not yet begun.'' ESBA documents systemic
insufficiency in the comparative analyses submitted by many plans and
issuers. During a seven-month period in 2021, all comparative analyses
submitted to ESBA were initially insufficient in terms of information
provided, plan details, and demonstration of parity compliance among
other factors.
While Congress has enacted multiple bills in pursuit of mental health
parity, regulation of plans and issuers as described in the 2022 report
remains a challenge. Variation in the state-by-state enforcement of
fully insured commercial health plans presents another variable in
considering why parity remains elusive. These parity issues have an
effect on access to mental health services. Anecdotally, we know that
children wait months for access to mental health services, or as
previously mentioned, children in need of inpatient level mental health
care must board in a medical bed until an inpatient psychiatric bed is
available. Most frequently, families and youth are waiting 3 months for
outpatient services, but in some specialty areas the wait can be 8-12
months before services begin.
Providers observe commercial reimbursement for mental health services
at significantly lower levels than reimbursement for medical and
surgical health services. Private practice youth mental health
providers often accept cash pay only, due to low reimbursement rates
and extremely high demand for services.
According to a 2019 Milliman Report titled Addiction and Mental Health
vs. Physical Health: Widening Disparities in Network Use and Provider
Reimbursement, there are significant disparities between medical/
surgical and mental health services in terms of both out-of-network
utilization levels and provider in-network reimbursement rates. The
report utilized a robust claims data analysis to explore the impact of
two non-qualitative treatment limitations (network adequacy and
reimbursement rates) on access to mental health services.
Among the key findings about network adequacy:
In 2017, a youth mental health office visit was 10.1 times more
likely to be out-of-network when compared to medical/surgical claims.
In 2017, patients in behavioral health inpatient facilities were
5.2 times more likely to be out of network when compared to similar
medical/surgical claims.
In 2017, patients seeking outpatient behavioral health services
were 5.7 times more likely to be out-of-network when compared to
similar medical/surgical claims.
In 2017, 17.2% of behavioral health office visits were out-of-
network, compared to 3.2% for primary care providers and 4.3% for
medical/surgical specialists.
Comparing average reimbursement as a percentage of Medicare-allowed
amounts in 2017:
Primary care provider reimbursement was 23.8% higher than
behavioral health reimbursement.
Low complexity evaluation and management codes for primary care
providers were 22.3% higher than behavioral health reimbursement.
Moderate complexity E & M codes for primary care providers were
19.7% higher than behavioral health reimbursement.
The Milliman quantitative analysis of claims data from years 2013-2017
demonstrate that in the domains of network adequacy and reimbursement
rates, disparities between mental health and medical/surgical health
services remain. A claims data analysis alone does not indicate
systemic violations of MHPAEA, but it informs our understanding of the
current mental health crisis and encourages additional review of the
marketplace.
I am grateful to the Senate Finance Committee for taking the time to
explore the ongoing youth mental health crisis and public policy aimed
at promotion of mental health and expanding access to high quality
mental health services for our nation's youth.
______
Nemours Children's Health
10140 Centurion Parkway North
Jacksonville, FL 32256
February 22, 2022
The Honorable Ron Wyden The Honorable Mike Crapo
Chairman Ranking Member
U.S. Senate U.S. Senate
Committee on Finance Committee on Finance
219 Dirksen Senate Office Building 219 Dirksen Senate Office Building
Washington, DC 20510 Washington, DC 20510
Dear Chairman Wyden and Ranking Member Crapo:
On behalf of Nemours Children's Health, thank you for holding this
important hearing, Protecting Youth Mental Health: Part II--Identifying
and Addressing Barriers to Care, on February 15, 2022. We are pleased
to submit this letter as written testimony for your consideration as
you develop a mental health legislative package. We urge you to include
the policies outlined below that support the health and well-being of
children and families, as well as the mental health infrastructure
needed to provide them with accessible, high-quality care.
Nemours Children's Health is one of the nation's largest multistate
pediatric health systems, including two free-standing children's
hospitals and a network of nearly 75 primary and specialty care
practices. Nemours Children's seeks to transform the health of children
by adopting a holistic health model that utilizes innovative, safe, and
high-quality care, while also caring for the health of the whole child
beyond medicine. Nemours Children's also powers the world's most-
visited website for information on the health of children and teens,
KidsHealth.org.
The Nemours Foundation, established through the legacy and philanthropy
of Alfred I. duPont, provides pediatric clinical care, research,
education, advocacy, and prevention programs to the children, families
and communities it serves.
Background
The COVID-19 pandemic has exacerbated a host of stressors for children
and families and contributed to the pediatric mental health crisis we
are currently facing. Children have experienced more stress from
changes in their routines, breaks in the continuity of learning and
health care, missed life events, and an overall loss of security and
safety.\1\ In addition, sentinel agencies are reporting declines in
referrals as fewer child-serving professionals are making reports of
concern for child safety, such as the decline in referrals for concerns
about maltreatment and neglect to child welfare agencies since March
2020.\2\
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\1\ Centers for Disease Control and Prevention. (2020). COVID-19
parental resources kit. Retrieved 2021, May 11th from: https://
www.cdc.gov/coronavirus/2019-ncov/daily-life-coping/parental-resource-
kit/index.html.
\2\ Brown, S.M., Orsi, R., Chen, P.C.B., Everson, C.L., and Fluke,
J. (2021). The impact of the COVID-19 pandemic on child protection
system referrals and responses in Colorado, USA. Child maltreatment,
10775595211012476.
Nationally, mental health-related emergency department visits increased
by nearly 25% for children age 5-11 and by over 30% for those 12-17
years during April through October 2020, compared to the same period in
2019.\3\ Many children are requiring more immediate and intensive
treatments, have a higher probability of admission, and are staying in
the hospital longer.\4\ These challenges may result in lasting impacts
on children if they do not receive appropriate supports. Unfortunately,
it is estimated that more than 45% of children diagnosed with a
behavioral health disorder do not receive treatment.\5\
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\3\ Leeb, R.T., Bitsko, R.H., Radhakrishnan, L., Martinez, P.,
Njai, R., and Holland, K.M. (2020). Mental health-related emergency
department visits among children aged <18 years during the COVID-19
Pandemic--United States, January 1-October 17, 2020. MMWR. Morbidity
and mortality weekly report, 69(45), 1675-1680, https://doi.org/
10.15585/mmwr.mm6945a3.
\4\ Krass, P., Dalton, E., Doupnik, S.K., and Esposito, J. (2021).
US pediatric emergency department visits for mental health conditions
during the COVID-19 Pandemic. JAMA Network Open, 4(4), e218533-e218533,
https://doi.org/10.1001/jamanetworkopen.2021.8533.
\5\ Centers for Disease Control and Prevention. (2021, March 22).
Data and statistics on children's mental health. Retrieved 2021, May
27th from: https://www.cdc.gov/childrensmental
health/data.html.
At Nemours Children's Hospital, Delaware, our emergency department saw
an increase of more than 80% in visits for suicidality or intentional
harm in 2021 compared to 2020. Nemours Children's Hospital, Florida
from 2020 to 2021, saw a 55% increase in patients in our emergency
department with chief concerns of suicidality or intentional harm. Our
behavioral health providers across our system have shared that our
patients are increasingly experiencing higher levels of anxiety and
depression, and grief from deaths of caregivers or family members. In
outpatient and ambulatory care across our Florida operations, 85% of
children screened had anxiety, depression, or another form of a
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behavioral health symptom.
We applaud the Surgeon General for raising the youth mental health
crisis as a priority public health challenge. As the Surgeon General
notes in his advisory, it will take time to resolve the many mental,
emotional and behavioral (MEB) health challenges that children and
youth are facing. However, the time to begin is now. We urge Congress
to consider these five priorities to address barriers to providing high
quality pediatric and youth mental health preventive services, supports
and care:
Address the social factors that contribute to poor mental
health.
Support the pediatric MEB health workforce.
Strengthen reimbursement for MEB health services.
Sustain and expand access to telehealth.
Invest in pediatric MEB health infrastructure.
Address the Social Factors that Contribute to Poor Mental Health
We urge Congress to center its approach to addressing MEB health issues
for children and youth in prevention. With a healthy start in life and
appropriate care and developmental supports, a child's health
trajectory can be significantly improved.
There is great opportunity through the Centers for Medicare and
Medicaid Services (CMS) to go well beyond medicine to advance
innovative, multi-sector, integrated care models that address the
unique providers, settings and needs of children, with a focus on
prevention and optimal development. The Medicaid program is an
important lever because it covers 27 million children and 42% of births
nationally.\6\
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\6\ MACPAC states that Medicaid covers 43% of births: https://
www.macpac.gov/wp-content/uploads/2020/01/Medicaid%E2%80%99s-Role-in-
Financing-Maternity-Care.pdf.
Over the past few years, CMS and the Department of Health and Human
Services (HHS) have taken significant strides to test new models as
well as improve interoperability and exchange of health data, which is
critical to promoting holistic approaches. Additionally, CMS has
promoted options for states, providers and payers to address social
determinants of health (SDOH) and advance value-based care through
guidance, waivers and new models. For the most part, these efforts have
been limited to a few vanguard states. To help support a broader
segment of the pediatric population while focusing on prevention and
early identification of MEB health needs, we need to incentivize
holistic pediatric payment and delivery models that address physical
health, MEB health and SDOH. CMS can help catalyze these models that
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have great potential for long-term impact.
We suggest that Congress authorize and fund a Whole Child Health
demonstration model within the Centers for Medicaid and CHIP Services
(CMCS). The demonstration would support and test integrated, community
based pediatric collaborations that align financial incentives and
resources across Medicaid and other public and private programs to
address SDOH, improve MEB health and well-being, and reduce health
disparities among pediatric populations. Models would be designed with
input and engagement from community residents, Medicaid beneficiaries,
and organizations, and be informed by a comprehensive needs and assets
assessment in target communities.
Additionally, we encourage Congress to direct CMS to review the early
and periodic, screening, diagnostic and treatment (EPSDT) requirements
and how they are being implemented across the states to support access
to needed mental health services and early intervention services
critical to children's well-being. CMS should provide guidance to
ensure consistent application across states on what is required to
ensure children are better supported at the community and family
levels, addressing the social challenges contributing to health
disparities and a lack of healthy early development and prevention
services.
Finally, we support enactment of the LINC to Address Social Needs Act
(S. 509, https://www.congress.gov/bill/117th-congress/senate-bill/
509?r=1), which would provide states with up to $150M for public-
private partnerships to develop or enhance integrated, cross-sector
solutions to better coordinate health and social services.
Support the Pediatric MEB Health Workforce
MEB health provider shortages are persistent and severe in pediatric
health care, and these shortages are projected to worsen over time.
