    [Senate Hearing 117-754]
    [From the U.S. Government Publishing Office]

                                                            S. Hrg. 117-754

                        PROTECTING YOUTH MENTAL HEALTH:
                     PART I_AN ADVISORY AND CALL TO ACTION

    =======================================================================

                                    HEARING

                                   before the

                              COMMITTEE ON FINANCE
                              UNITED STATES SENATE

                        ONE HUNDRED SEVENTEENTH CONGRESS

                                 SECOND SESSION

                                   __________

                                FEBRUARY 8, 2022

                                   __________

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                Printed for the use of the Committee on Finance

                                 _________

                     U.S. GOVERNMENT PUBLISHING OFFICE

    53-739-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

                             ADMINISTRATION WITNESS

    Murthy, Hon. Vivek H., M.D., MBA, Surgeon General, Office of the
      Secretary, Department of Health and Human Services, Washington,
      DC.............................................................     5

                   ALPHABETICAL LISTING AND APPENDIX MATERIAL

    Cassidy, Hon. Bill:
        Submission for the record....................................    47
    Crapo, Hon. Mike:
        Opening statement............................................     3
        Prepared statement...........................................   117
    Murthy, Hon. Vivek H., M.D., MBA:
        Testimony....................................................     5
        Prepared statement...........................................   118
        Responses to questions from committee members................   121
    Wyden, Hon. Ron:
        Opening statement............................................     1
        Prepared statement with attachment...........................   176

                                 Communications

    American Academy of Family Physicians............................   181
    American Academy of Pediatrics, American Academy of Child and
      Adolescent Psychiatry, and Children's Hospital Association.....   183
    Center for Adoption Support and Education........................   186
    Child and Adolescent Mental Health Coalition.....................   193
    Children and Family Futures......................................   195
    Fountain House...................................................   198
    The Jed Foundation...............................................   203
    Journey to Success...............................................   204
    National Alliance on Mental Illness..............................   206
    National Association for Children's Behavioral Health............   209
    National Association of School Psychologists.....................   210
    National Health Law Program......................................   213
    National Hospice and Palliative Care Organization................   219
    Partnership to End Addiction.....................................   220
    Rainbows for All Children........................................   222
    REAP.............................................................   225
    Reed, Ethan J.S.H................................................   225
    Sandy Hook Promise Action Fund...................................   226
    Sports and Fitness Industry Association..........................   227
    Texas Children's Hospital........................................   228
    UCLA Center for the Developing Adolescent........................   232
    University Hospitals Rainbow Babies and Children's Hospital......   233

                                     (III)

                        PROTECTING YOUTH MENTAL HEALTH:
                     PART I--AN ADVISORY AND CALL TO ACTION

                                  ----------

                           TUESDAY, FEBRUARY 8, 2022

                                           U.S. Senate,
                                          Committee on Finance,
                                                        Washington, DC.
        The hearing was convened, pursuant to notice, at 10 a.m.,
    via Webex, in Room SD-215, Dirksen Senate Office Building, Hon.
    Ron Wyden (chairman of the committee) presiding.
        Present: Senators Stabenow, Menendez, Carper, Cardin,
    Brown, Bennet, Casey, Warner, Whitehouse, Hassan, Cortez Masto,
    Warren, Crapo, Grassley, Thune, Portman, Cassidy, Lankford,
    Daines, and Young.
        Also present: Democratic staff: Shawn Bishop, Chief Health
    Advisor; Elizabeth Dervan, Health Counsel; Eva DuGoff, Senior
    Health Advisor; 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. On behalf of Senator Crapo and myself, it is
    our hope that this morning's hearing on the state of mental
    health for our youth serves as a wake-up call. Millions of
    young Americans are struggling under a mental health epidemic;
    struggling in school; struggling with addiction or isolation;
    struggling to make it from 1 day to the next. Our country is in
    danger of losing much of a generation if mental health care
    remains business as usual. For families across the land, this
    is the issue--the issue--that dominates their living rooms and
    their kitchens.
        The Children's Health Insurance Program and Medicaid--the
    largest payers of mental health care for vulnerable young
    people--are within our jurisdiction, and that means the Finance
    Committee has got to come up with solutions.
        I hear way too many heartbreaking stories from parents and
    young people at Oregon town hall meetings, at the grocery
    store, and in the schools that I have visited all across the
    State. I am certain that is the same for every member of this
    committee.
        Imagine being a parent scrambling desperately to find help
    for your kid who is in crisis--who may be a danger to
    themselves or somebody else. Too many parents are making call
    after call after call, only to find there are not any beds
    available, or that the wait list to see a psychiatrist could be
    weeks or months long, or they are told that their insurance
    company won't pay for the care that a psychiatrist says their
    child needs, even though the law requires equality between
    coverage for physical health and coverage for mental health.
    Yet too many families in America are put through bureaucratic
    torment when they try to get that coverage--coverage that they
    pay vast sums for. Your kid is suffering, the insurance company
    takes thousands of dollars in premiums from your pocket, and
    yet often you get little more than jazz in your ear while you
    sit on hold.
        So there is new urgency. Diagnosing an issue and getting
    the right care for young people was plenty hard before anybody
    ever heard of COVID-19. The crisis is significantly larger
    today. Kids are feeling isolated. Depression is up. Suicide
    attempts are up. An estimated 140,000 kids have lost a parent
    or a caretaker to COVID-19, and that number will continue to
    rise.
        The bottom line is, every loving parent wants what is best
    for their child, so as a Nation, can't we come together and
    show the same level of concern for our young people? That is
    why having Dr. Murthy here is so valuable, because he put out,
    at the end of the year, a clarion call to the country to come
    together and recognize how serious this is and to take it on.
        So we are very fortunate to have him. He has been a
    crusader for improving mental health care for our kids. He
    spent some time in Eugene, OR, where of course our now famous
    CAHOOTS program that brought together mental health providers
    and law enforcement people to tackle mental health got started.
    And Dr. Murthy can help us attack the challenge from all sides,
    including how to help families navigate a broken, complicated
    mental health-care system; how to respond to a young person in
    crisis without demonizing them or criminalizing them; how to
    build on what has proven to work when it comes to health care
    for kids, specifically CHIP and Medicaid. And when it comes to
    showing what works, our colleague Senator Stabenow has done
    terrific work on behavioral health. In our part of the world,
    we call her a trailblazer for showing us how to make sure that
    kids get help.
        So here is the road ahead for the committee, and I want to
    thank Senator Crapo. We have spent months and months saying
    that this is going to be a bipartisan effort. We know that the
    political scene is polarized. We believe this is so important,
    we've got to work on a bipartisan basis.
        And with today's hearing, the Finance Committee ramps up
    our legislative efforts. Several of our members are going to be
    partnering on specific policy challenges. We will have one
    Democrat and one Republican. The goal is to produce a
    bipartisan bill that brings it all together.
        Senators Carper and Cassidy will be focusing on the subject
    of today's hearing: mental health care for America's children.
    I have heard both of them, Senator Carper and Senator Cassidy,
    talk passionately about how taking care of kids here is the
    ball game, because we all understand that you have a choice.
    You can get there early or, if you don't, you play catchup ball
    for years and years to come.
        Then we will have Senator Stabenow and Senator Daines
    working on the mental health-care workforce. So, part of this--
    and you see it with Senator Stabenow's great work on behavioral
    health--we can have a great program, but we need more
    workforce. And all over the country, we are hearing about
    challenges there.
        Senator Cortez Masto and Senator Cornyn will look at how to
    make mental health care more seamless, because too many people
    fall between the cracks. Senator Bennet and Senator Burr will
    focus on how mental health care finally gets treated the same
    way as physical health care--a special passion of mine,
    particularly because we launched our investigations after the
    debacle at the Oregon Health Sciences Center, where they could
    not get their claims paid early on in the pandemic because the
    insurance companies were stalling. And Senators Cardin and
    Thune will team up on making it easier to get mental health
    care via telehealth.
        And finally, I want to just mention what the direction here
    is, really the lodestar for what the committee has talked about
    in the past. Everybody in America must be able to get the
    mental health care they need when they need it. That is really
    the North Star. So we are going to stay busy with hearings
    featuring mental health experts and advocates.
        This morning's hearing will be the first of two that put a
    special focus on our young people. And before wrapping up, I
    would like to say--because he is not here--today I want to
    thank the Senator from South Carolina, Senator Scott, who has
    talked with me at considerable length about the CAHOOTS bill
    that I mentioned, when we were able to secure a billion dollars
    in Medicaid for it. He was just instrumental in this alliance
    between mental health people and law enforcement, because both
    groups want to focus on what they have been trained for. Mental
    health folks want to focus on mental health. Law enforcement
    says, ``We do not want to focus on mental health; we want to
    focus on what we are trained for.'' Senator Scott has been very
    helpful.
        So, Dr. Murthy, thank you for joining us. I am going to
    turn it over to Senator Crapo for his opening remarks, and then
    we are looking forward to hearing from you.
        [The prepared statement of Chairman Wyden appears in the
    appendix.]
        The Chairman. Senator Crapo?

                 OPENING STATEMENT OF HON. MIKE CRAPO,
                       A U.S. SENATOR FROM IDAHO

        Senator Crapo. Thank you, Mr. Chairman, and thank you, Dr.
    Murthy, for being here today. This discussion comes at a
    crucial time. Our Nation is confronting an unprecedented range
    of challenges, many of which have serious implications for the
    mental health of all Americans--especially children. From
    school closures to lockdowns to other COVID-related
    restrictions, the pandemic has intensified feelings of social
    isolation, helplessness, and anxiety. Since the pandemic began,
    we have witnessed alarming spikes in suicide attempts and
    suicidal ideation among teenagers, along with a staggering rise
    in drug overdose deaths.
        Dr. Murthy, as you noted in your advisory, rates of
    psychological distress among young people appear to have
    increased across the board in the past few years.
    Unfortunately, even prior to COVID-19, many of these trends
    pointed in the wrong direction. That said, I share your sense
    of optimism in tackling the urgent issues at hand.
        In communities across the country, we have seen families,
    faith leaders, policymakers, and health-care providers come
    together to craft creative and sustainable mental health
    prevention, access, and treatment solutions.
        Thanks to the chairman's leadership, we have the
    opportunity to bolster these efforts through a bipartisan
    process to advance targeted, consensus-driven, and fiscally
    responsible policies that drive better outcomes for all
    Americans. By focusing on shared priorities and adhering to
    core guiding principles, this process can culminate in
    comprehensive legislation that our colleagues across the
    political spectrum will enthusiastically support. Building
    consensus will maximize our ability to see the work we conduct
    here signed into law.
        We must also uphold fiscal integrity, fully paying for any
    and all provisions we look to enact. As working families across
    the Nation contend with the highest inflation in 40 years,
    strained finances pose a grave threat to health-care access.
    Unrestrained government spending risks pushing inflation even
    higher--further accelerating the decline of Americans'
    purchasing power.
        Moreover, with each passing year, we are steadily moving
    closer to the Medicare trust fund's exhaustion date, at which
    time the program will no longer be able to pay full benefits
    for our Nation's seniors. We must be thoughtful and cautious to
    avoid exacerbating the fiscal challenges we face.
        Likewise, we must ensure that any pay-fors that we advance
    do not in any way compromise economic growth, undermine
    biomedical innovation, or undercut our recovery. Across-the-
    board bipartisan support will prove essential. By aligning our
    process with these basic principles and guard rails, we can
    produce a meaningful bill, carefully tailored to meet the
    challenges that confront us.
        This committee has a strong track record of generating
    consensus-based bills, from the CHRONIC Care Act to the
    Retirement Enhancement and Security Act, which ultimately
    passed as the SECURE Act in 2019. I believe that we can
    replicate that success here. As the committee begins its work,
    we do so having built a strong foundation of shared interests
    and objectives. For instance, the pandemic has highlighted the
    pressing need for expanded access to telehealth, especially for
    Medicare beneficiaries.
        Our committee took an essential first step toward
    addressing these barriers by codifying permanent Medicare
    coverage for mental health services, regardless of geographic
    location, including services provided in the home. However,
    gaps remain, and we will work to bridge them here.
    Strengthening the mental and behavioral health workforce will
    also prove vital, especially in the face of widespread provider
    stress, fatigue, and burnout, which the pandemic has escalated.
    I hear every day from doctors, nurses, and other health-care
    professionals across Idaho who are looking to reduce hours or
    leave their practices entirely in the months to come,
    confronted with an unprecedented range of demands.
        Too often, sadly, policymakers have inadvertently added to
    these challenges, imposing bureaucratic requirements and tasks
    that divert attention from patient care and hinder providers'
    workplace wellness. As we navigate potential policy options, we
    should look to avenues for enhancing flexibilities, both for
    providers and for States, as they seek to improve and innovate
    across the continuum of care. These and other focal points,
    from encouraging service integration to promoting
    modernization, present opportunities for bipartisan discussions
    that will enable our health-care system to serve all Americans
    more effectively.
        In that spirit, I look forward to your testimony, Dr.
    Murthy, and to a timely discussion of mental and behavioral
    health solutions. And thank you again for being here.
        [The prepared statement of Senator Crapo appears in the
    appendix.]
        The Chairman. Thank you, Senator Crapo. And I was glad you
    mentioned the telehealth issue, because it sort of highlights
    how this committee keeps building on its bipartisan work.
        General Murthy, when Chairman Hatch was head of the
    committee, Senator Crapo and I and Senator Stabenow all worked
    together, because Medicare is no longer primarily an acute-care
    program. It is primarily a chronic disease program: cancer and
    diabetes and hearts and stroke. And the big provision was the
    telehealth expansion. And we were really pleased when Seema
    Verma, looking at the landscape, said, ``Hey, we've got
    something that has already been fleshed out.'' And what the
    Finance Committee did in the CHRONIC Care bill on telehealth
    largely became the first telehealth provision. So we are going
    to keep working with you; we just have to keep building.
        Now before you testify, we have to give you an official
    introduction. And so, Dr. Murthy is the Nation's doctor. He is
    the Vice Admiral of the U.S. Public Health Service Commission
    Corps. This is his second tour in the role, serving as Surgeon
    General from 2014 to 2017. During that time, he undertook
    initiatives to address Ebola and Zika, the opioid crisis, and
    the growing threat of stress and loneliness to Americans'
    physical and mental health.
        Prior to serving as Surgeon General, he co-founded multiple
    organizations aimed at improving people's health and well-
    being, both here and abroad. He also practiced as a physician
    at Brigham and Women's Hospital in Boston, where he completed
    his medical training in internal medicine. He received his
    medical degree from Yale, his masters in public administration
    from the Yale School of Management, and his bachelor of arts
    from Harvard.
        Dr. Murthy, we now turn to you. The formalities are over.
    We would like to hear from you.

    STATEMENT OF HON. VIVEK H. MURTHY, M.D., MBA, SURGEON GENERAL,
        OFFICE OF THE SECRETARY, DEPARTMENT OF HEALTH AND HUMAN
                        SERVICES, WASHINGTON, DC