There is an opportunity to ensure that workforce development programs
support a broad base of provider types, including MEB health
specialists, primary care physicians, developmental and behavioral
pediatricians, nurses, social workers, community health workers, and
others. Developing this capacity and integrating more providers into
the MEB health care model would help address the provider shortage by
promoting identification of concerns and referrals from a variety of
providers. To ensure children have care options that meet their needs,
resources must support a range of child and
adolescent-centered, community-based prevention and treatment services.
We support the Helping Kids Cope Act of 2021 (H.R. 4944, https://www.
congress.gov/bill/117th-congress/house-bill/
4944?q=%7B%22search%22%3A%5B%
22hr+4944%22%5D%7D&s=1&r=1). This bill would provide funding for
pediatric behavioral health care integration and coordination, allowing
flexibility to fund a range of community-based activities such as
recruitment and retention of community health workers or navigators to
coordinate care, pediatric practice integration, supporting pediatric
crisis intervention, community-based initiatives such as school-based
partnerships, and initiatives to decompress emergency departments.
The high cost of education is another contributing factor to current
provider shortages. Students who graduate with psychology doctorates,
for example, have a median student loan debt of $82,000.\7\ We support
pediatric mental health workforce training and loan repayment programs
such as the Health Resources and Services Administration's (HRSA)
Pediatric Subspecialty Loan Repayment Program, and recommend that funds
are made available for MEB health providers across adult and pediatric
specialties. Additionally, we support loan repayment incentives, such
as those offered through the Minority Fellowship Program, to increase
workforce diversity across child-serving behavioral health providers.
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\7\ Stamm, K., Doran, J., Kraha, A., Marks, L.R., Ameen, E., El-
Ghoroury, N., Lin, L., and Christidis, P. (2015). How much debt do
recent doctoral graduates carry? American Psychological Association's
Center for Workforce Studies, 46(6): https://www.apa.org/monitor/2015/
06/datapoint.
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Strengthen Reimbursement for MEB Health Services
Provider shortages are compounded by low reimbursement, discouraging
individuals from entering the profession. Commercial health insurers,
Medicaid, the Children's Health Insurance Program (CHIP) and other
payers have historically provided insufficient coverage and payment for
MEB health services.\8\ Payment rates for behavioral health providers
are typically based on a fee schedule that is considerably lower than
that of a medical/surgical provider. Lower rates based on these fee
schedules has spillover effects on contract negotiation with payers,
challenging children's hospitals to successfully contract with payers
in a way that appropriately reimburses for MEB health services. When
such negotiations are not successful, access to services becomes even
more limited in a patient's covered provider network.
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\8\ Melek, S., Davenport, S., and Gray, T.J. (2019, November 19th).
Addiction and mental health vs physical health: Widening disparities in
network use and provider reimbursement. Milliman, Inc.: https://
assets.milliman.com/ektron/
Addiction_and_mental_health_vs_physical_health_Wid
ening_disparities_in_network_use_and_provider_reimbursement.pdf.
Sustainable reimbursement that supports Medicaid providers is needed to
enhance children's access to the full continuum of care. We urge
Congress to increase Medicaid reimbursement rates for pediatric MEB
health services to Medicare levels, or to increase the Federal Medical
Assistance Percentage (FMAP) for pediatric MEB health services to 100%.
We also support inclusion of an increased FMAP for a High Performing
Child Medical Home. A High Performing Child Medical Home would include
components that promote prevention, child development, parenting
supports, behavioral health, and referrals to various service providers
that can address social needs, risk factors and determinants of health.
Such an approach--which includes coordinated, team-based, whole-person
care models--could help to promote positive social and emotional
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development and potentially prevent MEB health issues from arising.
Finally, we support expanded utilization of family and youth peer
support specialists through enhanced Medicaid reimbursement, funding to
train and certify peer support specialists, and technical assistance
for state Medicaid programs interested in expanding the model. Peer
specialists can extend the existing provider workforce by using their
lived experience with MEB health needs to support others. In bright
spots across the country, peer support specialists are integrated into
care teams or into schools, and peer-led organizations as valued
community partners. Grief counseling, rising to new importance during
COVID-19, has long found benefits of peer support in normalizing
experiences for children, youth, and caregivers.\9\ Unfortunately,
youth and family peer support is not systematic, and few children have
access, while many peer supporters do not receive the reimbursement and
support they need. The same is true for many other professionals and
paraprofessionals in supporting roles, such as community health workers
(CHWs).
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\9\ McClatchey, I.S., Vonk, M.E., and Palardy, G. Efficacy of a
camp-based intervention for childhood traumatic grief. Res Soc Work
Pract. 2009;19(1):19-30.
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Sustain and Expand Access to Telehealth
Throughout the COVID-19 pandemic, greater state and federal regulatory
flexibilities have increased the availability and convenience of
telehealth services for children and families. Nationwide, psychiatry
continues to rely on telehealth at a far greater rate than any other
physician specialty. Between January 2021 to February 2022, nearly 65%
of all Nemours Children's telehealth visits were psychology and
psychiatry visits.
Extending and expanding telehealth for children and families also helps
address regional shortages with respect to the availability of mental
health care generally (e.g., in underserved rural areas), and specific
competencies (e.g., evidence-based approaches to grief counseling) that
are not widely available. This is a pathway to increase access and
address inequity, though additional barriers including access to
technology and broadband Internet will remain for some families. These
infrastructure deficiencies must also be addressed.
We strongly recommend permanent extension of the telehealth
flexibilities provided during the pandemic, particularly those that
allow providers to care for patients across state lines. One
intermediate step would be to pass the Temporary Reciprocity to Ensure
Access to Treatment (TREAT) Act (S. 168/H.R. 708, https://www.
congress.gov/bill/117th-congress/senate-bill/168/
text?q=%7B%22search%22%3A%5
B%22TREAT+Act%22%2C%22TREAT%22%2C%22Act%22%5D%7D&r=4&s=3), which would
provide temporary licensing reciprocity for health care professionals
for any type of services provided, within their scope of practice, to a
patient located in another state during the COVID-19 pandemic.
Additionally, we support the Enhance Access to Support Essential
Behavioral Health Services (EASE) Act (S. 2112/H.R. 4036, https://
www.congress.gov/bill/117th-congress/senate-bill/2112/
text?q=%7B%22search%22%3A%5B%22EASE+Be
havioral+Health+Act%22%2C%22EASE%22%2C%22Behavioral%22%2C%22Health%
22%2C%22Act%22%5D%7D&r=1&s=1) to expand the scope of required guidance,
studies, and reports that address the provision of telehealth services
under Medicaid, including in schools. Another important bill is the
Telehealth Improvement for Kids' Essential Services Act (TIKES) Act (S.
1798/H.R. 1397, https://www.congress.
gov/bill/117th-congress/senate-bill/1798/
text?q=%7B%22search%22%3A%5B%22TI
KES+Act%22%2C%22TIKES%22%2C%22Act%22%5D%7D&r=1&s=2), which would
promote access to telehealth services for children through Medicaid and
CHIP, as well as study children's utilization of telehealth to identify
barriers and evaluate outcomes.
Invest in Pediatric MEB Health Infrastructure
Finally, investments in pediatric mental health infrastructure are
critical and urgently needed to prevent children in crisis from
boarding in emergency departments and to enable their swift placement
in appropriate care. There is also a vital need to increase access to
alternatives to inpatient and emergency department care including step-
down, partial hospitalization, intensive outpatient services and day
programs. These types of programs ensure that children and adolescents
continue to receive intensive services and supports they need while
alleviating pressure on acute care settings. We support the Children's
Mental Health Infrastructure Act (H.R. 4943, https://www.congress.gov/
bill/117th-congress/house-bill/4943?q=%7B
%22search%22%3A%5B%22hr+4943%22%5D%7D&s=5&r=1) to support additional
pediatric care capacity for behavioral and mental health services.
CONCLUSION
Nemours stands ready to leverage our expertise and relevant experiences
to assist the Committee as it works to develop a comprehensive mental
health legislative package. Thank you for your consideration of our
recommendations, and we look forward to continued collaboration. Please
do not hesitate to reach out to me at [email protected] or
to Katie Boyer at [email protected] with questions or requests
for additional information.
Sincerely,
Kara Odom Walker, M.D., MPH, MSHS Daniella Gratale, MA
Executive Vice President Director,
Chief Population Health Officer Office of Child Health Policy and
Advocacy
______
Partnership to End Addiction
711 Third Avenue, Suite 500
New York, NY 10017
t 212-841-5200
f 212-956-8020
https://drugfree.org/
February 24, 2022
The Honorable Ron Wyden
Chairman
U.S. Senate
Committee on Finance
221 Dirksen Senate Office Building
Washington, DC 20510
The Honorable Mike Crapo
Ranking Member
U.S. Senate
Committee on Finance
239 Dirksen Senate Office Building
Washington, DC 20510
Dear Chairman Wyden and Ranking Member Crapo,
Thank you for holding this month's hearings, ``Protecting Youth Mental
Health: Part I--An Advisory and Call to Action'' and ``Protecting Youth
Mental Health: Part II--Identifying and Addressing Barriers to Care,''
held February 8 and February 15, 2022, and for initiating a process to
advance legislation to address the mental health and addiction crises.
We appreciate the opportunity to have this letter entered into the
hearing record.
Partnership to End Addiction is a national nonprofit uniquely
positioned to reach, engage, and help families impacted by addiction.
With decades of experience in research, direct service, communications,
and partnership-building, we provide families with personalized support
and resources--while mobilizing policymakers, researchers, and health
care professionals to better address addiction systemically on a
national scale.
We greatly appreciate the Committee dedicating two hearings to the
issue of youth mental health. We are also concerned by this growing
crisis, as untreated mental illness is a significant risk factor for
substance use, and mental illness and substance use disorder frequently
co-occur. As highlighted by many witnesses and committee members,
school-based mental health services are critically needed to reach more
youth. We urge the Senate to advance the Mental Health Services for
Students Act (S. 1841), the Pursuing Equity in Mental Health Act (S.
1795), and the Suicide Training and Awareness Nationally Delivered for
Universal Prevention (STANDUP) Act (S. 1543). We encourage Congress to
facilitate an earlier and broader approach to substance use prevention
\1\ that includes mental health, as well as other fields that promote
child health and resilience and structural changes that facilitate
healthy and stable families. As described in our blog \2\ published by
Health Affairs, there are a number of policy initiatives to improve
family stability and security and child health and resilience that
Congress has recently undertaken in COVID-19-related legislation or is
currently exploring in the Build Back Better Act. While these policy
changes are seemingly outside the realm of substance use, they are
critically important for prevention and will also reduce the risk for
other negative mental and behavioral health outcomes that have the same
risk and protective factors as substance use. As explained by the
Surgeon General in response to questions from Sen. Warren, increasing
access to affordable child care, for example, is important for
improving children's mental health, along with other early investments
in health and well-being. Sen. Casey and the Surgeon General similarly
highlighted that children's mental health does not exist in a vacuum,
and that broader family, community, and societal circumstances must
also be addressed in order to protect youth. We encourage the Committee
to consider such policies for inclusion in a legislative package.