        Dr. Murthy. Well, thank you so much for that kind
    introduction, Chairman Wyden. And to you, Ranking Member Crapo,
    and to members of the committee, thank you for the opportunity
    to be here today and to speak with you.
        I have the privilege of speaking to you today as Surgeon
    General of the United States, and as a Vice Admiral in the
    Public Health Service Commissioned Corps, one of our eight
    uniformed services in the U.S. Government. And I am most
    importantly here as the father of two young children. My son is
    5, and my daughter is 4, and they are the reason that I am
    grateful for this opportunity to speak with all of you today.
        Over the next few years, my children and many of their
    peers will start down the path to adulthood. Each of their
    paths will be different. All will be filled with challenges
    along the way. It is these challenges that I want to talk to
    you about today, because I am deeply concerned, as a parent and
    as a doctor, that the obstacles this generation of young people
    face are unprecedented and uniquely hard to navigate. And the
    impact that is having on their mental health is devastating.
    There are a number of longstanding, preventable factors that
    are driving this crisis.
        The recent ubiquity of technology platforms, especially
    social media platforms, has had harmful effects on many
    children. Though undoubtedly they serve as a benefit to the
    lives of many in important ways, these platforms have also
    exacerbated feelings of loneliness and futility and low self-
    esteem for some youth. They have also contributed to a
    bombardment of messages, both the traditional and social media,
    that undermine this generation's sense of self-worth, messages
    that tell our kids with greater frequency and volume than ever
    before that they are not good-looking enough, not popular
    enough, not smart enough, not rich enough--simply not enough.
        Similarly, while bullying has always been a problem, cyber-
    bullying has expanded the playing field. Anyone anywhere at any
    time can be tormented or be a tormentor. And meanwhile,
    progress on the issues that will determine the world this
    generation will inherit, like economic inequality, climate
    change, racial injustice, LGBTQ rights, the opioid epidemic,
    and gun violence, feels too slow. It is undercutting the
    fundamental American promise for many of our children--their
    hope in the possibility of a better future.
        All of these factors affecting youth mental health were
    true before the COVID-19 pandemic, but the last 2 years have
    dramatically changed young peoples' experiences at home, at
    school, and in their communities. It's not just the
    unfathomable number of deaths or the instability, it is also
    the pervasive sense of uncertainty and the nagging sense of
    fear. It is the isolation from loved ones, from friends, and
    from communities at a moment when human support systems are
    irreplaceable and more needed than ever before.
        But at the heart of our youth mental health crisis is a
    pervasive stigma that tells the young people they should be
    embarrassed if they are struggling with depression, anxiety,
    stress, or loneliness. It makes a human condition feel inhuman.
        I felt that stigma myself 35 years ago, growing up in Miami
    as a kid who did not look the same as other children, whose
    immigrant parents did not eat the same food or dress the same
    way as other parents did. And when that led me to feel
    persistently lonely, isolated, and anxious--when it led me to
    get bullied and called racial slurs by classmates who
    constantly told me that I didn't belong--I felt a deep sense of
    shame, like it was somehow my fault, like I had nowhere to go
    and no one, not even my unconditionally loving and supportive
    family, whom I could turn to for help.
        A world of shame and stigma, where children cannot get the
    help that they need, this is not the world that I want for my
    kids, for your children and grandchildren, and for kids across
    our country. But, Senators, we are on the verge of beating back
    one public health crisis in COVID-19, only to see another grow
    in its place.
        In 2019, the year before the pandemic, one in three high
    school students reported feeling persistent feelings of sadness
    or hopelessness, up 40 percent--40 percent--from a decade
    prior. From 2011 to 2015, youth psychiatric visits to emergency
    departments for depression, anxiety, and behavioral challenges
    increased by 28 percent. Between 2007 and 2018, suicide rates
    among youth aged 10-24 increased by 57 percent--a total of
    65,026 young people lost.
        As devastating as these numbers are, the real tragedy is
    that we are failing as a country to adequately respond to them.
    Even before the pandemic, we were not doing enough to provide
    adequate care and treatment options in every community. And
    COVID-19 has only made that disparity worse.
        We are not doing enough as a country to build and maintain
    a sufficient and diverse mental health workforce. And we are
    not doing enough to integrate our mental health-care system
    with the rest of the health-care system--particularly primary
    care. We are not, as a country, doing enough to prevent, and
    not just treat, this crisis. Many mental health challenges
    first emerge early in life, and studies suggest that the
    average delay between the onset of mental health symptoms and
    treatment is 11 years--11 long, confusing, isolating, and
    painful years.
        Now we have an opportunity, and I believe the
    responsibility, to make change happen now. Late last year, I
    released my Surgeon General's Advisory on Youth Mental Health,
    which outlines the policy, institutional, and individual
    changes it will take to reframe and address these challenges.
    Out of the many recommendations in the advisory, I would like
    to highlight four today.
        First, ensuring that every child has access to high-
    quality, affordable, culturally competent mental health care.
    To do this, we must make sure that children are enrolled in
    health-care coverage. We also need to expand our mental health
    workforce, from clinical psychologists, school counselors, and
    psychiatrists, to recovery coaches and peer specialists. And we
    need to make sure care is delivered at the right place and the
    right time, whether that's in health-care settings like primary
    care practices, or community-based settings like schools, or
    whether it is in-person or through telehealth.
        Second, focusing on prevention by investing in school and
    community-based programs that have been shown to improve the
    mental health and emotional well-being of children at low cost
    and high benefit. We have seen the extraordinary potential of
    certain strategies and programs--from Project AWARE, to Beyond
    Differences, to the Family Check-Up--and these are just a few
    examples. We need to invest in scaling these programs across
    the country. And that must go hand-in-hand with continuing to
    address the systemic economic and social barriers that
    contribute to and create the conditions for poor mental health
    for young people, their families, and their caregivers.
        Third, we need to better understand the impact that
    technology and social media have on mental health. At a
    minimum, if technology companies are going to continue to
    conduct a massive, national experiment on our children, then
    public health experts and the public at large must be the ones
    to analyze the data, to draw conclusions, and to draft
    recommendations--not the companies alone. That is how we give
    parents and caregivers the ability to make informed choices
    about their kids' use of technology.
        The final recommendation concerns individual and community
    engagement--the role that we each have to play in overcoming
    the stigma associated with mental illness and with seeking
    help. No child should feel ashamed of their hurt, their
    confusion, their isolation, and no one should feel too ashamed
    to ask for help.
        If we do not keep working toward a culture that normalizes
    and promotes mental health care, then the consequences of our
    inattention and neglect will continue to ripple across
    generation, across class, and across geography. It is something
    we each, as parents and siblings, as teachers, as friends, as
    leaders, have the power to start changing today, by choosing to
    reach out to the children in our lives, by letting them know
    that they are not alone in their struggles, and by sharing our
    own stories.
        Our obligation to act is not just medical--it is moral. It
    is not only about saving lives. It is about listening to our
    kids, who are concerned about the state of the world that they
    are set to inherit, and it is about our opportunity to rebuild
    the world that we want to give them--a world that fundamentally
    refocuses our priorities on people and community, and builds a
    culture of kindness, inclusion, and respect.
        My job as the Surgeon General is to help lay the foundation
    for a healthier Nation, but that foundation is not built solely
    by putting warning labels on cigarette packs. It is built by
    focusing our attention on our Nation's most pressing public
    health concerns, and by fostering connection, community, and
    resilience. A house where people are isolated; where they feel
    left behind economically, socially, and professionally; where
    they feel unsafe; and where they feel like they don't matter,
    this is a house that cannot stand. But I believe that, if we
    seize this moment and step up for our children and families in
    this moment of need, we can lay that foundation right now.
        I appreciate you having me here today. I appreciate you
    coming together to help take on this issue for our Nation, for
    my sake, and for millions of kids across this country, and I
    appreciate you giving this issue the attention it sorely
    deserves. Thank you, Senators.
        [The prepared statement of Dr. Murthy appears in the
    appendix.]
        The Chairman. Doctor, thank you. And this is exactly what
    we hoped for: a powerful kickoff, a call to action. And I want
    to start in another area where we have a bond. It is very clear
    to me that this is personal to both of us.
        You described as a young person, how you felt the stigma,
    the hot scorn and cruelty. My brother struggled with
    schizophrenia for years. Not a night went by in the Wyden
    household when we went to bed not worried that he was going to
    hurt himself or hurt somebody else. And I felt right at the
    heart of what he was dealing with was the stigma. And he looked
    at me, and he said, ``My brother plays basketball. Look at me;
    I'm sick.'' And it just really got me every single night.
        And the numbers just take your breath away. In early 2021,
    emergency department visits for suspected suicide attempts were
    51-percent higher for adolescent girls. That is what I meant
    when I said I was concerned about the possibility of losing
    much of a generation.
        So, tell us your assessment of where we are with respect to
    tackling stigma, because it sure looks to me like the problem
    has not gotten better. And what do you think--because you have
    the bipartisan leadership of the committee here, you have our
    attention--we need to do about it? Your thoughts.
        Dr. Murthy. Well, thank you, Senator. I realize that one
    cannot legislate stigma away, yet it stands as one of the great
    challenges to us being able to address our mental health
    crisis. Stigma fundamentally, Senator, as you know, is about
    shame. It is not shame of something we are going through, but
    shame of who we are. And the challenge for people who are
    struggling with their mental health--because they often come to
    believe that it is their fault, that it is reflective of a
    fundamental flaw they have--is that shame simply drives them
    further and further into a dark corner at the exact time when
    they need more human connection and support.
        There are things I think we can do as a country to address
    this stigma. Number one, we can reach out to the children in
    our lives. We can open up the conversation about mental health
    and help them understand it is okay to struggle from time to
    time; that it is human; that it is what we all go through; and
    that it is okay to ask for help.
        The second thing we can do is, we can share our stories
    with the people in our lives, and with the public more broadly.
    One of the things I have been grateful to see is more athletes,
    more elected leaders, more community leaders stand up and share
    their own struggles with mental health. Every time that
    happens, it tells another young person that they are not alone.
    And one of the great difficulties in the struggle with mental
    health is the feeling that you are alone. But cultural change
    ultimately takes all of us stepping up and recognizing the role
    we play in shaping how people talk about mental health and
    shaping the conversation around mental health; that we need to
    be talking about it more, not less.
        We need to be addressing it not just in our families, but
    talking about it in the halls of Congress, as all of you have
    done, which I so appreciate. But that is how stigma changes. It
    is when people stand up, speak up, and choose to think
    differently about an issue like mental health.
        The Chairman. We will certainly be talking to you often
    about that in our work.
        I want to turn now to the question of parity. And for all
    of our families who have watched loved ones suffer, that day
    when Paul Wellstone, a liberal Democrat, and Pete Domenici, a
    conservative Republican, got the parity law passed, we felt
    like a big boulder had been lifted off our shoulders. We were
    going to get a fair shake for mental health in America.
        And so, I have been doing oversight on these insurance
    companies for years, and I will tell you, I think the
    commitment to parity which is embedded in Federal law is
    honored more in the breach than in the observance. And
    particularly during the pandemic, the insurance companies just
    seemed to find one excuse after another to not follow through
    and cover people. And families could not find providers who
    take insurance. There were all kinds of games about could you
    get somebody in the network, out of the network, mountains and
    mountains of red tape. Because my time is out, we are going to
    talk to you, obviously, more about it.
        I would be interested in your take with respect to this
    parity issue, because I think I mentioned to you that my Oregon
    Health Sciences University, they could not get claims paid for
    months. I opened an investigation. All the claims got paid at
    once. That is not a system, that the only way they will pay
    claims is if their Senator puts it in the newspaper. So give us
    your assessment of where we are on the parity issue, and
    particularly what you see with respect to compliance. And I
    know this is not a scientific judgment of what you think.
        Dr. Murthy. Well, Senator, I remember where I was when I
    learned about the 2008 parity law. I was practicing medicine in
    Brigham and Women's Hospital. I had seen the toll of mental
    health on my patients, and I knew how hard it was for people to
    get mental health care. And I was hopeful when that law passed,
    that it would change that reality.
        I think the honest truth is that we still have a gap; that
    for many people parity does not exist in terms of the coverage
    they get for mental health services versus traditional health-
    care services. That is a travesty, and we have to close that
    gap.
        The Biden administration, and the Department of Health and
    Human Services in particular, have issued a report recently on
    these gaps that we currently face where health insurance
    companies need to step up and reimburse adequately for mental
    health services. The administration is expanding, in a
    multiagency way, the number of individuals to do the
    investigations. It is also moving to require insurers to
    provide proof that they are in fact meeting the parity
    requirements and are working to provide additional technical
    assistance to States so that they can also work to hold
    insurers accountable. This is going to be essential for access.
        The Chairman. I am over my time, and we are going to work
    on that with you as well.
        Senator Crapo?
        Senator Crapo. Thank you, Mr. Chairman.
        Dr. Murthy, in your advisory you note the rapid shift
    toward telehealth at the start of the pandemic, as well as the
    potential for telemedicine to serve a lasting role in improving
    health-care quality for our young people.
        Given your medical background and your ongoing engagement
    with health-care providers, what do you see as some of the best
    practices for clinicians as they work to integrate telehealth
    into their practices for the long term? And what factors should
    they consider as they tailor these models and services to
    younger patients?
        Dr. Murthy. Well, Senator, thank you for that question. I
    am a big believer in the power of technology to improve the
    quality and delivery of health care, if it is used
    appropriately. I think currently, telehealth has tremendous
    promise to expand access to mental health care.
        We still have challenges to address, including expanding
    broadband access. We still need to ensure that not only in the
    public payer system, but in the private payer system, that
    there is adequate reimbursement for virtual care. And we also
    have to ensure that privacy is protected at all times on these
    platforms. I think as individual clinicians look to utilize the
    virtual platforms in telemedicine, it is important not only for
    them to recognize and to honor those privacy concerns, but also
    to recognize that there are times when we do need to see people
    in person.
        The advent of telemedicine is not entirely a substitute for
    in-
    person care, but it is a good supplement, especially for people
    who have traditionally had difficulty accessing care. But
    finally, it requires a conversation with patients themselves.
    Not everyone will be comfortable utilizing telemedicine. Some
    will be more comfortable than others.
        Young people tend to be much more comfortable with
    technology, and this is the kind of tool that I believe, if
    appropriately introduced and utilized, can increase access for
    young people's mental health care.
        Senator Crapo. Well, thank you.
        Moving to the issue of providers, our Nation's health-care
    workforce has provided unparalleled resilience and expertise
    and dynamism as they have dealt with the COVID-19 crisis.
    Unfortunately, while the pandemic response efforts of these
    past 2 years have highlighted these strengths, the COVID-19
    problem has also exacerbated the stress, fatigue, and strain
    facing far too many of our front-line providers.
        A recent study found that one in every five physicians
    would likely leave their current practice within 2 years, and
    that nearly one-third of health-care professionals planned to
    reduce their hours in the next 12 months.
        Dr. Murthy, in the past you have discussed the pressing
    challenges posed by physician burnout, which has serious
    implications not just for health-care workers but for patients,
    particularly in communities plagued by shortages of providers.
        Expanded access to telehealth and other virtual health
    technologies could help to bridge these gaps. But other
    interventions, however well-intentioned, seem likely to
    increase bureaucratic strain and divert time and attention from
    patient care.
        My question to you is, what role do you see technology,
    from telehealth to AI and other cutting-edge innovations,
    playing in reducing provider burnout moving forward? And how
    can we promote these tools without creating needless new
    burdens and stressors for our health-care professionals?
        Dr. Murthy. Senator, I appreciate you highlighting the
    issue of clinician burnout. I am deeply concerned about it. I
    think it has gotten worse, not better. And I do think
    technology can play a positive role. But it can also be harmful
    if not utilized properly. I think if technology is used to
    provide greater access to telemedicine, which gives flexibility
    to both patients and clinicians, that can be a net benefit.
        If technology is designed around the needs of patients and
    health-care providers, that can also be beneficial. To give you
    a counter-example, if you look at electronic health records
    right now, many of them are designed for billing purposes much
    more so than for patient care. And that creates strain and
    burden for clinicians at a time when that technology should be
    used to enable easier care for their patients.
        Senator Crapo. Well, thank you very much. I appreciate
    this. And as the chairman said, we look forward to continuing
    the pursuit of these issues with you and the many that we have
    not had time to talk about in our questioning. Thank you very
    much.
        The Chairman. Thank you, Senator Crapo. And we are seeing
    it all the time in Oregon and Idaho, and we are working
    together.
        Senator Stabenow?
        Senator Stabenow. Thank you very much, Mr. Chairman and
    Ranking Member. I so appreciate the focus that you are giving,
    and the leadership you are giving to this. I have to say, Dr.
    Murthy, I so appreciate your report and focus on young people.
    We know that one out of five Americans will have a mental
    illness in their lifetime, and that number actually may be
    going up as it relates to the pandemic.
        As the chairman talked about, I think there are many, many
    of us in this chamber who have had experiences ourselves or in
    our families. For me, it was my dad being bipolar before there
    was a diagnosis, before there was treatment, before there was
    medication. I saw what happened when he did not have those
    things, and then when he did, and the transformation in him and
    our family. And so, I wish that for everyone, which means we
    have to treat health care above the neck the same as health
    care below the neck. So that is part of getting rid of the
    stigma.
        But we know that children and young adults have been
    particularly hard hit, and certainly your report shows that
    anxiety, depression, other issues, have become way too common
    in far too many children, and young people have gone without
    treatment. And social media only makes it worse every single
    day.
        So, our children need help, and I would like to talk about
    two different venues to do that. One is school-based health
    centers, which I think are absolutely essential in addressing
    what has been happening, particularly now with the pandemic, on
    school-aged youth. And school-based health centers can provide
    critical behavioral health services, both addiction services
    and mental health services, as well as physical. And we are
    inching along.
        And back during the Affordable Care Act negotiations, I was
    able to get $200 million over 5 years into the ACA for
    infrastructure to create health clinics, but we have never
    actually put money into the operations every year. And so this
    year, there is $60 million included in the Senate
    appropriations money, in the House as well, for the first time,
    for operations. And we need to do more to really strengthen
    that.
        Senator Capito and I are working--we have legislation, the
    Hallways to Health Act, to move forward to really aggressively
    address what we need for our children's schools. So, could you
    speak to the importance and benefits of reaching children in
    school-based settings like the school-based health clinics? And
    how can we use them to expand what we need to do in behavioral
    health?
        Dr. Murthy. Well, Senator, thank you for that question. And
    thank you also for your leadership on this issue, for all of
    your work to support and get certified community-based
    behavioral health centers in communities across the country.
        One general principle in health care that I believe applies
    here as well is that you are better off if you bring care to
    people where they are. Our kids are in school. The better we
    are able to bring care to schools through counselors, school
    nurses, school psychologists, the more easily we are going to
    be able to identify mental health struggles early and get kids
    the care that they need.
        That is why I think school-based clinics are so important.
    It is why the investments that were made through the American
    Rescue Plan to give billions of dollars to schools, in part to
    help them hire more mental health providers and counselors in
    schools, were so important. But we have to sustain those
    investments over time.
        I mentioned earlier that it is 11 years, typically, between
    the onset of symptoms and when a child ultimately gets
    treatment. We have to shorten that time frame. We cannot let
    kids struggle, and their family struggle, for 11 years. And
    getting care to them where they are, in schools, is one
    important way to help do that.
        Senator Stabenow. I totally agree.
        And then the second piece of that is that, after they have
    been identified, they are getting help in school. If there is
    no community-based care, then it all drops off, which is why,
    as we talk about Certified Community Behavioral Health Clinics,
    this is about institutionally creating parity in the community
    between physical health clinics and behavioral health clinics.
        And that is why this movement--I am so proud that Senator
    Blunt has joined me in this, and members of our committee,
    certainly the chairman. And the work that has been done in
    Oregon on this is really significant. We have a broad
    bipartisan bill to extend the opportunity across the country,
    which is absolutely critical because first, you have to have
    services in the community. The services that are being provided
    now in places with funding are providing services to children.
        We know that about 25 percent of the services now being
    provided through the behavioral health clinics are to children,
    and more can be done. And they are working with juvenile
    delinquency facilities, and criminal justice facilities, and so
    on. And the most important thing is that they are meeting
    people where they are, meeting children where they are.
    Traditionally now, the mental health system has taken only
    those who are very seriously mentally ill under Medicaid. This
    is about everyone who presents themselves, every parent who
    presents themselves at a clinic with their child. And they are
    required to be able to get access to services and so on within
    a week, which is transformative, as well as the psychiatric
    crisis services provided.
        So I wonder if you might speak more about what we have
    dubbed the CCBHCs, which is a mouthful, dealing with behavioral
    health services, and the important role of community-based
    services?
        Dr. Murthy. Well, thank you, Senator. I cannot emphasize
    enough how important it is to have treatment accessible to
    people in their communities, and ideally, to have that combined
    with virtual care services to provide maximum points of access.
        Mental health is a delicate issue for many families, and
    being able to go to places and people they trust is often
    essential. Knowing that there is a center in your community can
    make a big difference for someone who is wondering whether they
    should step forward and get care.
        But what is also important is that the care that is
    delivered--whether it is for mental health concerns, or
    substance use disorders--is actually evidence-based care, which
    is why I believe the CCBHCs and the standards that they are
    working to uphold, such that all evidence-based treatment is
    being made available, are very important.
        So my hope is that, through a combination of in-person
    services and virtual services, we can ultimately provide the
    networks of access that young people need to get the health
    care they deserve.
        Senator Stabenow. Thank you, Mr. Chairman.
        The Chairman. And Senator Stabenow is going to continue to
    pioneer in this area, since she has taken on the workforce
    issue, which we all know is absolutely crucial. So we look
    forward to her continuing her good work.
        Senator Grassley is next.
        Senator Grassley. Thank you for being here, and
    congratulations on your appointment to this very important
    position. I am going to ask some questions about legislation
    that I have sponsored and how it is being implemented. And so,
    if you do not know the details of that, you can answer in
    writing. But let me ask you anyway.
        I am going to start out with this lead-in. I passed the
    bipartisan ACE Kids Act with the cooperation of Senator Bennet
    of this committee. It aligns Medicaid rules and payments to
    incentivize care coordination, including mental health care for
    kids with complex medical conditions.
        This Congress, I am working with Senator Bennet again to
    pass the Accelerating Kids' Access to Care Act, to streamline
    access to out-of-State providers for these same kids and their
    families.
        My question is this: the Accelerating Kids' Access to Care
    Act builds onto the ACE Kids law that is now on the books, by
    cutting red tape for providers and families. As a health-care
    provider, is access to an out-of-State provider a challenge for
    families who have children with complex medical needs? And let
    me add a second question so you can answer both at one time.
    How important is it that a child have mental health support
    services coordinated with their physical health?
        Dr. Murthy. Well, Senator, thank you for that question and
    for your leadership on this issue. I could not agree with you
    more that we need to reduce the barriers to people getting
    care, including from out-of-State providers.
        One of the things that we saw during the pandemic was that
    there were emergency measures that were put in place that
    allowed people to essentially provide care across the State
    lines and then also allowed for the greater use and adoption of
    telemedicine. I think we should not go back on some of those
    measures. I think the more we are able to ensure that people
    can get care from wherever they need to, whether it is in their
    State or out of State, the better off kids will be.
        And finally, this is not just about children. It is about
    their families. As you know better than most, Senator, from the
    work you have done, when kids have complex medical conditions,
    that creates certain stressors for their family at large. That
    is not always easy for parents to handle while also juggling
    their jobs. You have to make this easier for parents, not
    harder. And allowing those families to be able to get the best
    quality care, wherever it is, is a key part of that process.
        Senator Grassley. Thank you for that. In my State of Iowa,
    and even some States further west that are less populated,
    mental health in rural areas is a very important thing. So I
    want to ask about rural use. Your 53-page advisory mentions
    youth in rural areas, who are at higher risk of mental health
    challenges, as they may face additional challenges in
    participating in school or in accessing mental health services.
    The advisory does not speak to specific resources for youth
    living in rural America.
        Could you explain why that might not be included? And maybe
    give me a short answer to that so I can ask for a longer answer
    on my last question.
        Dr. Murthy. Oh sure, Senator. Well, the advisories by
    nature are limited documents that are intended to call out
    challenges, and lay out actions that people can take. You are
    absolutely right that we need more resources for youth in rural
    areas.
        There are some governmental resources that are under
    development, like the 988 hotline. There are private platforms
    like Crisis Text Line, which currently serves many youth in
    rural areas. But this is one of the disparities in health that
    I am worried about: that in rural areas, it is harder for
    children to get the care they need.
        Senator Grassley. Okay.
        My last question: I helped pass the Seeding Rural
    Resilience Act with Senator Tester. The law requires the U.S.
    Department of Agriculture to work with HHS, including the
    Surgeon General, to raise mental health awareness among farmers
    and ranchers.
        Can you work with your USDA colleagues to ensure that this
    effort is developing as urgently as is possible and report back
    to me?
        Dr. Murthy. Yes, Senator, I would be happy to do that.
        Senator Grassley. I think I will submit the rest of my
    questions for answer in writing.
        [The questions appear in the appendix.]
        The Chairman. Thank you very much, Senator Grassley.
        We are going to be calling some audibles, because members
    have hectic schedules. I think now Senator Carper is available
    online, and if you did not hear it, we wanted to give a special
    shout-out to Senator Carper, because he is making a personal
    commitment to standing up for kids as they wend their way
    through the mental health system.
        Senator Carper?
        Senator Carper. Thanks, Mr. Chairman. General, welcome.