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\1\ https://drugfree.org/reports/rethinking-substance-use-
prevention-an-earlier-and-broader-approach/.
\2\ https://www.healthaffairs.org/do/10.1377/
forefront.20210607.239986/full/.
To address many of the issues raised during the hearing, including the
lack of access to evidence-based treatment and barriers to care,
inadequate insurance coverage, inappropriate crisis response, and the
need to meet people where they are with services and integrate services
into the many systems with which youth interact, we encourage you to
advance the following bills currently before your committee:
Medicaid Reentry Act (S. 285)
As noted in the hearings, youth with mental health disorders are
overrepresented in the juvenile justice system. While using Medicaid to
cover school-based mental health services was repeatedly discussed,
another place Medicaid can have a role in expanding access to care is
the criminal justice system. Individuals in jails and prisons have
disproportionately high rates of mental health and addiction, and they
face significant risk upon release. Individuals released from
incarceration are often unable to afford or access care due to a lack
of insurance coverage, as they lose their Medicaid benefits upon
incarceration, and it can often take weeks or months to reinstate
coverage. The Medicaid Reentry Act would help ease connections to
community-based mental health and addiction services by allowing
Medicaid-eligible individuals to restart coverage 30 days prior to
release.
Crisis Assistance Helping Out On The Streets (CAHOOTS) Act (S. 764)
As both Chairman Wyden and Sen. Cortez Masto highlighted in the
hearings, the CAHOOTS program in Eugene, Oregon, can serve as an
exemplary model for other states and localities to improve their
behavioral health crisis response systems by sending trained behavioral
health providers to address such crises, rather than police. People in
crisis related to mental illness and substance use disorder are more
likely to encounter police than get medical attention, resulting in
millions of people with mental health and addiction being jailed every
year. As you know, mental health and substance use disorders are health
care issues, not crimes, and an appropriate crisis response should
connect people to care, not jail. We encourage the Committee to advance
the CAHOOTS Act to provide states with enhanced Medicaid funding and
grants to adopt community-based mobile crisis services.
Non-Opioid Prevent Addiction in the Nation (NOPAIN) Act (S. 586)
Despite the existence of effective non-opioid pain management options,
availability remains limited due to misaligned reimbursement policies
that incentivize the use of opioids over the use of non-opioid
alternatives. Under current law, hospitals receive the same payment
from Medicare regardless of whether a provider prescribes an opioid or
non-opioid, which leads hospitals to largely rely on opioids dispensed
at a pharmacy after discharge at little or no cost to the hospital. The
NOPAIN Act would help address this by directing the Centers for
Medicare and Medicaid Services to provide separate Medicare
reimbursement for non-opioid treatments used to manage pain in the
hospital outpatient department and ambulatory surgery center settings.
This can help ensure that safe, non-addictive therapies are available
and reduce unnecessary exposure to opioids and the likelihood of opioid
misuse or addiction.
Tobacco Tax Equity Act (S. 1314)
While tobacco and nicotine were not directly discussed during the
hearing, nicotine is one of the most commonly used addictive substances
among youth. One of the most effective ways to reduce tobacco use among
youth is to increase the price of tobacco products. The Tobacco Tax
Equity Act currently before the Committee would increase the federal
tax rate on cigarettes, peg it to inflation to ensure it remains an
effective public health tool, and set the federal tax rate for all
other tobacco products at the same level (including e-cigarettes, which
are particularly popular among youth).
We also encourage you to address:
Insurance Parity
As several witnesses and members, including Chairman Wyden, noted, lack
of parity creates many barriers to behavioral health care for youth.
Existing parity law must be better enforced, as insurance companies
continue to violate it, as highlighted by the administration's recent
report cited by the Surgeon General. Further, despite Congress's prior
work to improve insurance coverage for mental health and addiction
treatment, it will be impossible to ensure parity unless the Mental
Health Parity and Addiction Equity Act is fully extended to Medicare,
all of Medicaid, and TRICARE. In addition to leaving millions of people
without adequate mental health and addiction coverage, Medicare's
exclusion from parity laws is additionally problematic because Medicare
serves as a benchmark for other forms of health coverage.
Thank you again for your commitment to addressing the mental health and
addiction crises and for considering the above bills for inclusion in a
legislative package. We would be happy to answer any questions or
provide additional information to assist in your work.
Sincerely,
Partnership to End Addiction
______
Primary Care Collaborative
601 13th St., NW, Suite 430N
Washington, DC 20005
https://www.pcpcc.org/
February 15, 2022
The Honorable Ron Wyden The Honorable Mike Crapo
Chairman Ranking Member
U.S. Senate U.S. Senate
Committee on Finance Committee on Finance
Washington, DC 25510 Washington, DC 25510
Dear Chairman Wyden and Senator Crapo,
I write today to submit this letter as the Primary Care Collaborative's
statement for the record regarding the Committee on Finance's hearing,
``Protecting Youth Mental Health: Part II--Identifying and Addressing
Barriers to Care,'' held February 15, 2022. PCC commends the
Committee's ongoing work to develop a bipartisan response to the mental
health and substance abuse crises in the United States, including the
emergency in children's mental health and well-being. This letter
describes the Primary Care Collaborative's (PCC) recommendations as
this work proceeds.
PCC is a nonprofit, nonpartisan, multi-stakeholder coalition of 60+
organizational Executive Members (https://www.pcpcc.org/executive-
membership) ranging from clinicians and patient advocates to employer
groups and health plans. PCC's members share a commitment to an
equitable, high value health care system with primary care at its base:
care that emphasizes comprehensiveness, longitudinal relationships, and
``upstream'' determinants for better patient experience and better
health outcomes. (See the Shared Principles of Primary Care, https://
www.pcpcc.org/about/shared-principles#Continuous.)
America's specialty behavioral health delivery system is overwhelmed by
increasing suicide rates,\1\ accelerating rates of substance use
disorder deaths,\2\ and a tripling in the prevalence of depressive
symptoms since the beginning of the pandemic.\3\ Moreover, noted
disparities in mental health by rurality and economic circumstances
exist, and for the first time in several years, there are
proportionally more drug-induced deaths among Blacks than whites.\4\
Your public, bipartisan commitments to meaningful legislation are an
important step toward a national response to these crises. However,
your legislation and the United States can only successfully meet this
challenge by leveraging team-based primary care that includes
behavioral health integration and is available in all communities.
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\1\ Hedegaard, H., Curtin, S.C., and Warner, M. Suicide mortality
in the United States, 1999-2019. NCHS Data Brief, no 398. Hyattsville,
MD: National Center for Health Statistics. 2021. DOI: https://
dx.doi.org/10.15620/cdc:101761.
\2\ Hedegaard, H., Minino, A.M., and Warner, M. Drug overdose
deaths in the United States, 1999-2019. NCHS Data Brief, no 394.
Hyattsville, MD: National Center for Health Statistics. 2020.
\3\ Ettman, C.K., Abdalla, S.M., Cohen, G.H., Sampson, L., Vivier,
P.M., and Galea, S. Prevalence of Depression Symptoms in US Adults
Before and During the COVID-19 Pandemic. JAMA Network Open.
2020;3(9):e2019686. doi:10.1001/jamanetworkopen.2020.19686
\4\ Pain in the Nation: Alcohol, Drug and Suicide Epidemics. Trust
for America's Health and Well-Being Trust. May 2021. https://
www.tfah.org/wp-content/uploads/2021/05/2021_PainIn
TheNation_Fnl.pdf.
Primary care teams with strong, ongoing patient-relationships are
uniquely able to identify behavioral health concerns, triage
challenges, and help patients find the right level and setting of care.
More mental health care is rendered in the primary care setting than
anywhere else, including the mental health care sector where this has
been the case for at least the past four decades.\5\ An adequate
response to the multiple current behavioral health crises demands
recognizing that reality. It also requires recognizing that primary
care clinicians, particularly those that serve populations who have
been historically marginalized, are overextended and desperately in
need of enhanced support. Team-based integrated behavioral health can
improve outcomes and decrease costs. By leveraging the full healthcare
team, the U.S. can most appropriately leverage behavioral health
professionals to help those in need of care.
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\5\ Regier et al., JAMA 1978; Jetty et al., Journal of Primary Care
and Community Health, 2021.
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The Foundation for Progress: Payment Reform and Investment in Primary
Care
Efforts to scale behavioral health-primary care integration are
hampered by the overall chronic underinvestment in the primary care
sector. To assure a strong foundation for comprehensive, integrated
advanced primary care, it will be necessary to change both how the U.S.
pays and how much the U.S. invests in primary care. The U.S. currently
devotes just 5-7 percent of health spending to primary care, a
proportion lower than other nations.\6\ Primary care practices need
pathways to rapidly transition from a predominantly fee-for-service
(FFS) model, to a predominantly population-based prospective payment
models that would include adjustments for health status, risk, social
drivers, and other factors. The National Academies of Science
Engineering and Medicine has recommended making hybrid models (part
FFS, part per member per month payment) \7\ as the default for Medicare
and Medicaid, rather than the fee-based system that consistently and
systematically undervalues the cognitive work reflected in primary care
and behavioral health services.
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\6\ Investing in Primary Care: A State-Level Analysis. Primary Care
Collaborative. July 2019. https://www.pcpcc.org/sites/default/files/
resources/pcmh_evidence_report_2019_0.pdf.
\7\ National Academies of Sciences, Engineering, and Medicine.
2021. Implementing high-
quality primary care: Rebuilding the foundation of health care.
Washington, DC: The National Academies Press. https://doi.org/10.17226/
25983.
Over the medium and long term, broader change in how we pay and how
much we pay for primary care is vital. PCC is working with our
Executive Members and other stakeholders to identify bold steps to
strengthen the primary care foundation needed for a health system that
achieves equitable outcomes through high-quality, affordable, patient-
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centered care.
However, in the interim, primary care teams and many of their patients
live daily with a national crisis of poor mental well-being and
substance use. Exacerbated by COVID-19 and associated economic
disruptions, this crisis hits hardest in communities already grappling
with health inequities. Because improvements in overall physical health
can be more difficult to achieve when individuals face behavioral
health comorbidities, this crisis also threatens to derail the fight
against other chronic health challenges including heart disease,
diabetes, and cancer.
The Finance Committee's legislative work must both respond to the
urgency of the immediate behavioral health crisis and lay the
groundwork for transformed and integrated whole-person primary care.