    Thank you for joining us. Thank you for your service.
        I want to thank you for joining us today and for your
    testimony. I want to thank our chairman, Senator Wyden, for the
    opportunity to serve as the co-chairman of this bipartisan
    working group. I am delighted to be chairing the Pediatrics and
    Young People portion of this effort with my friend and
    colleague Senator Cassidy.
        The pediatric and mental health crisis is not a challenge
    that this committee can meet by itself. But with those of us in
    this room working with others who share our vision, like you,
    Dr. Murthy, we can forge the way, and I believe we will do just
    that.
        In one of my first acts as Governor I established something
    called the Family Services Cabinet Council devoted to
    strengthening families, the basic building block of our
    society. The goal of our Council, which united five different
    departments across the government of the State of Delaware, was
    to focus on prevention, the root causes of it. Rather than
    spending our resources treating the symptoms of our problems
    relating to families, we would attack the root causes of those
    problems.
        And, General, in your opening statement you mentioned
    investing in schools and community-based programs that have
    been shown to improve mental health and emotional well-being of
    children at a low cost and high benefit. And my question, a
    simple question, would be, how can Congress build on these
    preventive and effective services?
        Dr. Murthy. Well, Senator, it is good to see you, and thank
    you for that question about prevention. I am particularly
    grateful for it, because I think, historically as a health
    system, we have focused the lion's share of our attention and
    energy on treatment, and not so much on prevention. And we are
    seeing the consequences of that with mental health. About 75
    percent of people who struggle with mental illness, their
    struggles appear before the age of 24. So, we have to get to
    kids early.
        Now the good news is that, within the CDC and NIH there are
    a number of programs that have been supported and funded over
    the years, and research that is ongoing that has demonstrated
    that there are in fact programs, prevention programs, that are
    school- and community-based that are effective in reducing the
    likelihood of mental health challenges down the line and are
    also cost-
    effective.
        The Family Check-Up program is one of those examples. When
    I was Surgeon General in the Obama administration, I had also
    published a report on alcohol, drugs, and health which laid out
    an entire chapter on prevention-based programs that worked not
    only to reduce substance use disorders, but also mental health
    challenges for young people, including programs like the Nurse-
    Family Partnership, the Good Behavior Game program, and others
    like that.
        The challenge we have right now, Senator, is these programs
    are often under-funded, under-studied, and under-appreciated by
    the public. I have talked to many educators over the last few
    years who, if they have heard of these programs, they do not
    know how to go about beginning to implement them. So this is a
    place where I do believe resources and technical assistance can
    make a big difference in helping our kids early in the time
    course of these challenges.
        Senator Carper. Thanks very much. The Family Services
    Cabinet Council that we established in Delaware, which Governor
    John Carney has resurrected, among the things that we did was,
    we focused largely not on the symptoms, but on the root causes.
    One of the things we found out in working with actually the
    faith community in Kent County in providing for the education
    of kids in schools, we learned they had been thrown out of
    school because of violence and disruption. And rather than just
    saying, well, we are going to send you back home to sit it out,
    we actually provided alternatives for them.
        One of those was with a church just north of Dover--an
    African American pastor, large church. And they created an
    alternative educational program for students, with remarkably
    good results, kids who just could not perform, could not behave
    at all in school--middle school, high school students. And I
    remember visiting the church and school, which was right beside
    the church. I said to the pastor of the church, I said, ``What
    is the problem with these kids? What is the problem with these
    kids who are showing up at your doorstep and being sent by
    schools?''
        She said, ``The problem with these kids is, nobody loves
    them.'' That is what she said. She said the problem with these
    kids is nobody loves them. She said too many of them do not
    have a father around, will never have a father around, and they
    just need to be loved and have someone who has high
    expectations for them.
        And you know what? We went to work on that. We just went to
    work on that and focused on, among other things, training--
    partnering with thousands of parents in neighborhoods across
    our State, offering in-home parenting services. It was the same
    thing in our prisons, doing the same thing in our prisons.
        So I have some questions for the record that I am going to
    submit to you, but I would just say to you, we can address the
    symptoms of these problems, but if that is all we do and we do
    not go after root causes--which are many and varied, and I
    mentioned a couple of big ones. And I would submit that one of
    my priorities in taking on this opportunity is to do just that.
        Thank you, Mr. Chairman and my colleagues. I look forward
    to working with all of you. General, great to see you. Thanks,
    my friend.
        The Chairman. Thank you, Senator Carper. And I am so glad
    that you are taking this on with Senator Cassidy. Both of you
    have a long tradition of working in a bipartisan way, and this
    issue is so crucial. It is exactly what we are going to need.
        Senator Thune is next.
        Senator Thune. Thank you, Mr. Chairman. And thank you, Dr.
    Murthy. And thanks to the chair and Senator Crapo for
    addressing this subject. This is a subject that is increasingly
    on the minds of administrators and teachers, parents, and
    students across the country. It is very real. When you talk to
    school administrators, there is this uptick. The statistics do
    not lie. Clearly these mental health issues are having a
    tremendous impact on young people, to the point that they are
    in many cases taking extreme measures. And we hate to see what
    is happening to our youth across America.
        I want to ask one question. This is a controversial subject
    and I know it, but we are in the 3rd year of the pandemic.
    Fatigue with public health measures has set in. We know a lot
    more about this than we did in 2020 in March, and yet
    communication is still confusing, and in some cases
    inconsistent. And I think it has undermined America's
    confidence in public health officials.
        Specifically, HHS has pushed a toddler mask mandate in Head
    Start programs in the U.S., including outside on the
    playground. Not even the WHO is recommending masking kids under
    five. And at the end of last year, President Biden said the
    pandemic response needs to be at the State level, yet the
    administration is taking decisions out of the hands of folks on
    the ground.
        There are a number of States that are announcing now that
    they are going to do away with mask mandates in their States.
        So I know this is--again, as I have said, it probably
    requires a lot more time than we have, but could you just tell
    me where the science is on this, on masks? And what should it
    be? Should it be a Federal Government thing, or should the
    States be able to make these decisions on their own?
        Dr. Murthy. Well, Senator, I appreciate that question. And
    I think you are exactly right to point out the fact that, year
    3 going into this pandemic, there are a lot of people who are
    frustrated, who are tired, who are exhausted. And I think we
    have to take that into account as we think about the next
    stages of the response.
        When it comes to masks, Senator, what we know, what we have
    learned in the last few years in particular, is that masks are
    a helpful tool to help reduce spread of the virus. When we look
    at schools in fact that have masking, there is less spread and
    there are in fact fewer school closures as a result of there
    being less spread of the infection.
        Now do parents in an ideal setting want their kids in
    masks? No parent would want a mask if it is not needed, but I
    think our goal should be to get to a place where we can pull
    back on these types of restrictions as quickly as possible, and
    as safely as possible. And in that process, there will be, I
    think, a very important role that States and localities play in
    tailoring the approach based on their individual community
    circumstances.
        I think increasingly, finally, as we look at this pandemic,
    we see that we have more tools now to help address the
    pandemic, to empower people to keep themselves safe, whether
    those are masks, or therapeutics, vaccines and boosters, and an
    increasing supply of tests. These are all tools now that we can
    use to live our lives more normally than we did 2 years ago.
        Senator Thune. I think it is just for parents, kids,
    everybody, very frustrating, and I hope that we can get to a
    point--and I agree. I mean, I think States need to be tasked
    and enabled and empowered to make a lot of those decisions.
        Changing gears quickly: telehealth. We have a couple of
    bills. I have one with Senator Menendez that would incentivize
    States to pursue certain health services initiatives under
    CHIP, providing greater flexibility to States that design
    initiatives to address behavioral health in schools. And we
    look forward to working with you on that.
        But a number of these solutions now include, within
    Medicaid and CHIP, telehealth. Do you think that has been a
    valuable thing? In my State, we have Avel School Health that
    provides access to a school nurse and behavioral health
    services remotely, where the workforce is not available. And we
    all talk about the need for more providers, which we do not
    have, but it seems to me at least telehealth can make a big
    difference there. Would you agree?
        Dr. Murthy. Absolutely, Senator. I think telehealth has to
    be part of our health-care delivery apparatus going forward. I
    think the pandemic has helped us see how powerful it can be in
    increasing access to care. I think it is particularly helpful
    for rural areas where people currently often have to drive many
    miles to see a mental health provider, if there even is one in
    their area.
        So I absolutely think we have to have them implemented.
    That means expanding access to broadband. It means ensuring
    that we reimburse adequately for those services, and that we
    have appropriate privacy measures in place for patients.
        Senator Thune. Thank you.
        Finally, the big tech companies' influence on young people
    today. We have seen all kinds of analyses and investigations
    and reporting on that. For example, The Wall Street Journal
    detailed how TikTok's algorithm serves up highly inappropriate
    videos to minors.
        I have a bill that addresses that. It would give consumers
    the option to engage with Internet platforms without being
    manipulated by opaque algorithms. And just a quick question. Do
    you agree that users should be able to use social media without
    being manipulated by algorithms that are designed to keep them
    engaged on the platform for hours on end?
        Dr. Murthy. Well, Senator, I do believe that people should
    be able to use social media without being manipulated, without
    having their data used in ways that they do not consent to. And
    I think all of us, particularly parents and children, deserve
    to have the data that technology companies have about the
    impacts of these technologies on our children.
        Currently there is a grand national experiment that is
    taking place upon our kids when it comes to social media, and
    we need to understand more about what is happening: which kids
    are at risk, what impact these algorithms and the broader
    platforms are having on our children. We need to understand so
    that parents can make informed decisions for their children.
        Senator Thune. A big part of this problem, and I think one
    of our challenges, Mr. Chairman, in addressing mental health
    issues is the influence of a lot of these algorithms that
    manipulate the content that people--and particularly young
    people--see online.
        Thank you.
        The Chairman. I think your point is important. Senator
    Booker and I introduced the Algorithmic Accountability Act,
    which really speaks to the proposition that, so often, people
    think algorithms are just purely computer science, nobody's
    biases and the like. I think we have come to learn that that is
    not always the case, that people bring their biases to the
    construction of these algorithms. I look forward to working
    with you on it.
        Senator Portman is next.
        Senator Portman. Thank you, Mr. Chairman. And, Dr. Murthy,
    I appreciate you being here and the work you have done on this
    topic of mental health, and behavioral health more broadly, for
    our kids.
        I looked at your recommendations for communities. One was
    that responding to mental health crises for young people should
    involve implementing evidence-based programs at the community
    level. And you cite what is called the Drug-Free Communities
    Act as an example of that.
        I am happy to see that, because I do believe that that is
    part of the answer here, to not just break down social
    isolation, but also deal with the drug issue and its
    interaction with mental health. We authored that legislation
    years ago, but I also started my own coalition back home that
    is still very active and that I am involved with.
        Can you elaborate on how drug use prevention intersects
    with mental health? And in particular, talk about how that
    investment in prevention might keep people from using or
    abusing drugs starting at a young age?
        Dr. Murthy. Well, Senator, first I thank you for your
    leadership on this issue. I know you have been a champion in
    addressing the addiction crisis in America, and we need that
    kind of leadership especially because, during this pandemic, we
    have seen overdose deaths increase to their highest levels.
        I am also glad that you raised the point about prevention.
    In 2016, when I published the Surgeon General's Report on
    Alcohol, Drugs, and Health, I had devoted an entire chapter to
    prevention programs, most of which were school- or community-
    based. And the powerful thing about those programs, Senator,
    was that they not only helped to reduce the likelihood that
    children would develop a substance use disorder down the line,
    but they also improved the mental health outcomes, improved
    graduation rates, and reduced teen pregnancies. They had a
    multiple benefit to the kids who participated in them.
        The other important point is that these were cost-effective
    programs, Senator. They saved somewhere between $2 to $11 for
    every $1 that was invested in them. I think we need more of
    these programs, not less. I think we need to provide not only
    more funding, but more technical assistance to schools and
    communities to implement these programs. I think prevention is
    always better than cure, and we have a lot more prevention that
    we can do.
        Senator Portman. Well, thank you for your work on that, and
    I look forward to continuing to work with you on the prevention
    side. You are absolutely right in terms of the efficiency of it
    and the cost. It is absolutely the best way to deal with the
    issue. We also do a lot of work, as you know, on the treatment
    and long-term recovery issues which are necessary. But
    prevention, I think, remains the most effective and has the
    most potential.
        On social isolation, you talked earlier about in-person
    learning. I am very big on getting our kids back to school
    because of the data that I have seen about what that does to a
    child not to have that interaction with their classmates and
    with their teachers.
        One of the things we have heard in Ohio is that people want
    to get their kids back to school, and schools in Ohio are for
    the most part responding to that. Eighty-seven percent of Ohio
    schools were open for 5-day in-person learning as of May 2021.
    Unfortunately, during Omicron that number decreased.
        But talk about testing. They have said that there is
    inadequate testing as a contributing factor that prevents in-
    person learning. CDC put forward this test-to-stay strategy
    which uses contact tracing and serial testing to allow kids to
    stay in school.
        Can you talk a little about that? With about 55 million
    kids enrolled in school in the country, that is a lot of tests,
    but I think it is absolutely essential to get them back to
    school. And can you speak to the effectiveness of this test-to-
    stay strategy and the scale of testing resources that would be
    needed to successfully implement that nationwide?
        Dr. Murthy. Well, thanks, Senator. I could not agree with
    you more that getting our kids back to school is essential. My
    children were not in school in 2020 during the pandemic. In the
    fall of 2021, they were able to go back to school. It has made
    a huge difference for them, and also for me and my wife, as
    parents.
        In order to keep our kids in school, I appreciate you
    pointing out the test-to-stay program. There are several things
    that can actually help our kids stay in school. One is basic
    prevention measures that can be used both to reduce the overall
    state of infections. Second, when kids are vaccinated per the
    CDC's quarantine rules, they also do not need to leave school
    if they are exposed. They can mask and then they can be tested.
    But third, even if children are not vaccinated, the test-to-
    stay program is a series of regular tests that allow them to
    stay.
        The administration is recognizing exactly what you said:
    that more tests are needed to implement that program for some
    schools, and they have doubled, in fact, the number of tests
    that they have made available to send to schools.
        We have also, more broadly for the country, increased the
    overall number of rapid tests that are available, with the
    President announcing about a month ago 1 billion tests that
    would be available to deliver directly to homes, as well as the
    additional tests that we were commissioning to be produced for
    the broader community.
        So, if there are schools or communities that are struggling
    and need access to tests, Senator, I would be happy to follow
    up with you afterwards and find out how to connect them to the
    right resources in the Federal Government so they can get the
    tests that they need.
        Senator Portman. We would love to follow up with you on
    that as it relates to Ohio, and thanks for your service.
        Dr. Murthy. Thank you, sir.
        The Chairman. Senator Cardin?
        Senator Cardin. Well, thank you, Mr. Chairman. Dr. Murthy,
    it is a pleasure to have you here. Thank you very much for your
    service to our country. We really appreciate that.
        I just really first want to concur in the comments that
    have been made by our chairman and ranking member in regards to
    mental health parity. We have had some great moments of moving
    forward, and yet there is still a lot more that we need to
    accomplish in regards to mental health parity.
        I appreciate the recommendations that are being made here,
    and I want to start with the recommendation to expand the use
    of telehealth for mental health challenges, addressing the
    regulatory barriers, ensuring appropriate payment, and
    expanding broadband access, all of which I agree with.
        But here, I think, is the challenge that we have. We
    worked, bipartisanly, to expand telehealth on this committee.
    We did it as a necessity during COVID-19, and now, as we are
    coming out of COVID-19, we would like to make permanent changes
    in our health-care system that permit the broader use of
    telehealth.
        It is particularly helpful for mental health, but other
    services as well. And one of the challenges is that when we go
    to do this, we are told that there will be an extra cost to the
    health-care system in using telehealth, which is
    counterintuitive. Telehealth is much more efficient for direct
    health-care costs, let alone the indirect costs to the patient
    who has to travel, and maybe get a hotel room, or whatever else
    is involved in an in-person visit.
        So how can you help us in the data we need to show that
    telehealth is not just more convenient, it is not just
    increasing access to people who would otherwise not get access,
    but it is also more cost-efficient to our health-care system?
        Dr. Murthy. Well, Senator, I think you raise a really
    important point, because we have to look at the costs globally,
    just as you said. I talk to providers all the time who tell me
    what is not working about our current health-care system. I
    think one of the most common examples, Senator, I hear is the
    doctor who says, ``I need to call my patients and ask them to
    come in to give them lab results, even though I could just tell
    them on the phone, because the system does not adequately allow
    me to have those kind of virtual care test appointments.''
        When something like that happens, a patient is taking time
    off from work to come in. The clinician is spending time in-
    person, with office staff supporting, et cetera. You have more
    time spent that does not need to be spent, time that could be
    saved. And time is money for individuals, for patients, as well
    as for the office staff.
        So I think, when you look at the cost globally, it makes
    sense that it is more efficient for us to use technology as an
    adjunct. To me, it would be not that different from saying that
    it is more efficient to be able to call a relative or a friend
    rather than go and visit them at their house every time you
    want to say ``hello'' or have a question.
        Technology can make things more efficient. I think what is
    critical though, as you mentioned, is that we have to use it
    appropriately. We have to ensure that practices are set up to
    use telemedicine appropriately. We have to reimburse for it
    adequately. We have to make sure that it has privacy measures
    in place.
        And from an equity perspective, we have to expand broadband
    access so that everybody has access.
        Senator Cardin. I totally agree with you; absolutely. But I
    also think we have to educate those who are doing the score-
    keeping here to explain that when you make our health care more
    efficient, it saves money. It does not add to the cost.
        I want to ask you one additional question--I have a little
    bit more time--and that is, the number one issue I hear from
    our health-care providers today is workforce, workforce,
    workforce. They just do not have enough individuals in any one
    of these capacities.
        Certainly, in mental health we do not have the adequate
    workforce that we need in order to provide the services. That
    has even been highlighted in a much more severe manner as a
    result of COVID-19. We have increased demands and less
    workforce that is available. But there is a chronic shortage in
    underserved communities because we do not have the diversity in
    the mental health providers that we desperately need.
        So, I would hope that you would be forceful in
    recommendations not just to increase the workforce in mental
    health, but to increase the opportunities so that we have a
    workforce that represents our community. In that regard, I
    would make a strong recommendation to engage the HBCUs, MSIs,
    and institutions that can reach out and offer opportunities to
    traditionally underserved communities.
        Dr. Murthy. Thank you, Senator. I could not agree with you
    more about the diversity of the workforce. I remember being in
    Maryland at Morgan State when I served the last time, talking
    about the workforce diversity issue that we have with dealing
    with the substance use disorder treatment. And there are
    similar disparities we are seeing, and gaps, when it comes to
    mental health-care treatment.
        I think there are a number of measures that we can take,
    from loan forgiveness to much more effective recruitment of
    racial and ethnic minorities into the workforce from early on
    in the education system. And this is critical. Because as you
    mentioned, this is going to help us provide better care to the
    communities across America if we have a more diverse workforce.
        Senator Cardin. Well, I look forward to working with you on
    that. I will be at Morgan on Friday, assuming we are not here.
    It is an incredible resource, not just for the students they
    educate, but for our community at large, in providing
    opportunities to underserved communities. And I think they can
    play a role, as other HBCUs can play a role, in helping us meet
    these needs.
        Thank you, Mr. Chairman.
        The Chairman. Thank you, Senator Cardin. I am sorry I had
    to be out of the room for a minute, but I just want everyone
    to----
        Senator Cardin. Do you want me to repeat everything I just
    said?
        The Chairman. Well, I am just going to take note of the
    fact that you have been advocating for these issues since your
    days in the Maryland legislature and the House Ways and Means
    Committee. We partnered often. And thank you for taking on some
    of the communications issues with Senator Thune. That is going
    to be really important.
        You might be interested, Dr. Murthy, that one of the
    responses we got with respect to the hearing on telehealth was
    the number of communities that are lacking broadband, worried
    that they are not going to get it any time soon. And they said,
    by the way--and I will be telling Senator Cardin and Senator
    Thune about this--if you have to, just get us audio-only until
    we get to the point where we have broadband. So we have a lot
    to do.
        Senator Lankford is here. Thank you, Senator.
        Senator Lankford. Thank you. Thanks very much. Thanks for
    being here, Dr. Murthy, and thanks for your service to the
    country.
        I have a ton of questions, and I will start trying to be
    able to run through some of them. Your report references
    children who lost a parent to COVID-19, which has been dramatic
    for us in Oklahoma, obviously. We have had a lot of children
    who have lost a parent, and bereavement is a very real issue in
    dealing with mental health issues for children.
        Somewhere around 15 to 20 percent--we are still getting the
    exact numbers in--of children who have lost a parent, lost a
    parent to COVID-19, which would mean 80 to 85 percent of the
    children who have lost a parent, lost their parent to something
    else than this.
        So my question is, for your report, just on the focus here
    of how we deal with bereavement in children. How do we keep
    this as a broader focus and not just make this a COVID-19 focus
    in particular? Because obviously, we are going to get through
    COVID-19 together on all this, but we are still going to have
    the other issues of cancer and suicide and so many other issues
    where children deal with bereavement. How do we keep that
    broader perspective?
        Dr. Murthy. Senator, I appreciate you broadening the lens
    there, because you are right. Many of our kids have been
    struggling with losing a caregiver before the pandemic, and
    this is going to be a charge for us post-pandemic.
        I think there are a few things that are important. Right
    now, as you know, there are Federal funds that are provided,
    often to support services for foster care and other services
    that kids may need when they lose a caregiver. And, while I
    think there is more that we can do legislatively, Senator, in
    terms of providing more support to those local institutions
    that provide the safety net for kids, I think this is a time
    also where, in addition to the government, we need communities
    to pull together around these kids.
        These kids are not just going to need help for a few months
    or for a year----
        Senator Lankford. It is a lifetime.
        Dr. Murthy. It is a lifetime. And the trauma also that goes
    into the loss of a caregiver is extraordinary. We are learning
    more and more, Senator, as you know, about adverse childhood
    experiences and the impact of that trauma in the long-term
    health of a child. Having trauma-informed care, ensuring our
    health-care providers are trained in how to address trauma
    early on in the provision of care, making sure schools have
    counselors who are also attuned to how to provide trauma-based
    care, is going to be essential in caring for----
        Senator Lankford. It is a big deal for us long-term.
    Neighborhoods, communities, extended family, churches, we've
    got to have a whole engagement within communities for this.
        But one of the things that we need to be able to look at as
    a committee--and be able to partner with HHS on--is how we
    actually fill the gap. I have learned that about 50 percent of
    the kids who have lost a parent are not getting their Social
    Security benefits based on that. And so we have to be able to
    find a way to be able to make sure that we are getting some of
    that support to them. And that is something that I would like
    to be able to partner together on.
        Your report also mentions dealing with marijuana use in
    children. We have seen substance abuse go down in several areas
    during COVID-19. The exception has been marijuana use. That has
    gone up. I am sure there are a lot of factors on that--
    obviously, the availability. Some of the different States have
    found ways to be able to make marijuana legal in their State.
    But for youth and adolescents, this has become a very serious
    issue.
        You have made some comments on this. I would be interested
    in you being able to drill down on the effects on youth of
    marijuana use and depression.
        Dr. Murthy. Yes, Senator. So, when it comes to youth, I
    worry that there is a perception that marijuana is completely
    harmless in children. Our data tells us otherwise. Our data
    tells us in fact that a portion, a substantial minority of
    people who use marijuana will actually develop an addiction to
    marijuana. And that number is significantly higher among youth.
        When kids also have underlying mental health conditions,
    the impact of marijuana use can also be more significant. And
    so I worry, Senator, about the messages that we may send that
    say this is utterly harmless and there is no problem here.
        I think we need to be responsible in how we teach our kids
    about marijuana. I think how we talk to families about
    marijuana use--and I think health-care providers also need to
    be empowered to have these conversations with youth early on,
    as well as teachers.
        Senator Lankford. Yes. We have to find a way to get that
    message out. That message is not getting out. Obviously, they
    are seeing role models and other individuals using marijuana,
    and there does not seem to be any voice that is out there
    talking about the real damage, in this area especially, and how
    to deal with depression and other issues.
        I have a challenging set of questions I want to be able to
    walk through as well, on dealing with another mental health
    issue and its long-term effects. And it deals with gender
    dysphoria, among children especially, and how we process this
    on the medical side--so puberty-blockers, cross-sex hormones,
    receiving surgical procedures to attempt to change the
    appearance from the biological sex among children.
        There have been some studies that have happened here, but
    there are also studies around the world that are raising new
    questions for adolescents in those areas, and saying you have
    got someone 12, 13, 14 years old who is taking some of these
    medications long-term that have serious effects. And when you
    are dealing with a 12- or 13-year-old, what is the standard for
    them actually when they are living with those consequences when
    they are 20, 30, 40? And is there responsibility to be able to
    put some warnings out and some precautions in this? How do we
    manage through that right now on a medical side?
        Dr. Murthy. Well, Senator, I appreciate you raising this. I
    mean, this is a very complex issue, as you know well, and I
    think what families need at a point like this is, they need
    clear guidance from the medical community.
        I think as the research has evolved, and as guidance has
    evolved on how best to take care of children in these
    circumstances, one of the things I worry about is that change
    propagates slowly in the medical profession. The time from when
    you make the discovery, for example, to when it is completely
    reflected in a clinical practice often takes years.
        We cannot afford that kind of time frame here. We have to
    do a better job putting our best minds together, in government