Paying for Behavioral Health Integration in Medicare and Medicaid
When provided adequate resources, primary care has the capacity to be
flexible. It can effectively provide what patients need and/or connect
those patients to other care or resources. At present, evidence
supports multiple integrated behavioral health delivery models in
primary care, including the collaborative care model and the primary
care behavioral health model.\8\, \9\ To maximize the number
of patients that can benefit from integrated care across diverse
practice settings and communities, primary care payment options must be
available to support a variety of evidence-based models of integration.
Payment policy that supports multiple care integration models has two
additional merits; it can support the development of real-world
implementation evidence across diverse populations, and spur further
innovation in behavioral health integration at the practice level and
in practice/payer collaboration.
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\8\ Dissemination of Integrated Care Within Adult Primary Care
Settings: The Collaborative Care Model. American Psychiatric
Association. 2016. https://www.psychiatry.org/psychiatrists/practice/
professional-interests/integrated-care/learn.
\9\ Kearney, L.K., Post, E.P., Pomerantz, A.S., and Zeiss, A.M.
(2014). Applying the interprofessional patient aligned care team in the
Department of Veterans Affairs: Transforming primary care. American
Psychologist, 69, 399-408. http://dx.doi.org/10.1037/a0035909.
For these reasons, PCC supports a multi-component policy approach to
behavioral health integration. This approach would provide immediate
support for scaling integration through the fee-based payment
methodologies most broadly in use today while testing new ways to
integrate behavioral health into comprehensive advanced primary care
payment models.
Promote Medicare's Existing Collaborative Care and Behavioral Health
Integration Codes
Existing behavioral health integration codes, currently available in
the Medicare Physician Fee Schedule, are underutilized in Medicare
relative to the prevalence of behavioral health conditions among
beneficiaries. Existing Medicare payment values for behavioral health
integration should be reassessed to determine whether they are
sufficient to expand utilization and meet the exigencies of the present
crisis.
Waive the Medicare Fee Schedule Budget Neutrality Requirements for
Primary Care--Behavioral Health Integration
The Medicare Physician Fee Schedule's budget neutrality requirements
are a barrier to increased payment and new payment codes for primary
care-behavioral health integration. When new codes are adopted, these
neutrality requirements can result in across-the-board cuts that affect
other primary care services. Insofar as Medicare depends on fee-based
payment to expand access to integrated behavioral health care in the
current behavioral health crisis, the Congress should exempt new
investments in behavioral health integration codes from the current fee
schedule budget neutrality requirements.
One approach would be to establish a new code available as an add-on
code for all Evaluation and Management claims when a practice can
demonstrate the capacity for integrated behavioral care. Such a code
would complement and support broader utilization of the existing
behavioral health codes, rather than replacing them. Practices would be
required to attest to certain core functionalities, such as the ability
to screen for behavioral health challenges, offer care management,
medication management, participate in measurement-based care through a
registry, deliver short-term psychosocial therapy in the practice, and
integrate evidence-based treatment for behavioral health conditions,
either in person or virtually.
Test Behavioral Health Integration Strategies as Part of a Per Member
Per Month Approach to Primary Care Payment
Moving more of the American health care financing system to a value-
based model is key to supporting care integration. When payers place
emphasis on outcomes rather than services, primary care practices are
put in a better situation to focus on the health of their patients
rather than the volume of their service. Policymakers should pursue the
development and testing of prospective primary care payment models,
such as per-member per-month approaches, that adequately support
integrated advanced primary care addressing both physical and
behavioral health care needs. However, work may be needed to optimize
the balance between external referrals and services delivered in the
primary care practice itself. Various integration thresholds,
standards, and performance measures should be tested using CMS
Innovation Center authorities, Medicaid 1115 demonstrations, other CMS
demonstration authorities, and/or Congressionally authorized
demonstrations. PCC encourages the Committee to work with CMS to ensure
that primary care integration remains a priority.
Address Low Medicaid Payment Rates in Some States for Pediatric Mental
Health Services and Access to Services in Schools
The American Academy of Pediatrics, American Academy of Child and
Adolescent Psychiatry and the Children's Hospital Association declared
a national emergency in child and adolescent mental health last fall,
an assessment endorsed by several of PCC's Executive Member
organizations including the American Academy of Family Physicians,
American Psychiatric Association, American Psychological Association,
and Mental Health America.\10\ Low payment rates, common in many state
Medicaid programs, weaken provider engagement and participation in
Medicaid and directly relate to the mental health access challenges for
children. Additionally, children's behavioral health needs should be
identified and access to services should be provided where they are.
Better assistance and technical guidance to schools regarding
appropriate reimbursement can help support service delivery to
Medicaid-
eligible and enrolled students, in coordination and collaboration with
their behavioral health providers.
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\10\ See https://www.soundthealarmforkids.org/partners/.
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Addressing Other Barriers to Behavioral Health Integration
Investing in and paying for integrated care, as described above, is
fundamental. But these changes alone may not be sufficient without
addressing certain specific barriers to broader integration of primary
care and behavioral health.
Remove In-person Requirements for Tele-mental Health Services
Once the current COVID-19 Public Health Emergency expires, current
Medicare statute and regulation bar reimbursement for tele-mental
health services unless a patient has had an in-person encounter with a
member of the same provider group in the previous six months and
require an in-person visit every twelve months. This limits the ability
of primary care practices to leverage tele-mental health services to
deliver comprehensive and integrated care. The CY 2022 Medicare Part B
Physician Fee Schedule Final Rule promulgated these in-person visit
requirements for Medicare reimbursement of tele-mental health services,
both prior to the initial telehealth service and every twelve months
thereafter. The Committee's legislation should remove the requirement
for in-person visit for tele-mental health visits enacted by the
Consolidated Appropriations Act of 2021, repeal the promulgated
requirements and leave the decision of the appropriate modality of
tele-mental health care to the care team and the patient.
Assure Access to Upfront Resources to Support Transition to Integrated
Care
For any primary care practice, the transition to new integrated models
of care delivery can involve significant expense, training, technology
upgrades and workflow changes. It may involve retraining or expanding
the primary care team, including, but not limited to, nurse case
managers, psychiatrists, nurse practitioners, psychologists, social
workers, counselors and peer support workers.
To support these changes, practices pursuing integration typically must
rely on time-limited grants or partnerships with larger entities, like
health plans or health systems. Others have depended on limited
duration demonstrations or CMS Innovation Center Models to resource
these changes. Yet this limited, ad-hoc approach has failed to enable
widespread, sustained implementation of behavioral health integration
in primary care.
HHS should work with Congress to develop and enact a broadly available
program of forgivable loans to finance costs associated with
transformation. Practice support for these transitional costs is
particularly crucial for primary care practices which are smaller in
size, operate independently, and/or serve lower-income communities. To
support rapid scaling, transitional support should be available on a
nationwide basis, not confined to a limited-scope demonstration.
Ensure Resources for Ongoing Practice Transformation
The reality is that practice transformation is not a one-time expense.
The best models of behavioral health integration may evolve based on
experience and new medical and implementation science. Moreover, the
challenge of practice transformation extends beyond behavioral health
integration. Some primary care practices are shifting to more
comprehensive models of care that integrate across more domains of care
including those that address health-related social needs and oral
health.\11\, \12\ Permanent, long-term sources of training
and technical assistance for comprehensive, integrated care models are
necessary to assure access to the best evidence-based approaches over
time.
---------------------------------------------------------------------------
\11\ The Primary Care Collaborative. (January 2021). Innovations in
Oral Health and Primary Care Integration: Alignment with the Shared
Principles of Primary Care. https://www.
pcpcc.org/resource/innovations-oral-health-and-primary-care-
integration-alignment-shared-principles, National Academies of Science,
Engineering and Medicine. (2019). Integrating Social Care into the
Delivery of Health Care: Moving Upstream to Improve the Nation's
Health. https://www.nap.edu/read/25467.
\12\ Kreuter, M.W., Thompson, T., McQueen, A., and Garg, R.
Addressing Social Needs in Health Care Settings: Evidence, Challenges,
and Opportunities for Public Health. Annu Rev Public Health.
2021;42:329-344. doi:10.1146/annurev-publhealth-090419-102204.
The Primary Care Collaborative. (January 2021). Innovations in Oral
Health and Primary Care Integration: Alignment with the Shared
Principles of Primary Care, https://www.
pcpcc.org/resource/innovations-oral-health-and-primary-care-
integration-alignment-shared-principles.
One potential policy vehicle to encourage practice transformation over
the long term--the Primary Care Extension Program (PCEP)--has already
been statutorily authorized.\13\ As the U.S. Agricultural Extension
service has promoted evidence-based practices in agriculture and
community development, the PCEP could assist primary care through
practice facilitation and community-based collaborations. Yet Congress
has so far failed to appropriate resources for this important work. PCC
urges the Committee to explore whether this program could provide the
technical assistance and support that primary care practices need or
whether other programs should be established.
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\13\ 42 U.S.C. Sec. 280g-12.
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Promoting Behavioral Health Integration Across Payers
Convene Stakeholders to Align Integration Efforts
Payers that work together to align documentation, measurement and model
design related to integrated care face potential anti-trust action.
However, state and/or federal bodies can convene payers and clinician
representatives with the goal of aligning documentation, measurement,
and payment innovations associated with behavioral health integration.
The Committee should seek to ascertain whether all states have the
resources necessary and whether CMS has the capacity to support the
states in this vital work.
Incorporate Behavioral Health Coding and Billing as Standard Features
in Electronic Health Records
Vendors require practices to pay extra for the module that supports
billing for existing integrated care codes. PCC has asked CMS, working
with the Office of the National Coordinator for Health Information
Technology, to adjust the definition of CEHRT technology to address
this challenge. PCC encourages the Committee to work with CMS to
realize this important policy goal.
Even as the COVID-19 pandemic continues to sweep American communities,
the depth of the mental and behavioral health crisis is difficult to
understate. The inequities in well-being that underlie that crisis are
glaring. The time is now for bold action to support behavioral health
integration in primary care. PCC urges you to work on a bipartisan
basis to enact strong legislation this year. Please contact PCC's
Director of Policy, Larry McNeely ([email protected]) with any
questions.
Sincerely,
Ann Greiner
President and CEO
______
Statement Submitted by Ethan J.S.H. Reed
Honorable Chairman Wyden, Ranking Member Crapo, and members of the
Finance Committee, thank you for giving me this opportunity and
platform as a young person in this country to express my concerns in
regards to the youth mental health crisis the young people are facing
across this country.
Currently, I am beginning work with congressional leadership and other
members of Congress--including several committees with jurisdiction on
mental health, to ensure Congress passes critical funding and
investments towards mental health services and professionals to provide
adequate support to the thousands of young people across this country
who are suffering from a mental health issue.
One of the most important things Congress can do right now to take
action on combating the current youth mental health crisis is to pass
immediate federal funding to mental health professionals and services.
Right now, there are multiple funding investments towards mental health
in the original Build Back Better Act, and so I am urging congressional
leadership to transfer the funding provisions into another form of
legislation to further expedite the funding. It is something I've
constantly heard as concerns from associates of Mental Health America,
experts in the field, and even members of Congress. It is with my best
hope that the honorable committee will support this effort on getting
much needed funding immediately passed.
As I understand, mental health telehealth capabilities are of major
concern to this Committee, and I share this concern for thousands, if
not millions of Americans across this country who do not have easier
access to facilitate mental health services and professionals. A few
years ago when I served on a state youth advisory council for the
Colorado legislature, I had the opportunity to speak with other young
people across the state--and more specifically, those in the rural
parts of Colorado such as the Eastern plains. Some of the youth
expressed the troubles of having readily access to mental health
services and professionals due to their area. I am proud to stand with
Congressman Joe Neguse of Colorado on his bill, H.R. 6076, the CARE for
Mental Health Professionals Act, which would allow providers to enter
into interstate compacts that would expand the workforce of
credentialed mental health professionals to serve patients whom may not
be in the same state as they are. This will help close the gap between
rural and urban communities across this country to be able to get the
services and support they need whenever, and wherever they may reside.
While those are some of the only pieces of legislation I've focused on
in regards to mental health, I am proud to support dozens of mental
health pieces of legislation that I believe as a young person will
truly provide adequate services and support to my generation as we
continue to face the mental health crisis. I thank each and every
member of Congress (including those in leadership) who have been
fighting the good fight with me, and I appreciate the efforts made by
so many--especially including Congressman Tony Cardenas of California.
Let's get to work for the young people of this country who are
struggling.
I welcome any and all comments, concerns, or questions about the work
or legislation I am proud to advocate and support. Thank you again for
giving me this opportunity to speak today.
______
The Trevor Project
P.O. Box 69232
West Hollywood, CA 90069
[email protected]
https://www.thetrevorproject.org/
March 1, 2022
The Honorable Ron Wyden
Chairman
U.S. Senate
Committee on Finance
219 Dirksen Senate Office Building
Washington, DC 20510-6200
The Honorable Mike Crapo
Ranking Member
U.S. Senate
Committee on Finance
219 Dirksen Senate Office Building
Washington, DC 20510-6200
Re: The Trevor Project Statement for the Record, Senate Committee on
Finance's Hearing on Protecting Youth Mental Health: Part II--
Identifying and Addressing Barriers to Care
Dear Chairman Wyden and Ranking Member Crapo,
The Trevor Project (Trevor) submits the following statement for the
February 15, 2022 Full Committee hearing, ``Protecting Youth Mental
Health: Part II--Identifying and Addressing Barriers to Care.'' We
respectfully request that this statement be entered into the hearing
record.
There is a mental health crisis in our nation, and it is having
particularly harmful impacts on marginalized communities such as LGBTQ
youth. These youth already confront a range of barriers to quality
mental health care, and it is more important than ever to open doors to
essential mental health services for these youth by ensuring that when
the 9-8-8 number for the National Suicide Prevention Lifeline (NSPL or
Lifeline) is activated in July, the Lifeline is equipped with the
specialized services that these young people need. It is also important
to ensure that access to quality mental health services is not impeded
by the marketing of dangerous practices that masquerade as mental
health care for LGBTQ youth. Thank you for your attention to this issue
and we look forward to working with you to address this crisis.
Founded in 1998, The Trevor Project is the world's largest suicide
prevention and crisis intervention organization for LGBTQ youth, and it
is the only accredited national organization providing crisis
intervention and suicide prevention programs, as well as a peer-to-peer
social network support for LGBTQ youth. Specifically, The Trevor
Project offers life-saving, life-affirming programs and services that
create safe, accepting, and inclusive environments over the phone,
online, and through text. With operations in all 50 states and
approximately 440 trained counselors, The Trevor Project is able to
reach thousands of youth with its services every week.
What is The Trevor Project's perspective on the current youth mental
health crisis?
There is no question that our nation is in the midst of a serious and
troubling mental health crisis. Unfortunately, for LGBTQ youth the
current crisis has only compounded the existing barriers that these
young people face to receiving the type of mental health care they need
and deserve. We are on the front lines of the national mental health
crisis, and our counselors hear from young people every day whose
mental health has been negatively impacted by the COVID-19 pandemic,
recent politics, and a wide range of instances of anti-LGBTQ
victimization.
The national mental health crisis is hitting our young people
especially hard. And for marginalized young people, such as those who
are LGBTQ and/or people of color, the crisis is hitting even harder.
U.S. Surgeon General Vivek Murthy recently explained in his Advisory on
the youth mental health crisis that LGBTQ youth often lost access to
key services during the pandemic, were sometimes confined to homes
where they were not supported or accepted, and face discrimination in
the health care system that makes them more hesitant to seek help.\1\
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\1\ HHS, ``Protecting Youth Mental Health: The U.S. Surgeon
General's Advisory,'' available at https://www.hhs.gov/sites/default/
files/surgeon-general-youth-mental-health-advisory.pdf.
At The Trevor Project, we have seen firsthand how these factors have
converged to put LGBTQ youth at tremendous risk. Suicide is the second
leading cause of death among young people,\2\ and CDC data \3\ shows
that LGBTQ youth are more than four times as likely to attempt suicide
compared to their straight and cisgender peers. The Trevor Project
estimates that more than 1.8 million LGBTQ youth (13-24) seriously
consider suicide each year in the United States, and at least one
attempts suicide every 45 seconds.\4\
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\2\ Hedegaard, H., Curtin, S.C., and Warner, M. (2018). Suicide
mortality in the United States, 1999-2017. National Center for Health
Statistics Data Brief, 330, Hyattsville, MD: National Center for Health
Statistics.
\3\ Johns, M.M., Lowry, R., Haderxhanaj, L.T., et al. (2020).
Trends in violence victimization and suicide risk by sexual identity
among high school students--Youth Risk Behavior Survey, United States,
2015-2019. Morbidity and Mortality Weekly Report, 69 (Suppl-1):19-27.
See also Johns, M.M., Lowry, R., Haderxhanaj, L.T., et al. (2020).
Trends in violence victimization and suicide risk by sexual identity
among high school students--Youth Risk Behavior Survey, United States,
2015-2019. Morbidity and Mortality Weekly Report, 69,(Suppl-1):19-27.
\4\ The Trevor Project, ``Estimate of How Often LGBTQ Youth Attempt
Suicide in the U.S.,'' available at https://www.thetrevorproject.org/
research-briefs/estimate-of-how-often-lgbtq-youth-attempt-suicide-in-
the-u-s/.
The Trevor Project's annual National Survey on LGBTQ Youth Mental
Health (National Survey), which includes some of the largest and most
diverse samples of LGBTQ youth ever conducted, seeks to amplify the
unique stressors, challenges, and disparities that place LGBTQ youth at
elevated risk for poor mental health and suicide. It is important to
remember that LGBTQ youth are not inherently prone to suicide because
of their sexual orientation or gender identity. Rather, they are placed
at significantly increased risk because of how they are mistreated and
stigmatized by society. Some of the most noteworthy findings from our
2021 National Survey, which captured the experiences of nearly 35,000
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LGBTQ youth across the country, include:
42% of LGBTQ youth seriously considered attempting suicide in
the past year, including more than half of transgender and nonbinary
youth. Yet, nearly half (48%) of LGBTQ youth reported wanting mental
health care in the past year but were not able to get it;
75% of LGBTQ youth reported that they had experienced
discrimination based on their sexual orientation or gender identity at
least once in their lifetime, and those who experienced discrimination
in the past year attempted suicide at more than twice the rate of those
who did not;
12% of white youth attempted suicide compared to 31% of Native/
Indigenous youth, 21% of Black youth, 21% of multiracial youth, 18% of
Latinx youth, and 12% of Asian/Pacific Islander youth.
Half of all LGBTQ youth of color reported discrimination based
on their race/ethnicity in the past year, including 67% of Black LGBTQ
youth and 60% of Asian/Pacific Islander LGBTQ youth;
13% of LGBTQ youth reported being subjected to conversion
therapy, with 83% reporting it occurred when they were under age 18;
and
Transgender and nonbinary youth who reported having pronouns
respected by all of the people they lived with attempted suicide at
half the rate of those who did not have their pronouns respected by
anyone with whom they lived. However, more than 60% of transgender and
nonbinary youth under the age of 18 said that none of the people they
lived with respected their pronouns.
The Trevor Project has also examined the impacts of the pandemic and
recent politics and public debates on the mental health and well-being
of LGBTQ young people and found:
70% of LGBTQ youth stated their mental health was ``poor'' most
of the time or always during COVID-19;
More than 80% of LGBTQ youth stated that COVID-19 made their
living situation more stressful--and only 1 in 3 LGBTQ youth found
their home to be LGBTQ-affirming;
Nearly 60% of transgender and nonbinary youth said that COVID-19
impacted their ability to express their gender identity; and
85% of transgender and nonbinary youth--and 66% of all LGBTQ
youth--say recent debates about state laws restricting the rights of
transgender people have negatively impacted their mental health.
Youth, and in particular LGBTQ young people, face significant barriers
to accessing mental health services. The Trevor Project has conducted
research that found that marginalized groups such as Black and Latinx
LGBTQ communities don't have access to healthcare resources, and when
they are available, they do not have the ability to address LGBTQ
issues or understanding of the experiences of minorities or the LGBTQ
community. Help when you are struggling is hard to ask for, and
financial and cultural barriers shouldn't exist to make that brave
action harder to take.
The crisis in front of us is clear to see. It should be a cause for
concern to everyone, regardless of political party. Our young people
are suffering, and LGBTQ young people are among those suffering the
most. What we do to help our young people matters, and countless young
lives are at stake. Fortunately, there are concrete steps Congress can
take to lower barriers to accessing essential mental health services
and help our young people now, including ensuring the Lifeline will be
ready to serve the country and specifically LGBTQ youth when 9-8-8 goes
live in July 2022 and that our LGBTQ youth are being protected from
forms of health care fraud so-called ``conversion therapy,'' sometimes
referred to as ``reparative therapy'' or ``sexual orientation or gender
identity change efforts.''
How can we ensure 9-8-8 ready is ready to serve youth in crisis?
The designation of 9-8-8 as the new dialing code for the NSPL in 2020
was an important step towards lowering barriers to care and addressing
the mental health crisis, particularly for LGBTQ youth. 9-8-8 is
scheduled to become the new dialing code for the NSPL in July 2022, and
the American public will only fully benefit from the implementation of
9-8-8 if the Lifeline is appropriately funded, and specialized services
are provided for LGBTQ youth as an acutely at-risk community.