    and outside of government, in terms of medical expertise to
    figure out how best to care for these kids and make sure their
    caregivers and families have that information as well.
        We have more work to do there.
        Senator Lankford. Yes, we do. I do not want the politics
    today to get in the way of just sound medical advice. It is
    also important to make information available, and a lot of the
    unknowns that are there, or what is known in other countries
    that are now stepping up and saying we are learning more, and
    there are real problems that are here with infertility and
    other issues that are there with depression and other things
    with youth long-term that we cannot just ignore based on the
    politics of the conversation so that we lose the health issues.
    So we need you to give us good health information in that area.
        Dr. Murthy. Absolutely. And, Senator, I have always
    believed something I was taught in the first days of medical
    school, that science and compassion are what should guide care.
    Those two things, not politics, not opinions, not bias, but
    science and compassion. We have to bring the benefit of science
    to deliver that compassion to families during a time that can
    be very difficult.
        The Chairman. Thank you, Senator Lankford.
        Colleagues, what we are going to do is, we are going to
    keep this going. I know a number of colleagues just raced in,
    because the door opened so quickly it almost blew me out of the
    room with your enthusiasm, and I thank you for it.
        Let's go next to Senator Cassidy. We are just going to keep
    going. And just so we know, Senator Cassidy has been the
    lynchpin around here to doing something bipartisan in health.
    We got the bipartisan prescription drug bill out in the last
    Congress. It was Senator Cassidy bringing people together.
        Senator, go ahead.
        Senator Cassidy. Thank you for that, Mr. Wyden, and thank
    you, Dr. Murthy.
        Just for a second, you and I are going to be doctors once
    more in a kind of literature review session, okay? There is an
    article that just came out, ``A Literature Review and Meta-
    Analysis on the Effects of Lockdowns on COVID-19 Mortality:
    Studies in Applied Economics,'' coming out of Johns Hopkins, a
    prestigious institution, prestigious well-accomplished authors
    doing a meta-analysis of, I think, 16 different studies.
        In fairness, it is not peer-reviewed, but it is pretty
    good. Now, a couple of things. They spoke about
    nonpharmaceutical interventions. And one thing they say--they
    use it to describe any government mandate which directly
    restricts people's possibilities, not including information
    campaigns, mass testing, social distancing, but including
    closing schools or businesses, mandated face masks, et cetera.
    So it is pretty broad.
        Now they found no statistical correlation--in fact, let me
    read the second paragraph of their abstract: ``While this meta-
    analysis concludes that lockdowns have had little to no public
    health effects, they have imposed enormous economic and social
    costs where they have been adopted. In consequence, lockdown
    policies are ill-
    founded and should be rejected as a pandemic policy
    instrument.''
        Now we speak of science guiding what we do. Clearly, we
    have seen that children have suffered, both in terms of
    learning loss and the lack of a detection of their possible
    mental health issues, physical health issues, et cetera.
        I think I know that you have opposed school shutdowns. Is
    that a fair statement? And what do you think in general of what
    these economists out of Johns Hopkins suggest, that what the
    government has done, well-intentioned and without having facts,
    has, it turns out, worsened the situation, particularly for
    child mental health, as opposed to improving it.
        And by the way, Mr. Chairman, I would like to submit this
    for the record.
        The Chairman. Without objection.
        [The study appears in the appendix beginning on p. 47.]
        The Chairman. Also, I will put into the record at this
    time, in January of this year, 2022, 95 percent of public
    elementary and medical schools were open and engaged in in-
    person learning, compared to 46 percent of schools in January
    2021. So I just wanted to put that document into the record at
    this time as well.
        [The document appears in the appendix beginning on p. 177.]
        The Chairman. And then I believe Dr. Cassidy had a question
    for Dr. Murthy.
        Senator Cassidy. And you are going to extend my time?
        The Chairman. Yes, absolutely. And we are going to get to
    Senator Hassan and Senator Warren.
        Dr. Murthy. Senator Cassidy, thank you for that. And I
    always appreciate our opportunities to talk as doctors, and to
    think about medicine in a human way.
        I think we have learned a lot during this pandemic. And I
    think one of the things that we learned early on is that in
    2020, the first year of the pandemic, there were many blunt
    measures taken, like taking kids out of school, for example,
    being the clearest example. What I think we have realized is
    that, yes, those did have significant harms to our kids.
        My kids, my two kids, were among the millions of children
    who were not in school in 2020 as a result of the pandemic
    restrictions. Let me tell you, it was hard on my kids. It was
    hard on their family, on my wife and I too. But now that our
    kids are back in school, as of the fall of 2021--and 95-plus-
    percent of schools were open for in-person learning starting in
    the fall of 2021--that has had an enormous benefit to our kids.
    And I think our responsibility is to keep learning from the
    data, learning from these experiences, approach these types of
    public health emergencies with a scalpel rather than with a
    blunt instrument.
        Senator Cassidy. I agree with you. I have limited time, but
    let me just assert, should there be another variant which is
    more--maybe is as infectious but more virulent than Omicron--we
    need to learn from this and not claim it as an excuse to shut
    down, but to recognize that the best evidence is that the cost/
    benefit ratio is too costly for the marginal benefit.
        Is that a fair statement?
        Dr. Murthy. Yes. I think we should do everything possible
    to keep our schools open. Even with Omicron, Senator, even
    though it was more transmissible, we were advocating for
    schools to stay open and to use the safety measures----
        Senator Cassidy. So if there is a shortage of testing, as
    there is currently a shortage of testing, nonetheless would a
    school feel comfortable, would the best science suggest they
    should stay open even if they cannot test?
        Dr. Murthy. Well, so if a school does not have access to
    safety layers of precaution, whether that is tests, masks, you
    know, if they are worried about the ventilation, if they
    cannot--if they do not feel that it is safe----
        Senator Cassidy. Ah, but the nonpharmaceutical intervention
    did not find benefit from those measures. And you are hedging a
    little bit, Doctor.
        Dr. Murthy. Well, let me tell you, I am giving nuance here,
    because this is a nuanced thing. It is not black and white.
    Like to get kids back in school, you need teachers in school
    too. If teachers are worried about their health, if parents are
    worried about the health of their children, then you need to
    have a conversation with----
        Senator Cassidy. I accept that. But doesn't it seem wise
    that the Federal Government be consistent in their message to
    those teachers so that they are like a clear bell ringing and
    the single, single note is, you can safely go back to school,
    and the cost/benefit ratio favors being in? Because you
    certainly get mixed messages from the Federal Government, I
    will say that.
        Dr. Murthy. So, Senator, I would agree.
        Senator Cassidy. Can I jump ahead, because----
        Dr. Murthy. Yes, of course.
        Senator Cassidy. Because we actually--to change topics,
    Medicaid provides a heck of a lot of mental health services for
    people. The quality data we get from States, shall we say, is
    not sterling. It is awful.
        I am a gastroenterologist. You can imagine which term comes
    to mind. So my point being, that is something we have control
    over, which would be to demand that States comply with
    something that was originally in Obamacare--I think it was
    Obamacare, right? Comply with the emphasis in terms of getting
    good data on longitudinal outcomes for the children they have
    identified with mental illness receiving Medicaid reimbursement
    for either that or addiction services, and to see how that
    State is doing.
        Knowing that is beyond your purview in one sense, but is
    that a policy that you think would be wise?
        Dr. Murthy. Well, Senator, I do think the lack of data is a
    huge problem. It is like you are flying blind if you do not
    understand what is actually happening in your community. So I
    think any steps that we can take to ensure we have accurate and
    timely data will help us to better sharpen our policies.
        Senator Cassidy. And, Mr. Chair, just because it is to you
    I am speaking right now, of course, because you are the man
    with the gavel, I hear anecdotally around the country that
    psychiatric services for Medicaid patients are extremely poor.
    Both absence of providers, absence of good follow-up, et
    cetera. It may not be true, but we won't know it until we see
    the data. And whatever we can do collectively to demand that
    States actually put it forward, because we have given them
    resources, is something we should do.
        I am way over. Thank you.
        The Chairman. And, Senator, I just told the Finance staff
    this will be an area we will follow up with you on, because
    there is no question that a big part of our work is going to be
    this debate. My sense is that we will need more revenue at some
    point for some of our objectives. But the first thing you ought
    to do is do a better job of spending what is out there. And to
    do a better job of spending what is out there, you've got to
    have good data. We will follow up with you.
        Okay; Senator Hassan?
        Senator Hassan. Thank you, Mr. Chairman, and thanks to the
    ranking member for this hearing. And to the Surgeon General, it
    is really good to see you, and thanks for being here.
        I have heard repeatedly, Dr. Murthy, from the parents of
    children who are struggling with mental health issues who
    cannot access treatment. Even if the families have private
    insurance, their provider networks are inadequate, and the
    workforce cannot meet what is now a crushing need for pediatric
    mental health services.
        Parents recount calling every provider in the region and
    being told that there are waits of 4 to 6 weeks for remote
    sessions, and 3 to 4 weeks for inpatient programs.
        How do these long wait times affect children's mental
    health? And what can we do to ensure that children in need can
    find treatment?
        Dr. Murthy. Well, Senator, it is good to see you again as
    well. And thank you for that question.
        I have heard those stories time and time again myself over
    the years, and long wait times are troubling for multiple
    reasons. When a child is not able to see a provider in a timely
    way, that means more time that that child is struggling, not
    getting the help they need, and potentially at risk of harm to
    themselves.
        But the other consequence is to their families. For the
    parents of children who cannot get help--I will tell you this:
    as a parent myself, there is no feeling worse than knowing that
    you cannot get your child the help he or she needs. That is the
    worst feeling for a parent.
        And there are millions of parents who are going through
    that because they see their child suffering and they cannot get
    them assistance. So that is why we have to close that gap. That
    is as much about workforce as it is about using technology to
    provide adequate care, as it is about making sure reimbursement
    is adequate so that we can support a health system with enough
    access.
        Senator Hassan. Thank you.
        I also want to talk about what is going on in our schools a
    little bit here. Schools are our first responders to the youth
    mental health crisis, but they often lack sufficient personnel
    to help students manage mental health issues.
        One New Hampshire counselor shared her experience,
    explaining, quote, ``My students are frustrated and feel as
    though they are on the back burner of care. It is assumed that
    now that children are back in school, the issues that they
    faced when at home will go away, but they are getting worse. We
    have minimal supports in the schools,'' close quote.
        So look, we know--we just talked about it. We need to
    increase the number of mental health professionals generally,
    but we also need to really focus on increasing the number of
    mental health professionals in schools. But in the meantime, we
    have to ensure that teachers have the support that they need to
    address the crisis occurring in their classrooms today.
        How can we give educators the training, resources, and
    support that they need to continue helping our children during
    this mental health crisis?
        Dr. Murthy. That is such a good question. Senator, I have
    always felt that there are a lot of parallels between health-
    care workers and teachers. They are both in the business of
    healing. And unfortunately, right now they have both been on
    the front lines of COVID, and they are burning out in
    extraordinary numbers.
        I think supporting educators is going to be critical to
    supporting kids. And to do that we, number one, have to make
    sure that the workload on educators is reasonable. What I have
    seen, even in my children's school, is that the educators have
    had to become public health experts. They have to make
    difficult decisions about everything from whether they have
    good ventilation, how frequently to do tests, to how to help
    kids with their masks. This is on top of everything they were
    doing before.
        So, we need more support for educators. Part of the support
    that we need is more counselors and mental health professionals
    in our schools. Rather than expecting kids to go miles and
    miles away to where the care is, they ought to bring the care
    to kids.
        And finally, we have to provide mental health support
    services for the educators themselves. They are under an
    extraordinary amount of stress and trauma. They need support.
    And we have to bring that support to them as well.
        Senator Hassan. Right. And one of the things too, I think,
    is we have some models, when we are dealing for instance with
    substance use disorder, some pilot programs that really have
    worked to help teachers understand what their students are
    perhaps going through if there is substance misuse at home, or
    if an older student is experimenting with substances. So I
    think there are some parallels there too, just to give teachers
    some basic tools.
        Let me turn to a topic that I think is a growing concern. I
    hear about it from my constituents, but I also hear about it
    from providers, that the increased use of social media by young
    people has accelerated the youth mental health crisis.
        However, as highlighted in your advisory statement,
    independent researchers face barriers when they are trying to
    access data from media companies. As a result, the relationship
    between digital technologies and mental health is really poorly
    understood.
        So how can we support research to better understand the
    impact of social media on youth mental health?
        Dr. Murthy. Well, Senator, you are right to point this out.
    We have a real problem with transparency now. Social media
    companies and other technology companies have data about how
    these platforms are impacting our children, about which kids
    are at greater risk, and our independent researchers do not
    have access to this data.
        We need that data, to be sure, probably, but we also need
    safety standards. I think that is a very reasonable thing to
    consider here. We have safety standards for cars and for other
    consumer sort of goods. This is a tool, these platforms that
    millions and millions of children are using. We need to protect
    our kids, and that is where safety standards, I think, will be
    essential as well.
        There are researchers standing by at the ready who want to
    do the investigation, who want to look at the data, who want to
    help parents figure out how to protect their kids. They are
    handcuffed right now because they do not have access to that
    data.
        Senator Hassan. Okay. Thank you. I look forward to working
    with you on moving forward on that.
        Thank you, Mr. Chair.
        The Chairman. I thank my colleague.
        Senator Warner is next on the web.
        Senator Warner. Thank you, Mr. Chairman.
        Dr. Murthy, it is great to see you again, at least
    remotely. Let me pick up on where my colleague, Senator Hassan,
    left off about some of these online challenges. I think Senator
    Thune mentioned this as well.
        I would say to my colleagues, we have broadly bipartisan
    legislation called the DETOUR Act that would prohibit the use
    of dark patterns, not only for kids but also for adults, and
    the ability of these platforms to kind of lure you in, with no
    way to opt out.
        We have all seen, you know, click here and no other exit
    vehicle. Our legislation as well specifically prohibits
    companies from using some of these manipulative features for
    children under 13.
        I know, Dr. Murthy, you have already kind of addressed
    this, but this kind of legislation--I do not want to be hitting
    you cold; you may not have seen it--but the idea of trying to
    look at manipulative tools and dark patterns has got to be part
    of this effort going forward.
        Dr. Murthy. Senator, it is good to see you again,
    virtually, as well. And I do think that there are potentially
    harmful tools and algorithms like on some of these platforms
    which can lure young people further and further down harmful
    paths, and which can have adverse impacts on their mental
    health and well-being.
        We need to limit kids' exposure to harmful content. And the
    algorithms, I think, are an important part of that. So I do
    think that this requires investigation. I do think that this is
    an area where safety standards would be very helpful as well.
        Senator Warner. Well, I appreciate that. And again, I
    commend my colleagues, Senator Fischer and Senator Thune on the
    Republican side, who have joined with me and Senator Klobuchar
    on this DETOUR Act. And as we make some movement here, looking
    at these dark patterns, looking at this kind of manipulative
    behavior, at least for our kids, I would argue it ought to
    extend to adults as well.
        I turn again to the topic that I think Senator Lankford
    raised, one of the huge outgrowths of COVID-19, unfortunately,
    as we passed 900,000 deaths just recently from COVID. As of
    November 2021, there are 167,000 children who have lost a
    parent or a caregiver from COVID-19. And the truth is--there
    has been a group put together called The Hidden Pain, and I
    would again urge my colleagues to go after these kids who are
    going to have special needs because they have lost a parent or
    a cargiver, and obviously there are huge mental health
    implications.
        Dr. Murthy, do you want to comment on that specific issue
    around kids who have lost their parent or caregiver?
        Dr. Murthy. Senator, this is one of the most heartbreaking
    consequences of this pandemic. The trauma of losing a caregiver
    is hard to put into words. It is one of the greatest traumas a
    child can go through. And the consequences of that loss will be
    there not just for months, but for years.
        I think it is so important, not just as a government but as
    a society, that we are there for those kids, whatever may come.
    I know that there are Federal funds that are currently going
    towards supporting foster services and other services to
    support those youth that local and State governments may incur.
    But I think this goes beyond government as well, to our
    thinking about how we ensure that health-care providers and
    educators understand how to provide a trauma-informed approach
    to education and care. Because trauma is what these kids have
    gone through.
        I think it is also going to be essential that community
    organizations--from churches, to synagogues, to YMCAs, and
    others--are able to step up and support these children, as many
    of them are doing already. But we are going to need that in the
    years going forward, because they have experienced a tremendous
    loss.
        Senator Warner. I agree, and I think we need an organized
    structure to support those efforts at the local level.
        My last question I want to raise with you--and this is not
    something that just came around with COVID. It is frankly a
    challenge that has touched my family, and probably many of my
    colleagues indirectly with friends or neighbors, and that is
    the enormous upsurge in challenges around eating disorders. I
    have dealt with this for the last 12 to 14 years, on a family
    basis, and I have seen the enormous growth of treatment
    centers. I have seen the enormous growth of boys, not just
    girls, but boys dealing with eating disorders.
        Obviously, this problem could be exacerbated by COVID and
    is something I think we need to address, and I think a
    disproportionate number--my child is a type 1 diabetic, and
    having an eating disorder is huge.
        We have seen increased numbers in children of color, with
    LGBTQ kids. Can you, in your last 10 seconds or so, at least
    touch on that issue, which is something I think we all are
    going to have to continually visit?
        Dr. Murthy. Absolutely, Senator. This is a place where we
    not only need good care for kids struggling with eating
    disorders, but this is where actually school counselors and
    mental health professionals in schools become so important.
    Because you want to catch the signs early. You do not want to
    wait years, or until severe health consequences develop and
    come to the attention of a health-care professional.
        Finally, I will just say, this is a place also where it is
    so important for us to understand the impact of social media on
    our kids. We know that some children, when they have
    encountered content that has made them more conscious of their
    body image in an unhealthy way, that may contribute to eating
    disorders. Again, this is a place where the data matters,
    transparency matters, and we have to make sure the companies
    are providing that data so we best know how to protect our
    children.
        The Chairman. What Senator Warner is talking about is
    extraordinarily important, and I am only moving on because we
    are going to try and see if we can get Senator Menendez,
    Senator Brown, and Senator Cortez Masto in before the vote.
        Senator Warner. Thank you, Mr. Chairman.
        The Chairman. Actually, it goes Menendez, Brown, Bennet,
    and Cortez Masto. We are going to see what we can do to get
    these things held.
        Senator Menendez?
        Senator Menendez. Thank you, Mr. Chairman. Dr. Murthy,
    welcome.
        The Maternal, Infant, and Early Childhood Home Visiting
    program is an evidence-based program that supports pregnant
    women and young families. This multiyear support is critical to
    having young people start off their lives healthier and better
    prepared for early childhood learning. It also helps parents,
    including through mental health screenings and connecting to
    community-based resources.
        So my question is, how can we further support this program
    so that more young people are starting off on a strong footing,
    and young parents, including pregnant women and those parenting
    foster youth, have an additional means of support?
        Dr. Murthy. Well, Senator, I appreciate the question. And I
    do agree that these early intervention programs, especially for
    poorer families, are absolutely essential. We have more and
    more evidence that these kinds of programs make a big
    difference, not just in the immediate setting, but for years
    down the line. And anything that I can do to work with you to
    support these kinds of efforts, I would be happy to do.
        I find that one of the challenges, Senator, is that even
    when the programs are funded, many communities know about them
    and they do not avail themselves of the funds, or they do not
    know what technical assistance is available to them to actually
    implement those programs. But these are incredibly important
    programs that help to reduce the risk of mental health
    challenges.
        Senator Menendez. Well, I welcome your support in the
    effort. And today the program is very successful and evidence-
    based, and so we need to have advocates within the
    administration to expand its opportunities.
        I want to take advantage of my colleague Senator Cortez
    Masto being here. I introduced the Pursuing Equity in Mental
    Health Act, along with Senator Cortez Masto and Senator Booker,
    because communities of color continue to disproportionately
    lack--or suffer, I should say, from the lack of access to
    mental health services and supports.
        Do you support the need for targeted investments into
    minority communities that support access to culturally
    competent care?
        Dr. Murthy. Senator, thank you for raising that. Mental
    health equity is and continues to be a profound challenge for
    our country. I do think we need to take a targeted approach
    here, in the sense of surging resources to communities that
    have been hard-hit.
        The challenge that many of our communities of color have
    had is, number one, from a workforce perspective, we do not
    have adequate representation of racial and ethnic minorities in
    our workforce. And that makes it more challenging when it comes
    to trust, which is such an important component of getting good
    mental health care. But we also know that access has been a
    profound challenge for many of these communities. And we have
    to make sure that we are doing more than we are now to make
    sure that both virtual care and in-person care are available.
        Finally, Senator, as a member of a racial and ethnic
    minority community, I will tell you that many of our
    communities struggle with the stigma around mental illness. It
    may come in different shapes and flavors, but that stigma is
    there in many of our communities and prevents us from coming
    forward, which is, again, why role models are so incredibly
    helpful.
        Senator Menendez. I strongly agree. I want to highlight
    that the pandemic's impact on children in minority communities
    has been particularly harsh.
        I want to take a look at the impact on Latino communities
    in particular for a few moments. One survey found that 29
    percent of Hispanic households with children have experienced
    three or more hardships during the pandemic, compared to around
    half of that for non-Hispanic White households with children.
    At the same time, Latino children were far more likely to
    experience the death of a primary caregiver during the
    pandemic, and more likely to contract the virus and be
    hospitalized themselves. These experiences were compounded by
    other preexisting disparities among Latino children, including
    higher uninsured rates, and lower access to mental health
    services and supports.
        So I look forward to working with you as to specific
    policies necessary to help advance mental health equity and
    begin to close some of the racial disparities that preceded and
    have been exacerbated by COVID-19. And can I get your
    commitment to work with us on that?
        Dr. Murthy. Senator, I would be happy to work with you on
    this issue.
        Senator Menendez. And then finally, you talked about
    representation. You know, the Minority Fellowship Program, I
    think is a critical component of this legislation. What else
    can we do to support the development of minority mental health
    providers in the pipeline?
        Dr. Murthy. Well, Senator, I think we can work with
    training institutions to be more proactive and aggressive in
    their recruitment of candidates from minority communities. I
    also think we have to invest upstream, even before we are
    talking about admission to a medical school or a nursing
    school. How are we getting young people in minority communities
    interested in the health-care profession at an early age when
    they are in grade school, when they are in college?
        These are places where I think we have to focus and plant
    that seed early, and then make sure opportunity is available
    when they get to the stage of entering a training program.
        Senator Menendez. Thank you. I look forward to working with
    you on all these different aspects.
        Thank you, Mr. Chairman.
        The Chairman. I look forward to working with my colleague.
        Senator Brown, I think, is next on the web.
        Senator Brown. Thank you, Mr. Chairman. Dr. Murthy, it is
    good to see you again remotely, and thanks for your exemplary
    public service for so many years.
        The advisory that you issued last year cites research about
    the suicide rate among Black children below age 13 and how it
    has been increasing in recent years. Black children have almost
    twice the far-too-high rate of suicide by White children. I did
    a roundtable discussion in Columbus with Ohioans not too long
    ago, several months ago. Dr. Arielle Sheftall, a principal
    investigator at Jones Hospital in Columbus, shared her research
    on the increase in Black youth suicides. Dr. Sheftall made the
    point that despite the fact that Black youth suicide and
    suicidal behaviors have been increasing over the last decade,
    our understanding of the risks and protective factors
    associated with these behaviors in Black youth is extremely
    limited. She argues we need more research on risk factors to
    implement more effective suicide prevention.
        How should research and policy come together to decrease
    the likelihood of youth suicide, especially in African American
    kids?
        Dr. Murthy. Well, Senator, it is good to see you again as
    well. And thank you for that question, and for particularly,
    attention to what is happening in racial and ethnic minority
    communities.
        It has been very disturbing to see the increase in mental
    health challenges, particularly suicide, in communities of
    color when it comes to young people. And yes, I do agree that
    there is more that we need to do to understand what factors are
    driving this, whether it is violence in communities, or some
    element of technology, or other elements that exist in the
    environment in which our kids are being raised.
        But I also think we cannot wait to act when it comes to
    making sure that these communities have help. One of the things
    I think about often--as a doctor who cared for patients over
    the years and saw so many who were not able to make
    appointments, and could not get their routine care--is we have
    to get care to kids where they are. Which means that if kids
    are in schools, as the majority of them are, we've got to get
    care to school environments.
        We have to provide counselors, mental health therapists,
    and others who can help identify and start to address problems.
    We have to use technology more effectively to get access to
    care to those children and their families.
        So yes, I agree we have more questions that we need to
    answer about risk factors. I also think we know a lot that we
    can act on right now to improve access to care.
        Senator Brown. Thank you.
        You brought up schools, and I wanted to ask--I planned to
    ask about full-service community schools that I have worked on.
    My eyes were opened--I know Senator Casey mentioned this too,
    and I think he is going to be one of the next questioners. It
    was brought to my attention several years ago in Cincinnati at
    a community school's building they have in their community
    school where they have done all kinds of interesting things.
    But our bill would help to connect schools with community
    partners to provide the integrated student support I think you
    are suggesting--physical health services, and obviously mental
    health services--not just to students but to community members
    there.
        We have seen how integrating education and health care can
    benefit students and communities, whether it is Medicaid-
    supported school-based mental health and behavioral health
    services through full-service community schools, or in the form
    of school-based health centers. How should CMS work with the
    Department of Education to provide guidance and best practices
    for States on how to better integrate mental health services
    into our public schools using Medicaid supports and building on
    the full-service community schools model? What is the path to
    do that right?
        Dr. Murthy. Well, Senator, thanks for that question. I love
    the model you are talking about, because it immediately comes
    to my mind that what you are speaking of is wrapping our
    children in supportive and protective services, including
    services and supports in the community. And I think that is
    exactly what we need, because schools cannot do this alone.
    They cannot do it by themselves. Educators are already tasked
    at a very high level.
        I know that this is certainly an area that CMS has been
    interested in when it comes specifically to Medicaid and how
    Medicaid can be used to better support mental health services
    in schools.
        I think the challenge that we have--despite some of the
    measures that CMS has supported to use Medicaid funding to
    support services in schools--is that we still, in some cases,
    need States to amend their Medicaid program to free up the use
    of Medicaid funds for those breadth of services in schools, and
    to apply those services to all kids, not just kids in IEPs.
        The other piece of this is that many States may need
    technical assistance in figuring out how to set up the types of
    school-based mental health-care initiatives that require
    thinking through billing, thinking through other logistics. And
    I think those too have been barriers to the States implementing
    this. But I know that CMS has certainly been supportive of the
    use of Medicaid funding to support mental health services in
    schools.
        Senator Brown. Thank you.
        Mr. Chairman, thank you very much.
        The Chairman. I thank my colleague.
        Are any of my colleagues still out there? Senator Bennet,
    have you spoken?
        Senator Bennet. No, sir.
        The Chairman. Senator Bennet.
        Senator Bennet. Thank you, Mr. Chairman. And I am out here,
    that is for sure. You need a telescope to see the chairman.
    But----
        Dr. Murthy. I can see you pretty well.
        Senator Bennet. Thank you, Dr. Murthy. That is why I came
    over here. But, Mr. Chairman and Ranking Member Crapo, I really
    appreciate you holding this hearing on youth mental health. I
    think it is incredibly timely, because our children and their
    parents and our schools are looking for ways to support
    themselves and to avoid a worse crisis, actually, that might
    unfold. And it is really important for us to support them.
        And, Dr. Murthy, it is wonderful to see you, and thank you
    for being here today and for your focus on this issue. I
    enjoyed spending time with you last month discussing the
    advisory, and I am grateful for your experience and your
    commitment to address youth mental and behavioral health. I am
    very pleased that the Surgeon General comes to this as a
    parent, because I think that is the perspective that is needed
    right now, maybe more than anything else.
        I also want to take this opportunity to say that I think we
    need to do our best--whatever we can to try to keep schools
    open for our kids' sake, and for their mental health. I was a
    Superintendent of the Denver Public Schools before I came here.
    I have a sense of the toll this has taken on our kids, and the
    interrupted schooling that especially our kids living in
    poverty have confronted as a result of the pandemic.
        So I hope, for their sake, that we are able to come
    together to support them in their schools and keep them open.
    You might remember, Dr. Murthy, that I said to you when we
    talked before that if somebody asked me before the pandemic
    what the biggest difference was between when I was a
    Superintendent and today when it comes to schools, before the
    pandemic my answer was mental health, mental health, mental
    health. And that is more true now because of the pandemic.
        So, with that preface, Dr. Murthy, I have two questions I
    would like to ask you. A few weeks ago, I spent time with some
    leaders from Summit County in Colorado to listen to them
    discuss local mental and behavioral health needs and potential
    solutions. One striking theme was the pitiful reimbursement
    rates for mental and behavioral services, plus wraparound
    services and casework, from both public and private insurance.
    One organization, called Building Hope, which provides
    scholarships to receive care, said that over 50 percent of
    their clients have private health insurance.
        The Sheriff of the county was also on, and he mentioned
    that establishing a mobile crisis unit, which pairs a clinician
    and a nonuniformed deputy to respond to crises, cost $1.5
    million for the community but saved the county $17 million.
    There was not a person on this call who disputed this. I am
    particularly grateful to Senator Cortez Masto, who has led on
    the issue of mobile crisis reimbursement on this committee. And
    what I heard in Summit County demonstrates that reimbursement
    reform should be a cornerstone to our mental and behavioral
    health work here in the Finance Committee.
        So, Dr. Murthy, could you speak to the importance of higher
    reimbursement in private insurance, and also in Medicaid and
    Medicare?
        Dr. Murthy. Well, thank you, Senator, for that. I always--
    when we chatted, I certainly appreciated your perspective as an
    educator yourself when it comes to our kids.
        But look, I think, as you know, we have profound issues
    with mental health-care access, and I think reimbursement is
    one piece of that puzzle. I think for too long we have had low
    and inconsistent reimbursement for mental health-care services.
        I think we have also not seen sort of the kind of
    implementation of the parity law that we need. And so, we still
    have private insurers that are providing less reimbursement for
    mental health versus for traditional medical services. So I
    think this is an important part of the pie. If we are going to
    train more and more providers of mental health care, we have to
    make sure that the systems and supports are there for them to
    be able to sustainably provide care, and a reimbursement is an
    important part of that.
        Senator Bennet. I have one other question that is actually
    related. I want to speak specifically about schools and
    Medicaid.
        In 2014, CMS reversed the free care policy, which now
    allows States more flexibilities in school-based Medicaid
    programs. Now Medicaid can bill for health services delivered
    in schools to all
    Medicaid-enrolled children, not just those with a special
    education plan.
        Colorado is one of the handful of States that received
    approval of their State plan amendment, which went into effect
    in October 2020. Now Colorado recognizes applied behavior
    analysts, speech, language, pathologist assistants, and school
    psychologists as Medicaid providers. And while there remain
    workforce challenges, Colorado schools are going to have the
    financing infrastructure necessary to support students where
    they spend most of their days.
        Dr. Murthy, do you think that CMS can work more proactively
    to help encourage Medicaid reimbursement in schools? Can CMS
    provide guidance on how to expand those services? What can you
    do to work with leaders at HHS, the Department of Education,
    the White House, and our school districts throughout the
    country, to make some progress on this matter?
        Dr. Murthy. Well, Senator, thanks for raising that. I would
    be certainly happy to work with my colleagues at CMS on this
    issue. I do think that the free care policy reversal to allow
    for all students, not just students on IEPs, to be able to
    benefit from
    Medicaid-funded mental health care in schools is very
    important.
        One of my worries is that there has not been enough uptake
    in States, I think partly because of the State amendments that
    have to be passed to do this, and partly, I think technical
    assistance is needed in more States to set up the billing and
    other procedures to make this a reality.
        But I think it is very powerful, and it is consistent with
    the principle we talked about early on, which is, we have to
    bring care to where our kids are. We cannot expect them to
    drive many, many miles with their families to see providers. We
    have to make it easier for them to get care. This is one way to
    do that.
        Senator Bennet. I know--I do not want to impose on my
    colleagues. Thank you, Dr. Murthy. Let me just associate myself
    also with comments that were made about the effect of social
    media on our kids in this country. And there is literally
    nothing preventing the social media companies, for the benefit
    of our society, from sharing data about the effect of social
    media and the algorithms that they have, with families and with
    parents in this country, and I hope they will consider it.
        Senator Crapo [presiding]. Thank you very much, Senator.
    And before we go to Senator Cortez Masto, who will be next, I
    have been informed that Dr. Murthy has a hard stop at 12:30.
    And the only way we are going to do that is if everybody sticks
    very strictly to your 5 minutes.
        Senator Cortez Masto?
        Senator Cortez Masto. Thank you. Dr. Murthy, thank you so
    much for being here. I want to thank the committee for holding
    this. I want to associate my position with some of the comments
    made by my colleagues around the telehealth, how important it
    is, and with Senator Bennet's comments earlier.
        Let me just say this. I think it is so important in this
    day and age that there is mental health parity with physical
    health. There is too much of a stigma around mental health, but
    nobody has a stigma about their physical health and getting the
    health care they need. And there are resources. There are
    sources for funding. There is some professional care that is
    there. But we do not have that for mental health.
        And so, Dr. Murthy, I want to talk to you about this,
    because I see it in my State of Nevada. We knew we were having
    mental health challenges even before the pandemic, particularly
    for our kids and young adults. The pandemic has exacerbated
    that, and we have to do more to provide essential services to
    them--the continuum of care, of services, the funding sources
    to get those services accessed, and then to build up
    professional capacity that is needed to provide those services.
        But let me ask you this. I so appreciate you putting out
    your Surgeon General's advisory. I think it is--thank you so
    much. It is a great educational piece for so many communities
    to really tackle. But here is my question for you: how do you
    plan to get the word out? How do you plan on getting the
    advisory out in the hands of the people who need it so that we
    can start incorporating some of the recommendations that are in
    it?
        Dr. Murthy. Well, Senator, it is good to see you again, and
    I am glad that you asked that question, because one of the
    things that I decided early on when I was Surgeon General,
    during my first tour of duty, was that we cannot just produce
    reports that sit on a shelf. We have to make sure that they are
    brought to life. And the people who bring them to life are
    community members who take the information, take the tools, and
    then create change in their communities; legislators as well.
        There are several approaches we are taking. We have been
    working already, with the launch of our advisory, with
    community partners, with parent groups, with other community
    organizations, faith organizations, and others to make sure--
    and educators are a key part of this as well--that people know
    about this advisory, they know about what the recommendations
    are in this advisory, and that we can help support them,
    whether that is connecting them to resources in the Federal
    Government, or whether it is connecting them to other community
    resources. But that is what we are trying to do.
        I am also aware, and I say this with humility, that none of
    us can do this job alone. And I know, as much as our office is
    going to try to do, we need the help of legislators like you
    and others to help get the word out, to help people recognize
    that, you know what, these recommendations can be acted upon.
    There are laws that can be passed to strengthen access to care.
    There are measures that communities can take to make sure that
    kids are supported who need it. There are things educators can
    do to make sure that we are including a greater focus on
    behavioral health and emotional learning in schools.
        So we are going to keep working at this, Senator, because
    the job is not done when the report comes out. We have a long
    way to go.
        Senator Cortez Masto. I cannot agree more. So let me add
    another area of coordination that is important.
        In your testimony, you urge coordination across all levels
    of government. And I strongly agree with that. I think there is
    a partnership at the Federal level that needs to occur. Too
    often there are silos, particularly in this space, and that is
    why I sent a letter to both the Secretaries of Education and
    HHS. This is such an important issue.
        So, can you talk a little bit about that? And I hope that
    that coordination that you just talked about in getting your
    advisory out there, includes the coordination with our Federal
    agencies.
        Dr. Murthy. Absolutely. And this is so important. You know,
    Secretary Becerra from HHS has asked for the Behavioral Health
    Coordinating Council to be formed. It has now formed and is
    bringing together parts of the Federal Government to work on a
    unified approach to behavioral health.
        You know, I will say that I myself personally have worked
    with and have been working with Secretary Cardona from the
    Department of Education. We have a shared passion and interest
    in mental health. The Department of Ed, as you know, has put
    out resources for students and for schools to focus on social
    and emotional well-being in our mental health, and that is a
    partnership that we are going to continue as well.
        But you are absolutely right. This has to be a
    collaborative effort. We cannot afford to be splintered and
    uncoordinated.
        Senator Cortez Masto. And then very quickly, I have seen
    the benefit of and the value of peer support services. Can you
    talk about the importance of peer support services?
        Dr. Murthy. These are really vital. You know, one of the
    programs that I came to learn about some years ago is the
    Beyond Differences program. It is not a government program. It
    is a program that was started by two parents who lost their
    child, and they were devastated by the struggles she had with
    loneliness, and with her own mental health. And this is
    essentially a peer program, a peer support program, where young
    people help other young people to build community and
    connection, and to build their self-esteem.
        When we think about the health-care workforce, I actually
    think we have to think broadly. This includes psychiatrists and
    psychologists and school counselors, but it also involves
    people who can be sources of support: educators, peer support
    programs. Everyone has a role they can play in helping to
    support the mental health and well-being of others, and this is
    where we also, I think, have to empower families to also see
    this.
        When they even begin conversations with their children on
    mental health and well-being, that is also a very important
    part of the puzzle. That tells kids that it is okay to talk
    about these subjects and to ask for help.
        Senator Cortez Masto. Thank you, Doctor.
        Senator Crapo. Thank you.
        Senator Warren?
        Senator Warren. Thank you, Mr. Chairman. So we are here
    today to discuss the recent advisory that the U.S. Surgeon
    General has issued on protecting the mental health of young
    people. And there are a lot of important recommendations in
    this report, such as how to treat mental health as an essential
    part of overall health. But I want to talk for just a few
    minutes about a recommendation for improving children's mental
    health that is powerfully necessary but often goes under-
    appreciated, and that is, access to quality child care. The
    child-care system in America is broken. It is hard to find. It
    is massively expensive. It is totally out of reach for most
    families. And wages for child-care workers are way too low.
        And then the pandemic hit, forcing thousands of child-care
    providers to close their doors, raising costs for the rest.
    Parents, women in particular, have borne the brunt of these
    policy failures.
        Dr. Murthy, helping families afford quality child care is
    important for a lot of reasons, like improving children's
    overall outcomes, and letting parents go to work, but you say
    in your report that it goes beyond that. So, can you just
    explain, why did your advisory recommendations include
    increasing access to affordable child care as a way to improve
    children's mental health?
        Dr. Murthy. Well, Senator, I thank you for that question. I
    appreciate it. And you're lifting up something that I
    absolutely agree needs more attention. Here is why we included
    that recommendation. I know this as a parent myself that child
    care is one of the greatest sources of stress for a parent when
    it is not adequately available. And when a parent is struggling
    with the high degree of stress and anxiety, that impacts
    children. We all know that. And we see that happening every
    day. That is one of the key reasons why affordable child care
    is essential.
        Senator Warren. So, when parents are struggling to find
    child care, the financial and the emotional stress directly
    harms children. But let's say a family somehow manages to find
    decent child care. They scrape together the money to be able to
    pay for it. And while that fee is a lot for the family, it is
    barely enough for the child-care provider to make ends meet. So
    the provider is struggling to provide enough staff and cannot
    pay the workers as much as they would make if they were working
    the checkout line at McDonald's.
        Dr. Murthy, your advisory also talked about the importance
    of investing in the child-care workforce. What impact does it
    have on children when child-care workers looking after them are
    under-staffed and underpaid?
        Dr. Murthy. Well, Senator, children do best when the people
    caring for them are also doing well. And when you are not being
    paid a living wage, when you are unable to do the basic things
    you need to support you and your family, that is
    extraordinarily stressful. That is anxiety-provoking. That is
    difficult, and it is harder, I think, for caregivers to do the
    job they want to do--which is to provide good quality care to
    their children--when they do not have an income that can
    support them and their families. So we have to take care of the
    people who are taking care of us and our children. That is what
    this is about.
        Senator Warren. Yep. You know, we rely on child-care
    workers to take care of our babies, to help them grow while
    their mommies and daddies are at work, and yet child-care
    workers on average are only making about $12 an hour.
        We need to invest in child care so that we can hire people,
    so we can retain them, make decent pay and benefits, and build
    expertise over time and improve the care that they give to our
    children. And right now, we have our toes on the line to get
    that done.
        A transformative investment in child care and pre-
    kindergarten is in Build Back Better, which would cut the cost
    of child care for families and raise wages for providers.
        So, Dr. Murthy, in our remaining time, this is the last
    question I am going to ask you. What kind of payoff will this
    investment in child care yield for children, for parents, and
    for child-care providers?
        Dr. Murthy. Senator, I do not know that I can count that
    high, because----
        Senator Warren. That is a great answer.
        Dr. Murthy [continuing]. It is a big payoff. I will say
    that I cannot think of a more important responsibility than
    caring for our children. And it makes sense that we invest in
    that area. But when we take care of kids early in life, they
    become young adults and older adults who also have a greater
    shot at good mental health and physical health.
        If we have learned one lesson from this pandemic, it is
    that early investments in health and well-being are important,
    and child care is an important part of that.
        Senator Warren. And these investments cannot wait. We need
    to get this done. Thank you, Dr. Murthy.
        Dr. Murthy. Thank you, Senator Warren.
        Senator Crapo. Senator Daines?
        Senator Daines. Thank you, Senator Crapo.
        Cindy and I are parents of four children. We have three
    grandchildren. And supporting the mental health needs of our
    children is a major concern of mine, especially at this time in
    our Nation's history.
        The COVID-19 pandemic has certainly challenged our children
    in so many ways, and oftentimes profoundly upended how they
    attend school. It has changed how they interact with their
    friends. It has had a profound effect on mental health. From
    universal masking to stay-at-home orders, we are seeing how
    these Draconian policies are affecting our children. After 2
    years of virtual learning and forced physical distancing, many
    schools across the country still have not returned to normal,
    and children are falling behind.
        More children and teenagers are struggling with mental
    health issues, and suicide attempts are on the rise. There is a
    wise old proverb that says, ``A parent is only as happy as
    their unhappiest child.'' That is so true. You can have four
    children, three are doing well, but the one who is struggling
    is right where we parents are emotionally and what consumes how
    we think about our kids.
        The New York Times published an article in the beginning of
    January, and I think the title said, ``No Way to Grow Up.'' It
    highlights how many pandemic policies have failed our children.
    I think that title really does sum it up: no way to grow up.
        What I am hearing is that lockdowns and closures have been
    questionable public health measures, and at the end of the day
    have been harmful to our children. When I talk to people across
    Montana, I hear stories about the mental health struggles that
    come from lockdowns, from isolation. According to one study,
    lockdowns have reduced schooling, increased unemployment,
    reduced economic activity, and contributed to political unrest
    and domestic violence.
        Dr. Murthy, do you agree that lockdowns and social
    isolation have helped contribute to some of the mental health
    challenges we are seeing today?
        Dr. Murthy. Senator, I appreciate that question from a
    fellow parent, and a grandparent, as I understand it. Look, I
    have spent years focused on the issue of isolation and
    loneliness. It has harmful effects on the mental and physical
    well-being of our children. And the severe disruption that we
    saw at the beginning of the pandemic, particularly with school
    closures, but with the uncertainty that kids had about their
    future with 160,000-plus children who have lost a caregiver,
    with kids seeing their friends and family members who have been
    impacted by this pandemic, that has taken a huge toll on our
    children.
        What we have an obligation to do is to use the power of our
    science, our knowledge, our experience to tackle this pandemic
    with a scalpel instead of a blunt axe, to put in place measures
    that can help protect people but recognize that the cost of
    major disruptions to our kids' lives is significant. And that
    is why we have to use layers of precaution that could allow
    them to stay in school. That is why I am glad that 95 percent
    of schools are now open for in-
    person learning; that 95-plus were open in the fall of 2021.
    Those included my kids, who were finally able to go back to
    school, and I was grateful for it.
        Senator Daines. Thank you for that thoughtful answer,
    Doctor. Last year the Biden administration issued a rule to
    require universal masking for toddlers attending Head Start.
    This heavy-handed mandate targeted Montana's most disadvantaged
    children, which is why I urged HHS to actually rescind that.
        I am also concerned how this kind of pandemic policy will
    impact a child's development. A study from Brown University
    found that face masks and other social-distancing measures in
    school or day care may be associated with delayed language
    development among children. Additionally, referrals of children
    to speech therapy have been on the rise since the pandemic
    began.
        Dr. Murthy, how do we undo the damage caused by pandemic
    policies to address the health challenges facing our children?
        Dr. Murthy. Well, Senator, I share your concern about the
    well-being of our kids, and I think getting back as close as
    possible to a sense of normalcy is going to be important for
    our children. They need to be able to play with their friends.
    They need to be able to see the people they love. They need to
    be able to be in school and learn in school.
        And part of how I think we do that is recognizing, number
    one, we have more tools to do that than ever before. We now,
    thank goodness, have medications and vaccines and boosters that
    can reduce the likelihood that people will lose their life or
    end up in the hospital, and that includes our children.
        We now have more tests and other mitigation measures--
    ventilation, masks, et cetera--that we know can be used in
    targeted ways to reduce spread. As cases come down, Senator, as
    our hospitals begin to see their caseloads drop, I think we
    will be in a place where we can consider pulling back on some
    of the measures that exist now, in terms of mitigation.
        And so, I am hopeful that we will get there. But we have
    already made a lot of progress compared to last year. A year
    ago today, less than half of our schools were open. Less than
    half of our kids were learning in-person. Now that number is at
    over 95 percent. We need to get it as close to 100 percent----
        Senator Daines. And that is progress, but I am concerned
    that, as we look at the health care we have faced with the
    pandemic, we have not been looking at the big picture.
        The Chairman. And I will just say to my friend, these are
    important issues. We still have Senator Casey, and we will
    follow up with our colleague. I thank my colleague for being
    willing to be part of the task force as well, which is very
    important.
        Senator Casey is next.
        Senator Casey. Mr. Chairman, thank you very much. And, Dr.
    Murthy, we are grateful to be with you again and to commend
    your exemplary public service at this difficult time for the
    Nation.
        I just probably will get one question in, because I know
    you have to go. I wanted to start with something that I
    proposed in early 2020, just weeks before the pandemic. I call
    it the five freedoms for America's children: the freedom to be
    healthy, the freedom to be economically secure, the freedom to
    learn, the freedom to be safe from harm, and the freedom from
    hunger.
        And then I put that into a piece of legislation that we
    introduced not too long ago. But I was thinking about those
    five freedoms for America's children when I was considering the
    advisory, and that children's mental health does not exist in a
    vacuum. It is largely impacted by their families, their
    communities, and their societal circumstances. We know that
    poor socioeconomic conditions can create unhealthy stress, both
    for a child and their parents, and can lead to adverse
    childhood experiences that are known to put children at risk
    for harms later in their childhood, or much later in life.
        You said on page 4 of your testimony, quote, ``Systemic
    economic and social barriers like safety, housing, food, and
    economic insecurity, contribute to and create the conditions
    for poor mental health for young children.''
        I wanted to ask you, just in terms of proposals going
    forward, as we discuss a broader, more holistic response to
    youth mental health aides, what broader policies to improve the
    well-being of children and families should we consider?
        Dr. Murthy. Well, Senator, thank you for that thoughtful
    question. I like how you framed these five freedoms for
    American children. It reflects, I think, a really powerful
    reality, which is that there are many factors that impact the
    mental health of our kids. And food insecurity is one of them;
    economic insecurity, homelessness. These are all important
    issues we have to address. Because I think, for a child to be
    well, they need to have secure attachments, good strong
    relationships in their life. They need to have safety. They
    also need to know that the future has a place for them. They
    need to know that they belong. They need to know that the
    future is bright.
        And many children look around them and they see the
    violence in their communities. They see the threat of climate
    change. They see the specter of racism and discrimination. And
    they wonder whether that is really true, whether the future
    truly is brighter for them, whether there really is a place for
    them.
        I think it is our obligation to address these issues, to
    create a healthier, more hospitable society and home for our
    children. We know these broader existential threats, in
    addition to the more immediate economic threats that families
    face, are really influential when it comes to the mental health
    of our children.
        So I think this is so much bigger than making sure our
    children have access to care--and they need that. This is more
    than ensuring we are investing in prevention programs in
    schools. It is about recognizing that the broader environment
    in which our kids are growing up has a profound impact on their
    mental health, their relationships, their economic security,
    and their safety as well. Our ability to address these broader
    challenges like racism, climate change, and violence, this is
    what will help our children have a foundation for good mental
    health going forward.
        Senator Casey. Well, Doctor, thank you. And I will submit a
    question for the record on Medicaid, and in particular
    integrating physical and behavioral health for children, but I
    will do that for the record.
        [The question appears in the appendix.]
        Senator Casey. Thank you, Mr. Chairman.
        The Chairman. Thank you, Senator Casey. And thank you for
    your passion for kids especially.
        Doctor, you are right on the clock. It is the hour to let
    you go, and I am going to do that with just one additional
    question. First, let me just say ``thank you'' again for being
    here with us. You have once again shown over the last 2\1/2\
    hours, going on 3 hours, you always give public service a good
    name, and it just really means so much to have you.
        I want to just ask one quick question and then get you out
    the door. Two and a half hours ago I talked about my concern
    about the prospect of losing much of a generation of young
    people if there is just mental health business as usual. And
    you said something that my staff and I flagged on over the
    course of the morning, and we would just like to make sure we
    understand.
        You said a couple of times there is an 11-year gap between
    the onset of mental health challenges and treatment. And as I
    was just walking over, I said, ``Holy Toledo, that is a huge
    number of people.''
        Can you tell us a little bit more, as we let you go, what
    you mean by that and what we ought to be doing about it? We
    will have to talk more about it when you have more time.
        Dr. Murthy. Absolutely. I would be happy to. And, Senator,
    this is an incredibly painful data point. It takes years for
    our kids to get help. That is what this data point is about.
    When we have chest pain, we know we can go to an emergency room
    and get care, usually within minutes or hours. If we have
    pneumonia, we know that we can quickly get care, at least in
    much of the country.
        The thought of having to wait 11 years after you have the
    onset of symptoms to actually get the care you need would be
    unacceptable when it came to our physical health and well-
    being. Yet somehow we find ourselves in a position where we
    have tolerated that for our mental health, and in particular
    for our kids.
        This is why, not only are our kids struggling, but their
    parents are. The toll on families watching children suffer like
    that, I do not even know how to describe it. As a parent, the
    worst feeling that I can think of is seeing my child suffering
    and not being able to do something about it. And that is the
    situation that so many parents are in today.
        Kids who do not receive help early become adults who often
    end up struggling with their mental health. Like with all
    things, prevention and early action, early intervention, are
    better than waiting too long. And that is why I am so glad that
    we are doing the work we are doing together today. I want us to
    close that gap. I want us to get kids the care they need.
        The Chairman. America is better than this. We are going to
    work with you to make sure that we deliver on this key
    question. Waiting 11 years cannot possibly continue.
        Thank you. Thank you again for being with us. The committee
    is adjourned.
        Dr. Murthy. Thank you, Senator.
        [Whereupon, at 12:33 p.m., the hearing was concluded.]