The Substance Abuse and Mental Health Services Administration (SAMHSA)
has previously reported that they expect call volumes to nearly double
as a result of the new dialing code and that 9-8-8 will receive
approximately 7.6 million calls in FY23. We estimate that NSPL could
receive more than 400,000 contacts from LGBTQ youth in 2023.
Alarmingly, this call volume will substantially increase wait times for
youth in crisis, operators are not specially trained to handle these
emergency calls and there is no standard of care for LGBTQ callers.
These wait times and lack of training serve as operational barriers for
LGBTQ youth seeking mental health services.
Ensuring that 9-8-8 is equipped with appropriate specialized services
for LGBTQ youth is a matter of life and death. The absence of
specialized mental health resources for LGBTQ youth will mean that
young people will not get critical, lifesaving services. This is the
very reason The Trevor Project exists, and according to a formal,
external evaluation of Trevor's services, almost three-quarters of
youth stated that they either would not or were unsure if they would
have contacted another service if The Trevor Project did not exist.
More than 80% of LGBTQ youth said it was important that a crisis line
include a focus on LGBTQ youth, should they need it.
Specialized services for LGBTQ youth must include the training of
existing counselors in LGBTQ cultural competency and the establishment
of an Integrated Voice Response (IVR) option for LGBTQ youth to receive
more specialized care. The implementation of an IVR option can transfer
LGBTQ youth callers to specialized groups like The Trevor Project,
where we have additional trained counselors, who are part of a pre-
existing nationwide response infrastructure and can take some of the
increased burden from existing NSPL call centers. Importantly, use of
IVR would facilitate efficient access to specialized care without the
delays and miscommunication that come with efforts to make ``warm
transfers'' between the Lifeline and specialized service providers.
Minimizing the barriers that allow LGBTQ youth to access services from
group such as The Trevor Project is essential because it allows these
young people to speak to counselors who can best help them. A multi-
year evaluation conducted by third party researchers found that over
90% of youth in crisis who reach out to The Trevor Project are
successfully de-escalated (meaning they are moved out of a state of
crisis) and that de-escalation is sustained even weeks later. It is
through these same proven training methods that the Lifeline will be
able to provide the highest quality of services to its contacts.
The inclusion of specialized services, and specifically an IVR option,
can play an important role in reducing barriers to mental health care
because it would both increase the capacity of the Lifeline to handle
calls, reducing wait times, and would ensure that LGBTQ youth can
access counselors that have knowledge of their experiences and are
specially trained to interact with individuals like them.
Fortunately, the need for 9-8-8 to include specialized services for
LGBTQ youth is a matter of bipartisan agreement. Congress has
repeatedly recognized the need for specialized services for LGBTQ
youth. When Senator Orrin Hatch argued for the enactment of the 9-8-8
legislation in 2018, he explained that:
The prevalence of suicide, especially among LGBT teens, is a
serious problem that requires national attention. No one should
feel less because of their gender identity or because of their
orientation. They deserve our unwavering love and support. They
deserve our validation and the assurance that not only is there
a place for them in this society but that it is far better off
because of them. These young people need us, and we desperately
need them.\5\
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\5\ https://www.govinfo.gov/content/pkg/CREC-2018-06-13/html/CREC-
2018-06-13-pt1-PgS3866-3.htm.
Leaders from both parties, including the former Republican FCC Chair,
have recognized the vital role that specialized services play in saving
lives. The Act, passed with widespread bipartisan support, built on
this promise and highlighted the need for specialized services for
LGBTQ youth. The FY20 and FY21 Labor, Health and Human Services
Appropriations Act Explanatory Statements directed SAMHSA to pursue the
implementation of specialized services for LGBTQ youth, including both
counselor training and the establishment of an IVR. Additionally, FY22
appropriations language currently under consideration by Congress would
---------------------------------------------------------------------------
allocate $7.2 million for specialized services, including IVR.
However, right now it is not clear if 9-8-8 will be ready for action in
July. There are positive signs. SAMHSA has stated that more than $560
million will be required to strengthen local crisis call capacity,
including their ability to address the needs of high-risk populations.
The agency has also announced that $282 million are being invested in
efforts to ``shore up, scale up and staff up'' the NSPL,\6\ and
recently reported to Congress that the agency ``has begun collaborating
with the Trevor Project'' in the effort to provide specialized services
to LGBTQ youth.\7\ However, time is running short, formal agreements
and funding have yet to be finalized, and it is not clear that
essential specialized services will be ready for LGBTQ youth in July.
---------------------------------------------------------------------------
\6\ SAMHSA, HHS Announces Critical Investments to Implement
Upcoming 988 Dialing Code for National Suicide Prevention Lifeline,
December 20, 2021, available at https://www.
samhsa.gov/newsroom/press-announcements/202112201100.
\7\ SAMHSA, 988 Appropriations Report, December. 2021, available at
https://www.
samhsa.gov/sites/default/files/988-appropriations-report.pdf.
Overall, a properly functioning Lifeline is an essential tool to
reducing barriers to mental care, particularly for LGBTQ youth. As the
July activation date approaches, Congress should fully fund the NSPL
and specialized services. This includes the training of counselors in
LGBTQ cultural competency, the establishment of an IVR option for LGBTQ
youth to receive specialized care, and the use of text and chat
services. Taking these steps would help ensure that LGBTQ young people
can get access to mental health resources and crisis intervention
services that can be the difference between life and death. In the
midst of a mental health crisis, no response is more important. The
Trevor Project is ready, willing, and able to help make sure that 9-8-8
succeeds.
How can we protect LGBTQ youth from conversion therapy?
One of the barriers that LGBTQ youth and their families face when
seeking appropriate mental health care is the continue prevalence of
dangerous and fraudulent practices that seek to exploit the mental
health challenges faced by these families. LGBTQ youth, already placed
at increased risk for mental health challenges is because they face
unique stressors and the threat of anti-LGBTQ victimization, should not
also have to worry about being the victims of conversion therapy.
Conversion therapy is not ``therapy'' at all--it is a dangerous and
discredited practice that harms both LGBTQ young people and their
families. The American Psychiatric Association (APA) has stated that
``The potential risks of reparative therapy are great, including
depression, anxiety, and self-destructive behavior.'' The Trevor
Project's 2021 National Survey found that:
LGBTQ youth who were subjected to conversion therapy reported
more than twice the rate of attempting suicide in the past year
compared to those who were not; and
13% of LGBTQ youth reported being subjected to conversion
therapy, including 21% of Native/Indigenous LGBTQ youth and 14% of
Latinx LGBTQ youth.
That's why twenty states and more than 100 localities have prohibited
licensed mental health providers from subjecting LGBTQ youth to
conversion therapy--but gaps in federal and state prohibitions persist,
and medical billing procedure makes it difficult to track the
occurrence and frequency of conversion therapy.
In order to effectively respond to the current mental health crisis, it
is time for this dangerous practice to end once and for all. While we
wait for Congress and states to close gaps in prohibitions against
providing or funding conversion therapy, Congress should encourage
agencies such as the Federal Trade Commission (FTC) to rigorously
investigate and prosecute instances of deceptive or fraudulent
advertising in connection with conversion therapy.
The mental health crisis has put more families with children in need of
effective mental health services, strained the ability for effective
provision and regulation of those services, and created an environment
that makes it easier anti-LGBTQ practitioners to prey on marginalized
families and children. For this reason, an effective response to the
current mental health crisis should include efforts to ensure both that
LGBTQ youth have access to the quality mental health care services they
need, and that they are not victimized by fraudulent conversion therapy
practices. These steps are an essential part of the necessary response
to the current mental health crisis, to ensure that we are protecting
LGBTQ youth in every corner of our country. They would reduce barriers
to care by helping effective and reputable mental health care providers
respond to families seeking help during the mental health crisis,
saving the lives of some of the most marginalized young people, and
assisting groups such as The Trevor Project in ending the harmful
practice of conversion therapy.
Conclusion
Reducing barriers to care in order to address the mental health crisis
facing our country requires a comprehensive, dynamic, and urgent
response. Making sure that 9-8-8 is ready to serve all who need it when
the number goes active in July--including providing specialized
services to LGBTQ youth--and helping end conversion therapy are
necessary components of any effective response to the unique mental
health challenges facing LGBTQ youth.
Too many young lives are at stake, and I urge you to take action--
through your position of power and in your personal life. Our research
has found that having at least one accepting adult can reduce the risk
of a suicide attempt among LGBTQ young people by 40 percent. Isn't that
profound--the impact that just one adult can make in the life of a
young person? When having these conversations, we must always remember
that suicide is preventable, and each and every one of us has the power
to help end this public health crisis.
Thank you again for your attention to and action on this issue. The
Trevor Project appreciates the opportunity to submit this statement and
looks forward to continuing to work with Congress and the
administration in addressing the mental health crisis and supporting
our most marginalized young people.
For any questions, please contact Preston Mitchum (he/him), The Trevor
Project's Director of Advocacy and Government Affairs at
Preston.Mitchum@TheTrevor
Project.org.
______
Voice for Adoption
3919 National Dr., Suite 200
Burtonsville, MD 20866
202-210-8118
[email protected]
https://voice-for-adoption.org/
Statement of Joe Kroll, Interim Director
Voice for Adoption (VFA) was established in 1996 to shape the public
debate on permanency for children in the U.S. foster care system and
the families who care for them. We advocate, educate, and collaborate
with members of Congress, policymakers, partner organizations,
agencies, and individuals to advance federal policies that promote and
sustain permanence for children and youth in foster care. We envision a
day when all children and youth in the U.S. foster care system will
have a safe, loving, and supported permanent family through
reunification, adoption, or guardianship.
In the federal fiscal year 2019, according to the Adoption and Foster
Care Analysis and Reporting System (AFCARS), more than 66,000 children
and teens were adopted from foster care in the U.S.--the highest number
ever reported. The number of children waiting to be adopted has trended
upward over the past five years, with 122,216 children in 2019 waiting
to be adopted. Sadly, approximately 20,000 youth (ages 18 to 21) age
out of the foster care system each year without a family.
The physical and mental health needs of children who have experienced
abuse, neglect, trauma, and losses are significant. The State Policy
Advocacy and Reform Center, in Medicaid to 26 for Former Foster Youth:
An Update on the State Option and State Efforts to Ensure Coverage for
All Young People Irrespective of Where They Aged Out of Care, explains
it: ``Children who have been abused or neglected often experience a
range of physical and mental health needs, physical disabilities and
developmental delays, far greater than other high-risk populations. For
example, foster children are more likely than other children who
receive health coverage through Medicaid to experience emotional and
psychological disorders and have more chronic medical problems.''