                                A P P E N D I X

                  Additional Material Submitted for the Record

                                  ----------

                        Submitted by Hon. Bill Cassidy,
                         a U.S. Senator From Louisiana
                                              SAE./NO. 200/January 2022

                          Studies in Applied Economics

    =======================================================================

     A LITERATURE REVIEW AND META-ANALYSIS OF THE EFFECTS OF LOCKDOWNS ON
                               COVID-19 MORTALITY

    _______________________________________________________________________

                By Jonas Herby, Lars Jonung, and Steve H. Hanke

     Johns Hopkins Institute for Applied Economics, Global Health, and the
                          Study of Business Enterprise

                                About the Series

    The Studies in Applied Economics series is under the general direction
    of Prof. Steve H. Hanke, Founder and Co-Director of The Johns Hopkins
    Institute for Applied Economics, Global Health, and the Study of
    Business Enterprise (hanke@jhu.edu). The views expressed in each
    working paper are those of the authors and not necessarily those of the
    institutions that the authors are affiliated with.

                               About the Authors

    Jonas Herby (herby@cepos.dk) is special advisor at Center for Political
    Studies in Copenhagen, Denmark. His research focuses on law and
    economics. He holds a master's degree in economics from University of
    Copenhagen.

    Lars Jonung (lars.jonung@nek.lu.se) is professor emeritus in economics
    at Lund University, Sweden. He served as chairperson of the Swedish
    Fiscal Policy Council 2012-13, as research advisor at the European
    Commission 2000-2010, and as chief economic adviser to Prime Minister
    Carl Bildt in 1992-94. He holds a PhD in Economics from the University
    of California, Los Angeles.

    Steve H. Hanke is a Professor of Applied Economics and Founder and Co-
    Director of The Johns Hopkins Institute for Applied Economics, Global
    Health, and the Study of Business Enterprise. He is a Senior Fellow and
    Director of the Troubled Currencies Project at the Cato Institute, a
    contributor at National Review, a well-known currency reformer, and a
    currency and commodity trader. Prof. Hanke served on President Reagan's
    Council of Economic Advisers, has been an adviser to five foreign heads
    of state and five foreign cabinet ministers, and held a cabinet-level
    rank in both Lithuania and Montenegro. He has been awarded seven
    honorary doctorate degrees and is an Honorary Professor at four foreign
    institutions. He was President of Toronto Trust Argentina in Buenos
    Aires in 1995, when it was the world's best-performing mutual fund.
    Currently, he serves as Chairman of the Supervisory Board of Advanced
    Metallurgical Group N.V. in Amsterdam. In 1998, he was named one of the
    twenty-five most influential people in the world by World Trade
    Magazine. In 2020, Prof. Hanke was named a Knight of the Order of the
    Flag.

                                    Abstract

    This systematic review and meta-analysis are designed to determine
    whether there is empirical evidence to support the belief that
    ``lockdowns'' reduce COVID-19 mortality. Lockdowns are defined as the
    imposition of at least one compulsory, non-pharmaceutical intervention
    (NPI). NPIs are any government mandate that directly restrict peoples'
    possibilities, such as policies that limit internal movement, close
    schools and businesses, and ban international travel. This study
    employed a systematic search and screening procedure in which 18,590
    studies are identified that could potentially address the belief posed.
    After three levels of screening, 34 studies ultimately qualified. Of
    those 34 eligible studies, 24 qualified for inclusion in the meta-
    analysis. They were separated into three groups: lockdown stringency
    index studies, shelter-in-place-order (SIPO) studies, and specific NPI
    studies. An analysis of each of these three groups support the
    conclusion that lockdowns have had little to no effect on COVID-19
    mortality. More specifically, stringency index studies find that
    lockdowns in Europe and the United States only reduced COVID-19
    mortality by 0.2% on average. SIPOs were also ineffective, only
    reducing COVID-19 mortality by 2.9% on average. Specific NPI studies
    also find no broad-based evidence of noticeable effects on COVID-19
    mortality.

    While this meta-analysis concludes that lockdowns have had little to no
    public health effects, they have imposed enormous economic and social
    costs where they have been adopted. In consequence, lockdown policies
    are ill-founded and should be rejected as a pandemic policy instrument.

                                Acknowledgements

    The authors thank Line Andersen, Troels Sabroe Ebbesen, Nicholas
    Hanlon, and Anders Lund Mortensen for their research assistance.

    The authors also with to thank Douglas Allen, Fredrik N. G. Andersson,
    Jonas Bjork, Christian Bj10),    specification (Table
                                             nine NPIs (SIPO,         any gathering ban,       3, Proportion of
                                             strengthened SIPO,       restaurant/bar limit     Cumulative Deaths
                                             public school closure,   to dining out only,      Over the Population),
                                             all school closure,      and nonessential         the estimate of all
                                             large-gathering ban of   business closure) did    school closures
                                             more than 10 people,     not show any impact      (.204) and mandatory
                                             any gathering ban,       (Table 3, ``Proportion   self-quarantine of
                                             restaurant/bar limit     of Cumulative Deaths     travelers (0.363) is
                                             to dining out only,      Over the                 deemed insignificant
                                             nonessential business    Population'').           based on schools CI
                                             closure, and mandatory                            [.029, .379] and
                                             self-quarantine of                                quarantine CI [.193,
                                             travelers) on COVID-19                            .532]. We believe,
                                             deaths.                                           these results should
                                                                                               be interpreted as a
                                                                                               significant increase
                                                                                               in mortality, and
                                                                                               that these results
                                                                                               should have been part
                                                                                               of their conclusion.
    ----------------------------------------------------------------------------------------------------------------
    Hale et al. (2020);      COVID-19       Uses the OxCGRT          Finds that higher
     ``Global assessment of   mortality      stringency and COVID-    stringency in the past
     the relationship                        19-deaths from the       leads to a lower
     between government                      European Centre for      growth rate in the
     response measures and                   Disease Prevention and   present, with each
     COVID-19 deaths''                       Control for 170          additional point of
                                             countries. Estimates     stringency
                                             both cross-sectional     corresponding to a
                                             models in which          0.039%-point reduction
                                             countries are the unit   in daily deaths growth
                                             of analysis, as well     rates six weeks later.
                                             as longitudinal models
                                             on time-series panel
                                             data with country-day
                                             as the unit of
                                             analysis (including
                                             models that use both
                                             time and country fixed
                                             effects).
    ----------------------------------------------------------------------------------------------------------------
    Hunter et al. (2021);    COVID-19       Uses death data from     Finds that mass          Finds an effect of
     ``Impact of non-         mortality      the European Centre      gathering restrictions   closing educational
     pharmaceutical                          for Disease Prevention   and initial business     facilities and non-
     interventions against                   and Control (ECDC) and   closures (businesses     essential services
     COVID-19 in Europe: A                   NPI-data from the        such as entertainment    after 1-7 days before
     quasi-experimental non-                 Institute of Health      venues, bars and         lockdown could
     equivalent group and                    Metrics and              restaurants) reduces     possibly have an
     time-series''                           Evaluation. Argues       the number of deaths,    effect on the number
                                             that they use a quasi-   whereas closing          of deaths. This may
                                             experimental approach    educational facilities   indicate that other
                                             to identify the effect   and issuing SIPO         factors are driving
                                             of NPIs because no       increases the number     their results.
                                             analyzed intervention    of deaths. Finds no
                                             was imposed by all       effect of closing non-
                                             European countries and   essential services and
                                             interventions were put   mandating/
                                             in place at different    recommending masks
                                             points in the            (Table 3).
                                             development of the
                                             epidemics.
    ----------------------------------------------------------------------------------------------------------------
    Langeland et al.         COVID-19       Estimates the effect of  Finds no significant     They write that ``6+
     (2021); ``The Effect     mortality      state-level lockdowns    effect of SIPO on the    weeks of lockdown is
     of State Level COVID-                   on COVID-19 deaths       number of deaths after   the only setting
     19 Stay-at-Home Orders                  using multiple quasi-    2-4, 4-6 and 6+ weeks.   where the odds of
     on Death Rates''                        Poisson regressions                               dying are
                                             with lockdown time                                statistically higher
                                             length as the                                     than in the no
                                             explanatory variable.                             lockdown case.''
                                             Does not specify how                              However, all
                                             lockdown is defined                               estimates are
                                             and what their data                               insignificant in
                                             sources are.                                      Table C. Looks as if
                                                                                               lockdown duration may
                                                                                               cause a causality
                                                                                               problem, because
                                                                                               politicians may be
                                                                                               less likely to ease
                                                                                               restrictions when
                                                                                               there are many cases/
                                                                                               deaths.
    ----------------------------------------------------------------------------------------------------------------
    Leffler et al. (2020);   COVID-19       Use COVID-19 deaths      Finds that masking       Their ``mask
     ``Association of         mortality      from Worldometer and     (mask recommendations)   recommendation''
     Pcountry-wide                           info about NPIs (mask/   reduces mortality. For   category includes
     coronavirus mortality                   mask recommendations,    each week that masks     some countries, where
     with demographics,                      international travel     were recommended the     masks were mandated
     testing, lockdowns,                     restrictions and         increase in per-capita   (see Supplemental
     and public wearing of                   lockdowns (defined as    mortality was 8.1%       Table A1) and may
     masks''                                 any closure of schools   (compared to 55.7%       (partially) capture
                                             or workplaces, limits    increase when masks      the effect of mask
                                             on public gatherings     were not recommended).   mandates. Looks at
                                             or internal movement,    Finds no significant     duration which may
                                             or stay-at-home          effect of the number     cause a causality
                                             orders) from Hale et     of weeks with internal   problem, because
                                             al. (2020) for 200       lockdowns and            politicians may be
                                             countries to estimate    international travel     less likely to ease
                                             the effect of the        restrictions (Table      restrictions when
                                             duration of NPIs on      2).                      there are many cases/
                                             the number of deaths.                             deaths.
    ----------------------------------------------------------------------------------------------------------------
    Mccafferty and Ashley    Other          Use data from 27 U.S.    Finds that no mandate
     (2021); ``COVID-19                      states and 12 European   (school closures,
     Social Distancing                       countries to analyze     prohibition on mass
     Interventions by                        the effect of NPIs on    gatherings, business
     Statutory Mandate and                   peak morality rate       closures, stay at home
     Their Observational                     using general linear     orders, severe travel
     Correlation to                          mixed effects            restrictions, and
     Mortality in the                        modelling.               closure of non-
     United States and                                                essential businesses)
     Europe''                                                         was effective in
                                                                      reducing the peak
                                                                      COVID-19 mortality
                                                                      rate.
    ----------------------------------------------------------------------------------------------------------------
    Pan et al. (2020);       COVID-19       Uses county-level data   Concludes that only      They focus on the
     ``COVID-19:              mortality      for all U.S. states.     (duration of, see        negative estimate of
     Effectiveness of non-                   Mortality is obtained    comment in next          duration of Level 4.
     pharmaceutical                          from Johns Hopkins,      column) level 4          However, their
     interventions in the                    while policy data are    restrictions are         implementation
     united states before                    obtained from official   associated with          estimate is large and
     phased removal of                       governmental websites.   reduced risk of death,   positive, and the
     social distancing                       Categorizes 12           with an average 15%      combined effect of
     protections varies by                   policies into 4 levels   decline in the COVID-    implementation and
     region''                                of disease control;      19 death rate per day.   duration is unclear.
                                             Level 1 (low)--State     Implementation of
                                             of Emergency; Level 2    level 3 and level 2
                                             (moderate)--school       restrictions increased
                                             closures, restricting    death rates in 6 of 6
                                             access (visits) to       regions, while longer
                                             nursing homes, or        duration increased
                                             closing restaurants      death rates in 5 of 6
                                             and bars; Level 3        regions.
                                             (high)--non-essential
                                             business closures,
                                             suspending non-violent
                                             arrests, suspending
                                             elective medical
                                             procedures, suspending
                                             evictions, or
                                             restricting mass
                                             gatherings of at least
                                             10 people; and Level 4
                                             (aggressive)--shelteri
                                             ng in place/stay-at-
                                             home, public mask
                                             requirements, or
                                             travel restrictions.
                                             Use stepped-wedge
                                             cluster randomized
                                             trial (SW-CRT) for
                                             clustering and
                                             negative binomial
                                             mixed model
                                             regression.
    ----------------------------------------------------------------------------------------------------------------
    Pincombe et al. (2021);  COVID-19       Uses daily data for 113  Finds that shelter-in-
     ``The effectiveness of   mortality      countries on             place recommendations/
     national-level                          cumulative COVID-19      orders reduces
     containment and                         death counts over 130    mortality growth rates
     closure policies                        days between February    in high income
     across income levels                    15, 2020, and June 23,   countries (although
     during the COVID-19                     2020, to examine         insignificant) but
     pandemic: an analysis                   changes in mortality     increases growth rates
     of 113 countries''                      growth rates across      in countries in other
                                             the World Bank's         income groups.
                                             income group
                                             classifications
                                             following Pshelter-in-
                                             place recommendations
                                             or orders (they use
                                             one variable covering
                                             both recommendations
                                             and orders).
    ----------------------------------------------------------------------------------------------------------------
    Sears et al. (2020);     COVID-19       Uses cellular location   Find that SIPOs lower    In the abstract the
     ``Are we #stayinghome    mortality      data from all 50         deaths by 0.13-0.17      authors state that
     to Flatten the                          states and the           per 100,000 residents,   death rates would be
     Curve?''                                District of Columbia     equivalent to death      42-54% lower than in
                                             to investigate           rates 29-35% lower       the absence of
                                             mobility patterns        than in the absence of   policies. However,
                                             during the pandemic      policies. However,       this includes averted
                                             across states and        these estimates are      deaths due to pre-
                                             time. Adding COVID-19    insignificant at a 95%   mandate social
                                             death tolls and the      confidence interval      distancing behavior
                                             timing of SIPO for       (see Table 4). The       (p. 6). The effect of
                                             each state they          study also finds         SIPO is a reduction
                                             estimate the effect of   reductions in activity   in deaths by 29%-35%
                                             stay-at-home policies    levels prior to          compared to a
                                             on COVID-19 mortality.   mandates. Human          situation without
                                                                      encounter rate fell by   SIPO but with pre-
                                                                      63 percentage points     mandate social
                                                                      and nonessential         distancing. These
                                                                      visits by 39             estimates are
                                                                      percentage points        insignificant at a
                                                                      relative to pre-COVID-   95% confidence
                                                                      19 levels, prior to      interval.
                                                                      any state implementing
                                                                      a statewide mandate.
    ----------------------------------------------------------------------------------------------------------------
    Shiva and Molana         COVID-19       Uses COVID-19-deaths     A stricter lockdown (1
     (2021); ``The Luxury     mortality      and OxCGRT stringency    stringency point)
     of Lockdown''                           from 169 countries to    reduces deaths by 0,1%
                                             estimate the effect of   after 4 weeks. After 8
                                             lockdown on the number   weeks the effect is
                                             of deaths 1-8 weeks      insignificant.
                                             later. Finds that
                                             stricter lockdowns
                                             reduce COVID-19-deaths
                                             4 weeks later (but
                                             insignificant 8 weeks
                                             later) and have the
                                             greatest effect in
                                             high income countries.
                                             Finds no effect of
                                             workplace closures in
                                             low-income countries.
    ----------------------------------------------------------------------------------------------------------------
    Spiegel and Tookes       COVID-19       Use data for every       Finds that some          In total they analyze
     (2021); ``Business       mortality      county in the United     interventions (e.g.,     the lockdown effect
     restrictions and COVID-                 States from March        mask mandates,           of 21 variables. 14
     19 fatalities''                         through December 2020    restaurant and bar       of 21 estimates are
                                             to estimate the effect   closures, gym            significant, and of
                                             of various NPIs on the   closures, and high-      these 6 are negative
                                             COVID-19-deaths growth   risk business            (reduces deaths)
                                             rate. Derives            closures) reduces        while 8 are positive
                                             causality by (1)         mortality growth,        (increases deaths).
                                             assuming that state      while other              Some results are far
                                             regulators primarily     interventions            from intuitive. E.g.
                                             focus on the state's     (closures of low- to     mask recommendations
                                             most populous            medium-risk businesses   increases deaths by
                                             counties, so state       and personal care/spa    48% while mask
                                             regulation in smaller    services) did not have   mandates reduces
                                             counties can be viewed   an effect and may even   deaths by 12%, and
                                             as a quasi randomized    have increased the       closing restaurants
                                             experiment, and (2)      number of deaths.        and bars reduces
                                             conducting county pair                            deaths by 50%, while
                                             analysis, where                                   closing bars but not
                                             similar counties in                               restaurants only
                                             different states (and                             reduces deaths by 5%.
                                             subject to different
                                             state policies) are
                                             compared.
    ----------------------------------------------------------------------------------------------------------------
    Stockenhuber (2020);     COVID-19       Uses data for the        Finds no significant     Groups data on
     ``Did We Respond         mortality      number of COVID?19       effect of stricter       lockdown strictness
     Quickly Enough? How                     infections and deaths    lockdowns on the         into four groups and
     Policy-Implementation                   and policy information   number of fatalities     lose significant
     Speed in Response to                    for 24 countries from    (Table 4).               information and
     COVID-19 Affects the                    OxCGRT to estimate the                            variation.
     Number of Fatal Cases                   effect of stricter
     in Europe''                             lockdowns on the
                                             number of deaths using
                                             principal component
                                             analysis and a
                                             generalized linear
                                             mixed model.
    ----------------------------------------------------------------------------------------------------------------
    Stokes et al. (2020);    COVID-19       Uses daily COVID-19      Of the nine sub-         Their results are
     ``The relative effects   mortality      deaths for 130           categories in the        counter intuitive and
     of non-pharmaceutical                   countries from the       OxCGRT stringency        somewhat
     interventions on early                  European Centre for      index, only travel       inconclusive. Why
     COVID-19 mortality:                     Disease Prevention and   restrictions are         does limiting very
     natural experiment in                   Control (ECDC) and       consistently             large gatherings
     130 countries''                         daily policy data from   significant (with        (>1,000) work, while
                                             the Oxford COVID-19      level 2 ``Quarantine     stricter limits do
                                             Government Response      arrivals from high-      not? Why do
                                             Tracker (OxCGRT).        risk regions'' having    recommending school
                                             Looks at all levels of   the largest effect,      closures cause more
                                             restrictions for each    and the strictest        deaths? Why is the
                                             of the nine sub-         level 4 ``Total border   effect of border
                                             categories of the        closure'' having the     closures before 1st
                                             OxCGRT stringency        smallest effect).        death insignificant,
                                             index (school, work,     Restrictions on very     while the effect of
                                             events, gatherings,      large gatherings         closing borders after
                                             transport, SIPO,         (>1,000) has a large     1st death is
                                             internal movement,       significant negative     significant (and
                                             travel).                 (fewer deaths) effect,   large)? And why does
                                                                      while the effect of      quarantining arrivals
                                                                      stricter restrictions    from high-risk
                                                                      on gatherings are        regions work better
                                                                      insignificant. Authors   than total border
                                                                      recommend that the       closures? With 23
                                                                      closing of schools       estimated parameters
                                                                      (level 1) has a very     in total these
                                                                      large (in absolute       counter intuitive and
                                                                      terms it's twice the     inconclusive results
                                                                      effect of border         could be caused by
                                                                      quarantines) positive    multiple test bias
                                                                      effect (more deaths)     (we correct for this
                                                                      while stricter           in the meta-
                                                                      interventions on         analysis), but may
                                                                      schools have no          also be caused by
                                                                      significant effect.      other factors such as
                                                                      Required cancelling of   omitted variable
                                                                      public events also has   bias.
                                                                      a significant positive
                                                                      (more deaths) effect.
                                                                      We focus on their 14-
                                                                      38 days results, as
                                                                      they catch the longest
                                                                      time frame (their 0-24
                                                                      day model returns
                                                                      mostly insignificant
                                                                      results).
    ----------------------------------------------------------------------------------------------------------------
    Toya and Skidmore        COVID-19       Uses COVID-19-deaths     Complete travel          The study looks at the
     (2020); ``A Cross-       mortality      and lockdown info from   restrictions prior to    lockdown status prior
     Country Analysis of                     various sources from     April 2020 reduced       to April 2020 and the
     the Determinants of                     159 countries in a       deaths by -0.226 per     effect on deaths the
     COVID-19 Fatalities''                   cross-country event      100.000 by April 1st     following year (until
                                             study. Controls for      2021, while mandatory    April 1, 2021). The
                                             country specifics by     national lockdown        authors state this is
                                             including socio-         prior to April 2020      to reduce concerns
                                             Peconomic, political,    increased deaths by      about endogeneity but
                                             geographic, and policy   0.166 by April 1,        do not explain why
                                             information. Finds       2021. Recommended        the lockdowns in the
                                             little evidence for      local lockdowns          spring of 2020 are a
                                             the efficacy of NPIs.    reduced deaths but       good instrument for
                                                                      results are based on     lockdowns during
                                                                      one observation.         later waves are.
                                                                      Partial travel
                                                                      restrictions,
                                                                      mandatory local
                                                                      lockdowns and
                                                                      recommended national
                                                                      lockdowns did not have
                                                                      a significant effect
                                                                      on deaths.
    ----------------------------------------------------------------------------------------------------------------
    Tsai et al. (2021);      Reproduction   Uses data for NPIs that  Finds that in the 8      Their Figure 1 shows
     ``Coronavirus Disease    rate, Rt       were implemented and/    weeks prior to           that Rt on average
     2019 (COVID-19)                         or relaxed in U.S.       relaxing NPIs, Rt was    increases app. 10
     Transmission in the                     states between 10        declining, while after   days before
     United States Before                    March and 15 July        relaxation Rt started    relaxation, which
     Versus After                            2020. Using segmented    to increase.             could indicate that
     Relaxation of                           linear regression,                                other factors
     Statewide Social                        they estimate the                                 (omitted variables)
     Distancing Measures''                   extent to which                                   affect the results.
                                             relaxation of social
                                             distancing affected
                                             epidemic control, as
                                             indicated by the time-
                                             varying, state-
                                             specific effective
                                             reproduction number
                                             (Rt). Rt is based on
                                             death tolls.
    ----------------------------------------------------------------------------------------------------------------
    Note: All comments on the significance of estimates are based on a 5% significance level unless otherwise
      stated.