Nearly 70 percent of children in foster care exhibit moderate to severe
mental health problems and 40 to 60 percent are diagnosed with at least
one psychiatric disorder. Lewis et al. explain, ``Depression, reactive
attachment disorders, acute stress responses, and post-traumatic stress
disorders are some of the common mental health diagnoses of children in
foster care.'' Researchers Kerker and Dore note that being taken into
foster care compounds existing problems, ``Although children frequently
enter foster care with preexisting conditions that put them at high
risk for mental health problems, . . . the very act of separating
children from their biological family may affect children's mental
health as well.''
For many years, the conventional wisdom was that once children were
adopted, any previous trauma a child experienced would be eliminated by
joining a permanent family. Thus, it was generally assumed that once a
child achieved legal permanence, their families would not need to seek
services or support from the child welfare system. However, research
has revealed that the trauma, abuse, and neglect children experience
has serious, often lifelong repercussions. Childhood trauma and abuse
affect brain development and have consequences throughout an
individual's life. Among other things, complex trauma can affect
children's ability to express and control emotions, concentrate, handle
conflict, form healthy relationships, interpret social cues, and
distinguish safe from threatening situations.
As a result, many children and families need help and support long
after permanence has been obtained, including when children reach
different milestones and experience transitions. In a longitudinal
study of adopted children, Rosenthal found difficulties several years
after adoption, particularly in adolescence: ``The study's core
finding--one that those in the special-needs adoption field know from
their everyday practice experience--is that `problems' in special needs
adoption do not dissipate in a steady, predictable fashion. Instead,
children and families continue to present complex challenges throughout
the adoption. In particular, behavioral problems are quite persistent
and may even intensify.''
The challenges for young people who leave care without permanency are
even more significant since they don't always have supportive, caring
adults in their lives. Youth who leave foster care due to age continue
to experience poor health outcomes into adulthood, including high rates
of drug and alcohol use, unplanned pregnancies, and poor mental health
outcomes. More than half of those who aged out of foster care report
being uninsured. More than one-fifth report unmet needs for medical
care--research findings from Chapin Hall at the University of Chicago
highlight additional troubling statistics. One-third of youth aging out
reported two or more emergency room visits in the past year, 22 percent
were hospitalized at least once, three-quarters of young women had been
pregnant, and 19 percent received mental or behavioral healthcare in
the past year.
At this time, there is no single access point for children, youth, and
parents dealing with serious mental health and substance abuse issues
to access services, treatments, and support. Foster care, juvenile
justice, and education appear to be the primary points of access for
the child welfare community, frequently exacerbating or creating much
more significant issues such as specific populations being
disproportionately over represented. In contrast, others may be denied
services and experience discrimination. This fragmented model of mental
health care provides no room for accountability. Instead of addressing
the failure to provide services, blame is often pushed to systems not
designed to provide these services, like the three above. In the end,
that accountability has to be placed on a mental health system whose
responsibility it is to ensure access, quality, and oversight are
provided.
Regardless of which agency has the responsibility to provide access and
ensure treatment effectiveness, no child or family involved with the
child welfare system, especially those taken into foster care and
promised our government's protections, should experience any form of
abuse or neglect, including discrimination based on race, religion,
sexual orientation, gender identity, or gender expression. The well-
being of our children, especially the well-being of their mental and
behavioral health, demand that we improve access and provide children
and families with trauma-informed, evidence-based, mental and
behavioral health systems with a single point of entry--creating a
mental health system that can be held accountable for failures in
treatment, but also responsible for ensuring that all services
providers and treatment options promote racial equity, strive to block
discrimination, and dismantle system racism--ensure that mental health
of those impacted by the System is preserved and nurtured and reduce
trauma rather than inflict it.
Given the body of scientific evidence regarding the long-term effects
of trauma on child development, child welfare, and behavioral health,
systems must ensure they offer children and families a robust array of
mental health and other post-permanency support and services.
VFA is pleased to provide recommendations to the Senate Finance
Committee and welcomes opportunities to meet with committee members to
discuss our requests further.
Fund Post-Permanency Support Services
Congress should require and fund a core set of support services
for children and families exiting foster care to a permanent family,
with such services to include trauma-informed and permanency-competent
mental and behavioral health services.
As noted above, research on the short- and long-term impact of trauma
has revealed that many children and families need support long after
legal adoption or guardianship has been obtained, including when
children reach different milestones and experience transitions. As a
result, child welfare systems must make a comprehensive array of
services available to adoptive and guardianship families, including
critical mental health services. These services must be available when
needed and without waiting times and responsive to the needs of each
family; a ``one size fits all'' approach is not acceptable.
Importantly, professionals must deliver them with the expertise and
training to meet adoptive and guardianship families' unique needs.
Delay of services and inadequately trained mental health providers can
exacerbate family problems and ultimately disrupt a child's adoption or
guardianship placement.
State, local, and tribal child welfare systems need to have federal
guidance and funding so they can fully develop and maintain
comprehensive and responsive post-permanency services. Several states,
including Tennessee, Alabama, and Illinois, provide a model of
providing comprehensive, in-home mental health services to adoptive or
guardian families.
Improving Access for Children and Young People
Congress should maintain access to Medicaid for youth who age
out of foster care up until age 26 and assure this coverage extends
across state lines when a young person moves to a new state. This
requirement should take effect immediately rather than in 2023 as
currently written.
Congress should protect this Medicaid benefit in every state by
precluding work requirements for youth who have experienced foster
care.
Congress should extend access to Medicaid to children who leave
foster care to adoption and guardianship, just as it extends the
benefit to those who emancipate from care.
More than 20,000 youth age out of the foster care system every year.
Statistics about their uncertain futures are dire, and the lifetime
societal costs are astronomical. The Affordable Care Act (ACA) is a
critical lifeline for these youth. As a result of the ACA, young people
who aged out of care without a permanent family can remain on Medicaid
until age 26, just as other young people can stay on their parent's
health care plans. The Congressional Research Service reported that in
2015, 70 percent of 21-year-olds who had aged out of care were on
Medicaid, showing how necessary this provision is to this population.
For those who age out of care or who exit to adoption or guardianship,
access to Medicaid is a critically important way to meet the lifelong,
significant mental health, substance use, and behavioral health care
needs of young people who have experienced abuse and neglect and the
challenges of separation from their birth parents. Losing coverage at
age 18, when so many other transitions and changes are happening, is
particularly risky for this population with a much higher rate of
mental and behavioral health challenges.
Strengthening Workforce
Congress should:
Support the expansion of adoption-competency training for mental
health providers and caseworkers and encourage their participation by
providing ongoing funding to the National Adoption Competency Mental
Health Training Initiative and other similar adoption-competency
programs.
Provide federal incentives to recruit and train more master's-
level clinicians. There is a shortage of well-trained mental health
specialists who can meet the complex and unique needs of the child
welfare and adoption community.
Provide funding for targeted recruitment and retention
initiatives to recruit, train, and support BIPOC and LGBTQ+ clinicians
to address the unique needs of BIPOC and LGBTQ+ children and families
in foster care and adoption.
Although funding is critically important to ensure access to post-
placement support services, it is equally essential that services be
permanency and adoption competent--reflecting the impact of trauma,
grief, loss, and other critical issues in adoption and permanency.
Children, youth, and families must have workers and other service
providers who understand and respond to these issues and build their
skills to serve children with their specific experiences. Families must
have professionals who understand adoption and provide mental health
services designed to respond to clinical issues and build parenting
skills for families parenting children who have experienced trauma and
broken attachments.
But more than training is needed. We have an urgent need to recruit
additional highly skilled, diverse providers into the field. BIPOC and
LGBTQ+ children and youth are over-represented in the foster care
population. Having a workforce and service providers who reflect their
background and understand their experiences will improve outcomes for
children.
Services provided by highly trained staff who reflect the population of
children and families in adoption and guardianship will be more
effective at ensuring that families thrive and remain together,
preventing foster care re-entry.
Increasing Access to Care
Congress should increase Medicaid rates to align with private
insurance.
The vast majority of children in and exiting foster care have Medicaid
as their insurance provider. But these children and their families face
significant obstacles accessing services due to low reimbursement rates
and too few providers who accept Medicaid (often due to low rates),
particularly in non-urban communities. Clinicians must be reimbursed at
fair rates through Medicaid, which authorizes just a fraction of the
rates clinicians get privately or through some other insurance
providers. Reasonable reimbursement rates will ensure that skilled
clinicians are willing to see our children and families.
Congress should ensure that Medicaid includes coverage for
family therapy, not just services to individuals, as well as
nontraditional treatments that effectively help those affected by
trauma.
Too often, Medicaid (and other insurance policies) covers only services
to the insured individual, when the issues facing those in adoption,
guardianship, and foster care are often related to the family system.
Medicaid should explicitly cover therapeutic services provided to the
entire family of children, including the children, their siblings, and
birth, foster, and adoptive parents and guardians.
Youth and families must also have access to Medicaid coverage for
nontraditional forms of therapy (such as neurofeedback, mind-body-
sensory trauma interventions, and other alternative innovations).
Congress should support the development and advancement of
services sensitive to racial and cultural and other needs of LGBTQ+ and
BIPOC individuals, including ensuring that Medicaid and other insurers
cover them.
In addition to recruiting and retaining diverse providers as
recommended above, we must do more to ensure that the various children
and families served by the child welfare system have access to mental
health and behavioral health services designed to address their unique
needs, including the impact of racism, homophobia, transphobia, and
other discrimination. Funding should support ongoing development and
research on new or adapted interventions sensitive to the racial,
cultural, and different needs of LGBTQ+ and BIPOC children and
families. In addition, Congress should ensure that these services are
supported by Medicaid and other insurers and are accessible to those
who need them.
Congress should require Medicaid and other insurers to cover the
subspecialty of therapists to include competence in child welfare and
adoption.
There currently is no recognized ``subspecialty'' of adoption/
permanency competence despite the wide recognition of the unique needs
of children in adoption and other permanent families. Congress should
support and incentivize the creation of such a subspecialty whereby
therapists complete either accredited adoption competency training or
trainings that have an evidence base to show a positive change in
practice and child and family outcomes. This is consistent with
Medicaid managed-care companies' needs to ensure they spend their
capped dollars on effective treatments specific to the audience.
Congress should amend the Dosha Joi Immediate Coverage for
Former Foster Youth Act (S. 712) and the Expanded Coverage for Former
Foster Youth Act (S. 709) to include explicit language stating that
Medicaid covers individual therapy and telehealth therapy services for
young people who are or were in foster care.
Currently, young people who have Medicaid coverage may not have access
to a full range of services that they need to meet their well-
documented needs. Congress should ensure that those covered by Medicaid
can access the type of services they specifically need, including
individual therapy rather than simply group care and telehealth
services.
Congress should also support expanded telehealth options,
including allowing reimbursement to providers in other states,
maintaining equal reimbursement rates for telehealth and in-person
visits, and setting national standards for telehealth services.
Expanding telehealth services is vital to supporting many children,
youth, and families, including, but not limited to, those residing in
more remote locations. These individuals have limited access to
providers and a reduced selection of treatment options. This may
prevent access to services at all or, at a minimum, result in delays in
access. Such limitations can cause additional problems as untreated
mental and behavioral health problems worsen untreated.
By lifting geographic barriers to telehealth, children and families
would have access to services from providers who can best meet their
needs, with reduced wait times and choices for more adoption- or
permanency-competent providers.
National standards for telehealth services would ensure that the
provided services are of high quality and are most likely to serve each
client effectively.
Congress should increase the Federal Match Assistance Percentage
(FMAP) rate for all children's mental health and supportive services
provided under the Early and Periodic Screening, Diagnostic, and
Treatment (EPSDT) entitlement, covering all children under the age of
21 in all states and territories. In addition, Congress should expand
access to these services for children and youth in foster care and who
have exited care to adoption and guardianship while ensuring that such
services are adoption/permanency-competent for this population.
Increasing the FMAP would encourage states to use this vital, underused
resource for children covered by Medicaid. According to MACPAC, more
than 40 million children were eligible for EPSDT services in 2014, but
less than 60 percent of children who should have received at least one
screening received one. Such screenings are essential concerning
psychiatric care, which typically requires a determination of the
medical necessity for future coverage. As noted above, children in and
exiting foster care to permanency have significantly higher mental and
behavioral health needs rates. They would particularly benefit from
such screenings and the coverage that the screening results may make
available to them. But for the screening and services to be effective
for this population, they must consider specific issues common in
foster care, including the impact of trauma, grief and loss, and broken
attachments.
Congress should refine language in the Timely Mental Health for
Foster Youth Act (S. 3625) to mandate all jurisdictions to participate
and require an additional mental health screening by trauma-informed
professionals conducted 60 days before youth exit care to permanency or
due to emancipation. Ensure that professionals work with families or
young people to arrange for services to address any needs identified.
In many cases, children receive mental health assessments soon after
entering foster care to determine their needs and identify services to
be provided. Because needs change over time, such screening must also
be done before children exit the system--and thus lose access to some
services and supports--so that their current state of health is
determined. The assessment process must include identifying and
connecting to access services that address the child or youth's
identified needs.
Congress should mandate that the National Youth in Transition
Database (NYTD) measure outcomes for healing and trauma through a
qualitative question that addresses how to best support youth with
their mental health and healing needs.
The NYTD current data collection falls short of identifying the needs
of youth who have exited care and what is helping them heal. Additional
questions, developed with the input of young people who have been in
care, will help assess needs and identify which services and supports
are successfully meeting those needs. The reported data would also hold
states accountable for assisting young people in their healing process.
Ensuring Parity
Congress should ensure that all health insurance provides true
parity for mental and behavioral health services in all health
insurance plans. Congress should hold more hearings, issue state report
cards, and direct HHS to craft model state laws to reach parity.
In 2020, the Psychiatric Times noted that we had not achieved mental
health parity despite previous legislation and other action. Citing a
report card based on 2017 data, the Times reported on ``continued and
increased disparities between behavioral health care and physical
health care coverage, indicating possible evidence of non-compliant
insurance practices.'' Data showed more out-of-network visits and
higher co-pays for behavioral health than physical health in many
states. Many of these disparities can be attributed to managed care
rules.
There should not be limits on the number of visits and other mental and
behavioral health services if such limits are not put on physical
health needs. Services should be provided based on the individual's
needs and the professional opinion of the service provider.
The mental health needs of children and young people who have been in
foster care are significant. Their experiences and their families as
they struggle to access appropriate services show us how fractured this
country's mental health system is. We need a robust, comprehensive
mental and behavioral health system that serves all Americans while
also providing targeted investments and support for those children for
whom the government accepted responsibility when it removed the
children from their families and placed them in foster care.
______
Youth Villages
3320 Brothers Blvd.
Memphis, TN 38133
March 1, 2022
U.S. Senate
Committee on Finance
Dirksen Senate Office Bldg.
Washington, DC 20510-6200
Chairman Wyden, Ranking Member Crapo, and Members of the U.S. Senate
Committee on Finance, I want to thank you for the opportunity to submit
a written statement regarding the Committee's continued support and
interest in youth mental health in the United States as evidenced by
your recent hearings on February 8, 2022: ``Protecting Youth Mental
Health: Part I--An Advisory and Call to Action'' and February 15, 2022:
``Protecting Youth Mental Health: Part II--Identifying and Addressing
Barriers to Care.''
As you may know, Youth Villages \1\ is a national leader in children's
mental and behavioral health committed to building strong families,
delivering effective services, and significantly improving outcomes for
children, families and young people involved in child welfare and
juvenile justice systems across the country. Founded in 1986, the
organization's 3,300 employees help more than 30,000 children annually
in 23 states and the District of Columbia.\2\
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\1\ https://youthvillages.org/.
\2\ https://youthvillages.org/about-us/locations/.
We full-heartedly agree with the members of the Senate Finance
Committee and Surgeon General Dr. Murthy that there is a youth mental
health crisis and that as a nation we must do more. We are extremely
grateful for the Committee's leadership on the issue and your desire to
work with young people and organizations that serve them to craft and
implement solutions to the challenges this unique population faces. The
challenges as mentioned in the hearings span beyond kids in crisis, but
to parents, caregivers, and the workforce dealing with a range of
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challenges from access to services to burnout.
We know that when youth and families have the services and support that
they need, they will be successful even when dealing with the most
severe mental health challenges. Prevention is key to combatting the
mental health crisis through investment in effective high-quality
services and supports that offer timely support and flexibility for
children, youth, and family's needs. I want to tell you about a young
person who overcame difficulties with mental health that we served
through our Intercept \3\ program, which is designated as ``Well-
Supported'' by the title IV-E Prevention Clearinghouse.
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\3\ https://youthvillages.org/services/intensive-in-home-treatment/
intercept/.
Cassidy was 16 years old and had multiple stays in in-patient mental
health centers. She struggled with depression, anxiety, and suicidal
ideation. In just one year, Cassidy was hospitalized for her mental
health nine times. Approximately five million children across the
country have a serious mental health condition, and hospital stays can
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cause significant trauma to a young person.
Youth Villages helps keep kids at home and in their communities while
receiving mental health treatment by working with the whole family to
provide intensive support, new parenting and communication skills, and
evidence and strengths-based mental health intervention services.
As part of the Intercept program, Cassidy and her mother, Ellen had the
ability to call the 24/7 Youth Villages crisis line to help de-escalate
crisis situations when they arose as well as meeting with their family
intervention specialist three times every week, sometimes at home,
sometimes in the community--even at Cassidy's favorite coffee shop.
They would work on coping skills and grounding techniques,
affirmations, communication, and Cassidy's self-esteem. Her specialist
would conduct safety sweeps at home and would work with them to create
safety plans. Thanks to her time and success in Intercept, it has been
more than a year since Cassidy's last hospitalization. She is enrolled
in a therapeutic school and is on the honor roll. Ellen and Cassidy
both feel comfortable and safe leaving Cassidy at home alone now--
something Ellen never thought she would be able to do again. Cassidy
sometimes still struggles with self-image and negative thoughts;
however, her specialist created a personalized affirmation book for her
to use as a tool when she is having a tough time. For the first time,
Cassidy is looking forward to what is next. She now envisions a future
for herself and dreams big. She has started visiting colleges and wants
to pursue a career in art.
Cassidy should not be the exception for youth with mental health
issues. She should be the norm. We share this story because Youth
Villages knows what is at stake as the Committee continues to work on
solutions for the youth mental health crisis America is facing. Without
the proper services and supports, especially those that are intensive,
trauma informed, community based, and family oriented, young people's
lives could be in jeopardy. Youth Villages stands with you, ready and
committed to doing our part to help end this crisis and ensure that
children, youth, and families can live successfully.
We would like to thank the Committee for including youth voice in the
conversation on mental health reform. Youth Villages agrees with Trace
Terrell that young people should not get lost in the system(s) and
should be able to obtain the level of care they need and where it is
developmentally appropriate. Youth Villages LifeSet program, which was
designed to help young people ages 17 to 23 who are aging out of child
welfare, juvenile justice or children's mental health systems get a
good start on independent adulthood, shows a positive impact with
meeting the needs of multi-systemic young people. For young people
transitioning from the foster care system, there is a need for
increased coordination and targeted case management that focuses on a
youth's mental health care and all their needs outside of clinical
support.
Young people who experience foster care are resilient and capable.
Still, they need support as they move toward adulthood. Nathe'anna's
journey--overcoming health issues, the COVID-19 shutdown and a natural
disaster--proves that point. Nathe'anna, the youngest of four children,
came into foster care around 7 years old. When she turned 18 in a group
home, COVID-19 hit. Then, she had to have gall bladder surgery, alone
because of visitor restrictions. Her LifeSet specialist Kelly Adams was
there, through phone calls, offering support and encouragement.
After her recovery, Nathe'anna returned to school virtually. Soon
after, her community was struck by Hurricane Ida. There were weeks with
no electricity and roads closed. Kelly stayed connected. LifeSet turned
into a lifeline. Today, Nathe'anna is working toward becoming an
emergency medical technician.
``I watched every one of my brothers and sisters age out of foster
care. This program wasn't around for them, and they had negative
outcomes,'' she said. ``LifeSet is a program that gives you a chance,
that gives you hope.''
Thank you again for the Committee's interest and commitment to
addressing the youth mental health crisis and the opportunity to submit
Cassidy's story for the record. Last October, Youth Villages submitted
a letter to the Senate Finance Committee addressing numerous concerns
surrounding the mental health crisis and its impact on youth and
families. We offered some of the following policy solutions, if
included in the bipartisan legislation, will help improve mental and
behavioral health outcomes for children, youth, and families:
We would like to reiterate that to address the high turnover and
burnout among behavioral health practitioners, the Committee should
find ways to increase payment rates to providers and provide
educational incentives for mental health professionals.
Prior to the pandemic, many children and youth with complex
needs faced barriers in accessing high-quality services, especially
young people in foster care. The Committee should provide additional
funding for research and evidence-based programs to expand high quality
services for young people, specifically those with foster care or
juvenile justice experiences.
If you have any questions about our Intercept program, how we address
youth mental health, or the solutions we see to this crisis, please
contact Director of Federal Policy, Shaquita Ogletree at
[email protected].
Respectfully submitted,
Pat Lawler
CEO
[all]