    It is difficult to make a conclusion based on the overview in Table 1.
    Is -0.073 to -0.326 deaths/million per stringency point, as estimated
    by Ashraf (2020), a large or a small effect relative to. the 98%
    reduction in mortality predicted by the study published by the Imperial
    College London (Ferguson et al. (2020). This is the subject for our
    meta-analysis in the next section. Here, it turns out that -0.073 to
    -0.326 deaths/million per stringency point is a relatively modest
    effect and only corresponds to a 2.4% reduction in COVID-19 mortality
    on average in the U.S. and Europe.

     4 Meta-Analysis: The Impact of Lockdowns on COVID-19 Mortality

    We now turn to the meta-analysis, where we focus on the impact of
    lockdowns on COVID-19 mortality.

    In the meta-analysis, we include 24 studies in which we can derive the
    relative effect of lockdowns on COVID-19 mortality, where mortality is
    measured as COVID-19-related deaths per million. In practice, this
    means that the studies we included estimate the effect of lockdowns on
    mortality or the effect of lockdowns on mortality growth rates, while
    using a counterfactual estimate.\26\
    ---------------------------------------------------------------------------
        \26\ As a minimum requirement, one needs to know the effect on the
    top of the curve.

    Our focus is on the effect of compulsory non-pharmaceutical
    interventions (NPI), policies that restrict internal movement, close
    schools and businesses, and ban international travel, among others. We
    do not look at the effect of voluntary behavioral changes (e.g.,
    voluntary mask wearing), the effect of recommendations (e.g.,
    recommended mask wearing), or governmental services (voluntary mass
    ---------------------------------------------------------------------------
    testing and public information campaigns), but only on mandated NPIs.

    The studies we examine are placed in three categories. Seven studies
    analyze the effect of stricter lockdowns based on the OxCGRT stringency
    indices, 13 studies analyze the effect of SIPOs (6 studies only analyze
    SIPOs, while seven analyze SIPOs among other interventions), and 11
    studies analyze the effect of specific NPIs independently (lockdown vs.
    no lockdown).\27\ Each of these categories is handled so that
    comparable estimates can be made across categories. Below, we present
    the results for each category and show the overall results, as well as
    those based on various quality dimensions.
    ---------------------------------------------------------------------------
        \27\ The total is larger than 21 because the 11 SIPO studies
    include seven studies which look at multiple measures.
    ---------------------------------------------------------------------------
    Quality Dimensions
    We include quality dimensions because there are reasons to believe that
    can affect a study's conclusion. Below we describe the dimensions, as
    well as our reasons to believe that they are necessary to fully
    understand the empirical evidence.

          Peer-reviewed vs. working papers: We distinguish between peer-
    reviewed studies and working papers as we consider peer-reviewed
    studies generally being of higher quality than working papers.\28\
    ---------------------------------------------------------------------------
        \28\ Vetted papers from CEPR COVID Economics are considered as
    working papers in this regard.

          Long vs. short time period: We distinguish between studies based
    on long time periods (with data series ending after May 31, 2020) and
    short time periods (data series ending at or before May 31, 2020),
    because the first wave did not fully end before late June in the U.S.
    and Europe. Thus, studies relying on short data periods lack the last
    part of the first wave and may yield biased results if lockdowns only
    ---------------------------------------------------------------------------
    ``flatten the curve'' and do not prevent deaths.

          No early effect on mortality: On average, it takes approximately
    3 weeks from infection to death.\29\ However, several studies find
    effects of lockdown on mortality almost immediately. Fowler et al.
    (2021) find a significant effect of SIPOs on mortality after just 4
    days and the largest effect after 10 days. An early effect may indicate
    that other factors (omitted variables) drive the results, and, thus, we
    distinguish between studies which find an effect on mortality sooner
    than 14 days after lockdown and those that do not.\30\ Note that many
    studies do not look at the short term and thus fall into the latter
    category by default.
    ---------------------------------------------------------------------------
        \29\ Leffler et al. (2020) writes, ``On average, the time from
    infection with the coronavirus to onset of symptoms is 5.1 days, and
    the time from symptom onset to death is on average 17.8 days.
    Therefore, the time from infection to death is expected to be 23
    days.'' Meanwhile, Stokes et al. (2020) writes that ``evidence suggests
    a mean lag between virus transmission and symptom onset of 6 days, and
    a further mean lag of 18 days between onset of symptoms and death.''
        \30\ Some of the authors are aware of this problem. E.g., Bj21 days         Medicine        Specific NPIs    United States
     ``Association between                                                                                (Other)
     statewide school closure and
     COVID-19 incidence and
     mortality in the U.S.''
    --------------------------------------------------------------------------------------------------------------------------------------------------------
    Berry et al. (2021);           Yes              Peer-review         30-May-20       8-14 days        Public policy   SIPO             United States
     ``Evaluating the effects of                                                                          (Social
     shelter-in-place policies                                                                            science)
     during the COVID-19
     pandemic''
    --------------------------------------------------------------------------------------------------------------------------------------------------------
    BjMay 31, 2020),
    the
    precision-weighted estimates are as follows (average for all studies in
    parentheses for easy comparison): Lockdown (complete/partial): 0.5%
    (0.6%), Facemasks/Employee face masks: -21.2% (-21.2%), Business
    closures (/bars & restaurants): -8.1% (-10.6%), Border closures (/
    quarantine): -0.1% (-0.1%), School closures: 0.5% (-4.4%), Limiting
    gatherings: 1.4% (1.6%).

                                                  Table 7: Overview of Estimates From Studies of Specific NPIs
    --------------------------------------------------------------------------------------------------------------------------------------------------------
                              Lockdown          Facemasks/      Business Closure
                             (Complete/       Employee Face        (/Bars And     Border Closure  (/  School Closures        Limiting           Quality
                              Partial)            Masks           Restaurants)       Quarantine)                            Gatherings         Dimensions
    --------------------------------------------------------------------------------------------------------------------------------------------------------
    Chernozhukov et al.                               -34.0%             -28.6%                                                                           4
     (2021)

    Bongaerts et al.                                                     -31.6%                                                                           2
     (2021)

    Chaudhry et al.                  0.0%                                                     0.0%                                                        2
     (2020)*

    Toya and Skidmore                0.5%                                                    -0.1%                                                        3
     (2021)

    Aparicio and                                                          -1.3%                                  0.5%               0.8%                  4
     Grossbard (2021)

    Auger et al. (2020)                                                                                        -58.0%                                     2

    Leffler et al.                   1.7%                                                   -15.6%                                                        2
     (2020)

    Stokes et al.                                                          0.3%             -24.6%              -0.1%              -6.3%                  3
     (2020)

    Spiegel and Tookes                                -13.5%             -50.2%                                                    11.8%                  3
     (2021)

    Bonardi et al.                   0.0%                                                     0.0%                                                        1
     (2020)*

    Guo et al. (2021)                                                     -0.4%              36.3%              -0.2%               5.7%                  3
    --------------------------------------------------------------------------------------------------------------------------------------------------------
    Precision-weighted               0.6%             -21.2%             -10.6%              -0.1%              -4.4%               1.6%
     average

    Arithmetic average               0.6%             -23.8%             -18.6%              -0.7%             -14.4%               3.0%

    Median                           0.3%             -23.8%             -14.9%               0.0%              -0.1%               3.2%
    --------------------------------------------------------------------------------------------------------------------------------------------------------
    4 of 4 quality                n/a [0]         -34.0% [1]          -2.9% [2]            n/a [0]           0.5% [1]           0.8% [1]
     dimensions

    3 of 4 quality               0.5% [1]         -13.5% [1]         -21.5% [3]           0.0% [3]          -0.1% [2]           5.6% [3]
     dimensions

    2 of 4 quality               1.7% [2]            n/a [1]         -31.6% [2]         -15.6% [2]         -58.0% [1]            n/a [1]
     dimensions or
     fewer
    --------------------------------------------------------------------------------------------------------------------------------------------------------
    * It is not possible to derive common estimates and standard errors from Chaudhry et al. (2020) and Bonardi et al. (2020). Chaudhry et al. (2020) states
      that the effect of the various NPIs is insignificant without listing the estimates and standard errors. Bonardi et al. (2020) states that partial or
      regional lockdowns are as effective as stricter NPIs but does not provide information to calculate common estimates. Instead, we assume the estimate
      is 0% when calculating arithmetic average and median, while the estimates are excluded from the calculation of precision-weighted averages because
      there are no standard errors.

    Figure 7 shows a funnel plot for all estimates in Table 7, except
    Chaudhry et al. (2020) and Bonardi et al. (2020), where common standard
    errors cannot be derived. Two estimates from Toya and Skidmore (2020)
    stands out with a precision far higher than those of other studies, and
    estimates are placed with some `tail' to the left, which could indicate
    some publication bias, i.e., reluctance to publish results that show
    large positive (more deaths) effects of lockdowns. The most precise
    estimates are gathered around 0%, while less precise studies are spread
    out between -58% and 36%. The precision-weighted average of all
    estimates across all NPIs is -0.6%.

    [GRAPHIC] [TIFF OMITTED] T0822.007

    .epsOverall Conclusion on Specific NPIs
    Because of the heterogeneity in NPIs across studies, it is difficult to
    draw strong conclusions based on the studies of multiple specific
    measures. We find no evidence that lockdowns, school closures, border
    closures, and limiting gatherings have had a noticeable effect on
    COVID-19 mortality. There is some evidence that business closures
    reduce COVID-19 mortality, but the variation in estimates is large and
    the effect seems related to closing bars. There may be an effect of
    mask mandates, but just two studies look at this, one of which one only
    looks at the effect of employee mask mandates.

    5 Concluding Observations

    Public health experts and politicians have--based on forecasts in
    epidemiological studies such as that of Imperial College London
    (Ferguson et al. (2020)--embraced compulsory lockdowns as an effective
    method for arresting the pandemic. But have these lockdown policies
    been effective in curbing COVID-19 mortality? This is the main question
    answered by our meta-analysis.

    Adopting a systematic search and title-based screening, we identified
    1,048 studies published by July 1, 2020, which potentially look at the
    effect of lockdowns on mortality rates. To answer our question, we
    focused on studies that examine the actual impact of lockdowns on
    COVID-19 mortality rates based on registered cross-
    sectional mortality data and a counterfactual difference-in-difference
    approach. Out of the 1,048 studies, 34 met our eligibility criteria.
    Conclusions
    Overall, our meta-analysis fails to confirm that lockdowns have had a
    large, significant effect on mortality rates. Studies examining the
    relationship between lockdown strictness (based on the OxCGRT
    stringency index) find that the average lockdown in Europe and the
    United States only reduced COVID-19 mortality by 0.2% compared to a
    COVID-19 policy based solely on recommendations. Shelter-in-place
    orders (SIPOs) were also ineffective. They only reduced COVID-19
    mortality by 2.9%.

    Studies looking at specific NPIs (lockdown vs. no lockdown, facemasks,
    closing non-essential businesses, border closures, school closures, and
    limiting gatherings) also find no broad-based evidence of noticeable
    effects on COVID-19 mortality. However, closing non-essential
    businesses seems to have had some effect (reducing COVID-19 mortality
    by 10.6%), which is likely to be related to the closure of bars. Also,
    masks may reduce COVID-19 mortality, but there is only one study that
    examines universal mask mandates. The effect of border closures, school
    closures and limiting gatherings on COVID-19 mortality yields
    precision-weighted estimates of -0.1%, -4.4%, and 1.6%, respectively.
    Lockdowns (compared to no lockdowns) also do not reduce COVID-19
    mortality.
    Discussion
    Overall, we conclude that lockdowns are not an effective way of
    reducing mortality rates during a pandemic, at least not during the
    first wave of the COVID-19 pandemic. Our results are in line with the
    World Health Organization Writing Group (2006), who state, ``Reports
    from the 1918 influenza pandemic indicate that social-distancing
    measures did not stop or appear to dramatically reduce transmission [.
    . .] In Edmonton, Canada, isolation and quarantine were instituted;
    public meetings were banned; schools, churches, colleges, theaters, and
    other public gathering places were closed; and business hours were
    restricted without obvious impact on the epidemic.'' Our findings are
    also in line with Allen's (2021) conclusion: ``The most recent research
    has shown that lockdowns have had, at best, a marginal effect on the
    number of COVID-19 deaths.'' Poeschl and Larsen (2021) conclude that
    ``interventions are generally effective in mitigating COVID-19
    spread.'' But 9 of the 43 (21%) results they review find ``no or
    uncertain association'' between lockdowns and the spread of COVID-19,
    suggesting that evidence from that own study contradicts their
    conclusion.

    The findings contained in Johanna et al. (2020) are in contrast to our
    own. They conclude that ``for lockdown, ten studies consistently showed
    that it successfully reduced the incidence, onward transmission, and
    mortality rate of COVID-19.'' The driver of the difference is three-
    fold. First, Johanna et al. include modelling studies (10 out of a
    total of 14 studies), which we have explicitly excluded. Second, they
    included interrupted time series studies (3 of 14 studies), which we
    also exclude. Third, the only study using a difference-in-difference
    approach (as we have done) is based on data collected before May 1,
    2020. We should mention that our results indicate that early studies
    find relatively larger effects compared to later studies.

    Our main conclusion invites a discussion of some issues. Our review
    does not point out why lockdowns did not have the effect promised by
    the epidemiological models of Imperial College London (Ferguson et al.
    (2020)). We propose four factors that might explain the difference
    between our conclusion and the view embraced by some epidemiologists.

    First, people respond to dangers outside their door. When a pandemic
    rages, people believe in social distancing regardless of what the
    government mandates. So, we believe that Allen (2021) is right, when he
    concludes, ``The ineffectiveness [of lockdowns] stemmed from individual
    changes in behavior: either non-compliance or behavior that mimicked
    lockdowns.'' In economic terms, you can say that the demand for costly
    disease prevention efforts like social distancing and increased focus
    on hygiene is high when infection rates are high. Contrary, when
    infection rates are low, the demand is low and it may even be morally
    and economically rational not to comply with mandates like SIPOs, which
    are difficult to enforce. Herby (2021) reviews studies which
    distinguish between mandatory and voluntary behavioral changes. He
    finds that--on average--voluntary behavioral changes are 10 times as
    important as mandatory behavioral changes in combating COVID-19. If
    people voluntarily adjust their behavior to the risk of the pandemic,
    closing down non-
    essential businesses may simply reallocate consumer visits away from
    ``nonessential'' to ``essential'' businesses, as shown by Goolsbee and
    Syverson (2021), with limited impact on the total number of
    contacts.\47\ This may also explain why epidemiological model
    simulations such as Ferguson et al. (2020)--which do not model behavior
    endogenously--fail to forecast the effect of lockdowns.
    ---------------------------------------------------------------------------
        \47\ In economic terms, lockdowns are substitutes for--not
    complements to--voluntary behavioral changes.

    Second, mandates only regulate a fraction of our potential contagious
    contacts and can hardly regulate nor enforce handwashing, coughing
    etiquette, distancing in supermarkets, etc. Countries like Denmark,
    Finland, and Norway that realized success in keeping COVID-19 mortality
    rates relatively low allowed people to go to work, use public
    transport, and meet privately at home during the first lockdown. In
    these countries, there were ample opportunities to legally meet with
    ---------------------------------------------------------------------------
    others.

    Third, even if lockdowns are successful in initially reducing the
    spread of COVID-19, the behavioral response may counteract the effect
    completely, as people respond to the lower risk by changing behavior.
    As Atkeson (2021) points out, the economic intuition is
    straightforward. If closing bars and restaurants causes the prevalence
    of the disease to fall toward zero, the demand for costly disease
    prevention efforts like social distancing and increased focus on
    hygiene also falls towards zero, and the disease will return.\48\
    ---------------------------------------------------------------------------
        \48\ This kind of behavior response may also explain why
    Subramanian and Kumar (2021) find that increases in COVID-19 cases are
    unrelated to levels of vaccination across 68 countries and 2947
    counties in the United States. When people are vaccinated and protected
    against severe disease, they have less reason to be careful.

    Fourth, unintended consequences may play a larger role than recognized.
    We already pointed to the possible unintended consequence of SIPOs,
    which may isolate an infected person at home with his/her family where
    he/she risks infecting family members with a higher viral load, causing
    more severe illness. But often, lockdowns have limited peoples' access
    to safe (outdoor) places such as beaches, parks, and zoos, or included
    outdoor mask mandates or strict outdoor gathering restrictions, pushing
    people to meet at less safe (indoor) places. Indeed, we do find some
    evidence that limiting gatherings was counterproductive and increased
    ---------------------------------------------------------------------------
    COVID-19 mortality.

    One objection to our conclusions may be that we do not look at the role
    of timing. If timing is very important, differences in timing may
    empirically overrule any differences in lockdowns. We note that this
    objection is not necessarily in contrast to our results. If timing is
    very important relative to strictness, this suggests that well-timed,
    but very mild, lockdowns should work as well as, or better than, less
    well-timed but strict lockdowns. This is not in contrast to our
    conclusion, as the studies we reviewed analyze the effect of lockdowns
    compared but to doing very little (see Section 3.1 for further
    discussion). However, there is little solid evidence supporting the
    timing thesis, because it is inherently difficult to analyze (see
    Section 2.2 for further discussion). Also, even if it can be
    empirically stated that a well-timed lockdown is effective in combating
    a pandemic, it is doubtful that this information will ever be useful
    from a policy perspective.

    But, what explains the differences between countries, if not
    differences in lockdown policies? Differences in population age and
    health, quality of the health sector, and the like are obvious factors.
    But several studies point at less obvious factors, such as culture,
    communication, and coincidences. For example, Frey et al. (2020) show
    that for the same policy stringency, countries with more obedient and
    collectivist cultural traits experienced larger declines in geographic
    mobility relative to their more individualistic counterpart. Data from
    Germany Laliotis and Minos (2020) shows that the spread of COVID-19 and
    the resulting deaths in predominantly Catholic regions with stronger
    social and family ties were much higher compared to non-Catholic ones
    at the local NUTS 3 level.\49\
    ---------------------------------------------------------------------------
        \49\ The NUTS classification (Nomenclature of territorial units for
    statistics) is a hierarchical system for dividing up the economic
    territory of the EU and the UK. There are 1,215 regions at the NUTS 3-
    level.

    Government communication may also have played a large role. Compared to
    its Scandinavian neighbors, the communication from Swedish health
    authorities was far more subdued and embraced the idea of public health
    vs. economic trade-offs. This may explain why Helsingen et al. (2020),
    found, based on questionnaire data collected from mid-March to mid-
    April, 2020, that even though the daily COVID-19 mortality rate was
    more than four times higher in Sweden than in Norway, Swedes were less
    likely than Norwegians to not meet with friends (55% vs. 87%), avoid
    public transportation (72% vs. 82%), and stay home during spare time
    (71% vs. 87%).That is, despite a more severe pandemic, Swedes were less
    affected in their daily activities (legal in both countries) than
    ---------------------------------------------------------------------------
    Norwegians.

    Many other factors may be relevant, and we should not underestimate the
    importance of coincidences. An interesting example illustrating this
    point is found in Arnarson (2021) and Bjork et al. (2021), who show
    that areas where the winter holiday was relatively late (in week 9 or
    10 rather than week 6, 7 or 8) were hit especially hard by COVID-19
    during the first wave because the virus outbreak in the Alps could
    spread to those areas with ski tourists. Arnarson (2021) shows that the
    effect persists in later waves. Had the winter holiday in Sweden been
    in week 7 or week 8 as in Denmark, the Swedish COVID-19 situation could
    have turned out very differently.\50\
    ---------------------------------------------------------------------------
        \50\ Another case of coincidence is illustrated by Shenoy et al.
    (2022), who find that areas that experienced rainfall early in the
    pandemic realized fewer deaths because the rainfall induced social
    distancing.
    ---------------------------------------------------------------------------
    Policy Implications
    In the early stages of a pandemic, before the arrival of vaccines and
    new treatments, a society can respond in two ways: mandated behavioral
    changes or voluntary behavioral changes. Our study fails to demonstrate
    significant positive effects of mandated behavioral changes
    (lockdowns). This should draw our focus to the role of voluntary
    behavioral changes. Here, more research is needed to determine how
    voluntary behavioral changes can be supported. But it should be clear
    that one important role for government authorities is to provide
    information so that citizens can voluntarily respond to the pandemic in
    a way that mitigates their exposure.

    Finally, allow us to broaden our perspective after presenting our meta-
    analysis that focuses on the following question: ``What does the
    evidence tell us about the effects of lockdowns on mortality?'' We
    provide a firm answer to this question: The evidence fails to confirm
    that lockdowns have a significant effect in reducing COVID-19
    mortality. The effect is little to none.

    The use of lockdowns is a unique feature of the COVID-19 pandemic.
    Lockdowns have not been used to such a large extent during any of the
    pandemics of the past century. However, lockdowns during the initial
    phase of the COVID-19 pandemic have had devastating effects. They have
    contributed to reducing economic activity, raising unemployment,
    reducing schooling, causing political unrest, contributing to domestic
    violence, and undermining liberal democracy. These costs to society
    must be compared to the benefits of lockdowns, which our meta-analysis
    has shown are marginal at best. Such a standard benefit-cost
    calculation leads to a strong conclusion: lockdowns should be rejected
    out of hand as a pandemic policy instrument.

    6 Appendix A. The Role of Timing

    Some of the included papers study the importance of the timing of
    lockdowns, while several other papers only looking at timing of (but
    not on the inherent effect of) lockdowns have been excluded from the
    literature list in this review. There's no doubt that being prepared
    for a pandemic and knowing when it arrives at your doorstep is vital.
    However, two problems arise with respect to imposing early lockdowns.

    First of all, it was virtually impossible to determine the right timing
    when COVID-19 hit Europe and the United States. The World Health
    Organization declared the outbreak of a pandemic on March 11, 2020, but
    at that date Italy had already registered 13.7 COVID-19-deaths per
    million (all infected before approximately February 22nd, because of
    the roughly 18-day gap between infection and death, c.f. e.g.,
    Bj-1.16 - 1 = -0.69 decline in daily deaths
                                                              per million per SD. We convert to total effect by
                                                              multiplying with 90 days and ``per point'' by dividing
                                                              with SD = 22.3 (corresponding to the SD for the 147
                                                              countries with data before March 19, 2020--using all
                                                              data yields similar results) yielding -2.77 deaths per
                                                              million per stringency point. The common estimate is
                                                              the average effect in Europe and United States
                                                              respectively calculated as (Actual COVID-19 mortality)/
                                                              (COVID-19 mortality with recommendation policy) -1,
                                                              where (COVID-19 mortality with recommendation policy)
                                                              is calculated as ((Actual COVID-19 mortality) -
                                                              Estimate  Difference in stringency  population).
                                                              Stringencies in Europe and United States are equal to
                                                              the average stringency from March 16 to April 15, 2020
                                                              (76 and 74 respectively) and the stringency for the
                                                              policy based solely on recommendations is 44 following
                                                              Hale et al. (2020).
    ----------------------------------------------------------------------------------------------------------------
    Guo et al. (2021);          21-Sep-20......  Research    We use estimates for ``Proportion of Cumulative Deaths
     ``Mitigation                                 on Social   Over the Population'' (per 10,000) in Table 3. We
     Interventions in the                         Work        interpret this number as the change in cumulative
     United States: An                            Practice    deaths over the population in percent and is therefore
     Exploratory Investigation                                the same as our common estimate.
     of Determinants and
     Impacts''
    ----------------------------------------------------------------------------------------------------------------
    Hale et al. (2020);         6-Jul-20.......  medRxiv     The study is not included in the meta-analysis, as it
     ``Global assessment of                                   looks at the effect of NPIs on growth rates and does
     the relationship between                                 not include an estimate of the effect on total
     government response                                      mortality. They ascertain that ``sustained over three
     measures and COVID-19                                    months, this would correspond to a cumulative number
     deaths''                                                 of deaths 30% lower,'' however this is not a
                                                              counterfactual estimate and three months goes beyond
                                                              the period they have data for.
    ----------------------------------------------------------------------------------------------------------------
    Hunter et al. (2021);       15-Jul-21......  Eurosurvei  The study is not included in the meta-analysis, as they
     ``Impact of non-                             llance      report the effect of NPIs in incident risk ratio which
     pharmaceutical                                           are not easily converted to relative effects.
     interventions against
     COVID-19 in Europe: A
     quasi-experimental non-
     equivalent group and time-
     series''
    ----------------------------------------------------------------------------------------------------------------
    Langeland et al. (2021);    5-Mar-21.......  Culture     The study is not included in the meta-analysis, as it
     ``The Effect of State                        and         looks at the effect of NPIs on odds-ratios and does
     Level COVID-19 Stay-at-                      Crisis      not include an estimate of the effect on total
     Home Orders on Death                         Conferenc   mortality.
     Rates''                                      e
    ----------------------------------------------------------------------------------------------------------------
    Leffler et al. (2020);      26-Oct-20......  ASTMH       Their ``mask recommendation'' includes some countries,
     ``Association of Pcountry-                               where masks were mandated and may (partially) capture
     wide coronavirus                                         the effect of mask mandates. However, the authors'
     mortality with                                           focus is on recommendation, so we do interpret their
     demographics, testing,                                   result as a voluntary effect--not an effect of mask
     lockdowns, and public                                    mandate. Using estimates from Table 2 and assuming
     wearing of masks''                                       NPIs were implemented March 15th (8 weeks in total by
                                                              end of study period), common estimates are calculated
                                                              as 8est -1.
    ----------------------------------------------------------------------------------------------------------------
    Mccafferty and Ashley       27-Apr-21......  Pragmatic   The study is not included in the meta-analysis, as it
     (2021); ``COVID-19 Social                    and         looks at the effect of NPIs on peak mortality and does
     Distancing Interventions                     Observati   not include an estimate of the effect on total
     by Statutory Mandate and                     on al       mortality.
     Their Observational                          Research
     Correlation to Mortality
     in the United States and
     Europe''
    ----------------------------------------------------------------------------------------------------------------
    Pan et al. (2020); ``COVID- 20-Aug-20......  medRxiv     The study is not included in the meta-analysis, as they
     19: Effectiveness of non-                                cluster the NPIs (e.g., SIPO, mask mandate and travel
     pharmaceutical                                           restrictions are clustered in Level 4).
     interventions in the
     united states before
     phased removal of social
     distancing protections
     varies by region''
    ----------------------------------------------------------------------------------------------------------------
    Pincombe et al. (2021);     4-May-21.......  Health      Policy implementations were assigned according to the
     ``The effectiveness of                       Policy      first day that a country received a policy stringency
     national-level                               and         rating above 0 in the OxCGRT stay-at-home measure. As
     containment and closure                      Planning    the value 1 is a recommendation ``recommend not
     policies across income                                   leaving house,'' we cannot distinguish recommendations
     levels during the COVID-                                 from mandates and, thus, the study is not included in
     19 pandemic: An analysis                                 the meta- analysis.
     of 113 countries''
    ----------------------------------------------------------------------------------------------------------------
    Sears et al. (2020); ``Are  6-Aug-20.......  medRxiv     Finds that SIPOs lower mortality by 29-35%. We use the
     we #stayinghome to                                       average (32%) as our common estimate. Common standard
     Flatten the Curve?''                                     errors are calculated based on estimates and standard
                                                              errors from (Table 4) assuming they are linearly
                                                              related to estimates.
    ----------------------------------------------------------------------------------------------------------------
    Shiva and Molana (2021);    9-Apr-21.......  The         The estimate with 8 weeks lag is insignificant, and
     ``The Luxury of                              European    preferable given our empirical strategy. However, they
     Lockdown''                                   Journal     use the 4-week lag when elaborating the model to
                                                  of          differentiate between high- and low-income countries,
                                                  Developme   so the 4-week lag estimate for rich countries is used
                                                  nt          in our meta-analysis. Common estimate is calculated as
                                                  Research    the average of the effect in Europe and United States,
                                                              where the effect for each is calculated as (policy
                                                              stringency - recommendation stringency)  estimate.
    ----------------------------------------------------------------------------------------------------------------
    Spiegel and Tookes (2021);  18-Jun-21......  The Review  We use weighted average of estimates for Table 4, 6,
     ``Business restrictions                      of          and 9. Since authors state that they place more weight
     and COVID-19 fatalities''                    Financial   on the findings in Table 9, Table 9 weights by 50%
                                                  Studies     while Table 4 and 6 weights by 25%. We estimate the
                                                              effect on total mortality from effect on growth rates
                                                              based on authors calculation showing that estimates of
                                                              -0.049 and -0.060 reduces new deaths by 12.5% 15.3%
                                                              respectively. We use the same relative factor on other
                                                              estimates.
    ----------------------------------------------------------------------------------------------------------------
    Stockenhuber (2020); ``Did  10-Nov-20......  World       When calculating arithmetic average/median, the study
     We Respond Quickly                           Medical     is included as 0%, because estimates in Table 6 are
     Enough? How Policy-                          and         insignificant and signs of estimates are mixed (higher
     Implementation Speed in                      Health      strictness can cause both fewer and more deaths). We
     Response to COVID-19                         Policy      don't calculate common standard errors.
     Affects the Number of
     Fatal Cases in Europe''
    ----------------------------------------------------------------------------------------------------------------
    Stokes et al. (2020);       6-Oct-20.......  medRxiv     We use estimates from regression on strictness alone
     ``The relative effects of                                (Right panel in Table ``Regression results, policy
     non-pharmaceutical                                       strictness.'' Baseline is ``policy not introduced
     interventions on early                                   within policy analysis period'' in ``Additional
     COVID-19 mortality:                                      file''). We use the average of 24 and 38 days from
     Natural experiment in 130                                model 5. There are 23 relevant estimates in total
     countries''                                              (they analyze all levels within the eight NPI measures
                                                              in the OxCGRT stringency index). We calculate the
                                                              effect of each NPI (e.g., closing schools) as the
                                                              average effect in all of U.S./Europe. This is done by
                                                              calculating the effect for each state/country based on
                                                              the maximum level for each measure between Mar 16th
                                                              and Apr 15th (e.g., if all schools in a state/country
                                                              are required to close (school closing level 3) the
                                                              relevant estimate for that state/level is -0.031
                                                              (average of -0.464 and 0.402). We assume all NPIs are
                                                              effective for 54 days (from March 15th to June 1st
                                                              minus 24 days to reach full effect). Standard errors
                                                              are converted to common standard errors following the
                                                              same process (this approach is unique for Stokes, as
                                                              our general approach is not possible).
    ----------------------------------------------------------------------------------------------------------------
    Toya and Skidmore (2020);   1-Apr-20.......  CESifo      It is unclear how they define ``lockdown.'' They write
     ``A Cross-Country                            Working     that ``many countries [. . .] imposed lockdowns of
     Analysis of the                              Papers      varying degrees, some imposing mandatory nationwide
     Determinants of COVID-19                                 lockdowns, restricting economic and social activity
     Fatalities''                                             deemed to be non-essential,'' and since all European
                                                              countries and all states in the U.S. imposed
                                                              restrictions on economic (closing unessential
                                                              businesses) and/or social (limiting large gatherings)
                                                              activity, we interpret this as all European countries
                                                              and all U.S. states had mandatory nationwide
                                                              lockdowns. The effect of recommended lockdowns is set
                                                              to zero in the meta-analysis, as only one country was
                                                              in this lockdown category (i.e., too few observations,
                                                              cf. eligibility criteria). The estimate for complete
                                                              travel closure is -0.226 COVID-deaths per 100,000.
                                                              Hence, if all of Europe imposed complete travel
                                                              closure, the total effect would be -0.266 * 748
                                                              million (population) * 10 (100,000/1,000,000) equal to
                                                              1,690 averted COVID-19 deaths. However, according to
                                                              OxCGRT-data European countries only had complete
                                                              travel bans (Level 4: ``Ban on all regions or total
                                                              border closure'') in 11% of the time between March 16
                                                              and April 15, 2020. So the total effect is 1,690 * 11%
                                                              = 194 averted deaths. During the first wave 188,000
                                                              deaths in Europe was related to COVID-19 (by June 30,
                                                              2020), so the total effect is approximated to -0.1% in
                                                              Europe and, following the same logic, 0% in U.S.,
                                                              where no states closed their borders completely. We
                                                              use the average, -0.05%, in the meta-analysis. The
                                                              estimate for mandatory national lockdown is 0.166 (>0)
                                                              COVID-deaths per 100,000. Since all European countries
                                                              (and U.S. states) imposed lockdowns, the total effect
                                                              is 1,241 (553) extra COVID-19 deaths corresponding to
                                                              0.7% (0.4%). We use the average of Europe and the
                                                              U.S., 0.5%, in the meta-analysis. Calculations of the
                                                              effect of ``Mandatory national lockdown'' follow the
                                                              same logic, but we assume 100% of Europe and United
                                                              States have had ``Mandatory national lockdown.''
    ----------------------------------------------------------------------------------------------------------------
    Tsai et al. (2021);         3-Oct-20.......  Oxford      The study is not included in the meta-analysis, as they
     ``Coronavirus Disease                        Academic    report the effect of NPIs on Rt which are not easily
     2019 (COVID-19)                                          converted to relative effects.
     Transmission in the
     United States Before
     Versus After Relaxation
     of Statewide Social
     Distancing Measures''
    ----------------------------------------------------------------------------------------------------------------

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                                     ______

                    Prepared Statement of Hon. Mike Crapo,
                           a U.S. Senator From Idaho
        Thank you, Mr. Chairman, and thank you, Dr. Murthy, for being here
    today.

        This discussion comes at a crucial time. Our Nation is confronting
    an unprecedented range of challenges, many of which have serious
    implications for the mental health of all Americans--especially
    children. From school closures to lockdowns and other COVID-related
    restrictions, the pandemic has intensified feelings of social
    isolation, helplessness, and anxiety. Since the pandemic began, we have
    witnessed alarming spikes in suicide attempts and suicidal ideation
    among teenagers, along with a staggering rise in drug overdose deaths.

        Dr. Murthy, as you noted in your advisory, rates of psychological
    distress among young people appear to have increased across the board
    in the past few years. Unfortunately, even prior to COVID-19, many of
    these trends pointed in the wrong direction. That said, I share your
    sense of optimism in tackling the urgent issues at hand. In communities
    across the country, we have seen families, faith leaders, policymakers,
    and health-care providers come together to craft creative and
    sustainable mental health prevention, access, and treatment solutions.

        Thanks to the chairman's leadership, we have the opportunity to
    bolster these efforts through a bipartisan process to advance targeted,
    consensus-driven, and fiscally responsible policies that drive better
    outcomes for all Americans. By focusing on shared priorities and
    adhering to core guiding principles, this process can culminate in
    comprehensive legislation that our colleagues across the political
    spectrum will enthusiastically support. Building consensus will
    maximize our ability to see the work we conduct here signed into law.
    We must also uphold fiscal integrity, fully paying for any and all
    provisions we look to enact.

        As working families across the Nation contend with the highest
    inflation in 40 years, strained finances pose a grave threat to health-
    care access. Unrestrained government spending risks pushing inflation
    even higher--further accelerating the decline of Americans' purchasing
    power. Moreover, with each passing year, we are steadily moving closer
    to the Medicare trust fund's exhaustion date, at which time the program
    will no longer be able to pay full benefits for our Nation's seniors.
    We must be thoughtful and cautious to avoid exacerbating the fiscal
    challenges we face.

        Likewise, we must ensure any pay-fors that we advance do not in any
    way compromise economic growth, undermine biomedical innovation, or
    undercut our recovery. Across-the-board bipartisan support will prove
    essential. By aligning our process with these basic principles and
    guard rails, we can produce a meaningful bill, carefully tailored to
    meet the challenges that confront us.

        This committee has a strong track record of generating consensus-
    based bills, from the CHRONIC Care Act to the Retirement Enhancement
    and Security Act, which ultimately passed as the SECURE Act in 2019. I
    truly believe we can replicate that success here.

        As the committee begins its work, we do so having built a strong
    foundation of shared interests and objectives. For instance, the
    pandemic has highlighted the pressing need for expanded access to
    telehealth, especially for Medicare beneficiaries. Our committee took
    an essential first step toward addressing these barriers by codifying
    permanent Medicare coverage for mental health services, regardless of
    geographic location, including services provided in the home. However,
    gaps remain, and we will work to bridge them here.

        Strengthening the mental and behavioral health workforce will also
    prove vital, especially in the face of widespread provider stress,
    fatigue, and burnout, which the pandemic has escalated. I hear every
    day from doctors, nurses, and other health-care professionals across
    Idaho who are looking to reduce hours or leave their practices entirely
    in the months to come, confronted with an unprecedented range of
    demands.

        Too often, sadly, policymakers have inadvertently added to these
    challenges, imposing bureaucratic requirements and tasks that divert
    attention from patient care and hinder providers' workplace wellness.
    As we navigate potential policy options, we should look to avenues for
    enhancing flexibilities, both for providers and for States, as they
    seek to improve and innovate across the continuum of care.

        These and other focal points, from encouraging service integration
    to promoting modernization, present opportunities for bipartisan
    discussions that will enable our health-care system to serve all
    Americans more effectively.

        In that spirit, I look forward to your testimony, Dr. Murthy, and
    to a timely discussion of mental and behavioral health solutions.

                                     ______

    Prepared Statement of Hon. Vivek H. Murthy, M.D., MBA, Surgeon General,
        Office of the Secretary, Department of Health and Human Services
        Chairman Wyden, Ranking Member Crapo, members of the committee, I'm
    Dr. Vivek Murthy. I have the privilege of speaking to you today as
    Surgeon General of the United States; as Vice Admiral in the United
    States Public Health Service Commissioned Corps; and as the father of
    two young children, who are four and five. They're the reason I'm
    grateful for this opportunity to speak with you today.

        Over the next few years, both of my children will enter an
    important stage of their education and development, where they'll learn
    how to build friendships, deal with problems, and lay the foundation of
    a personal values system. They and millions of their peers will start
    down the path to adulthood. Each path will be different. All will be
    filled with challenges along the way.

        It's these challenges that I want to talk about today. I'm deeply
    concerned, as a parent and as a doctor, that the obstacles this
    generation of young people face are unprecedented, and uniquely hard to
    navigate. And the impact that's having on their mental health--their
    emotional, psychological, and social well-being--is devastating.

        There are a number of longstanding, preventable factors driving
    this crisis of loneliness and hopelessness.

        The recent ubiquity of technology platforms, especially social
    media platforms, has had harmful effects on many children. Though
    undoubtedly a benefit to our lives in important ways, these platforms
    have also exacerbated feelings of isolation and futility for some
    youth. They've reduced time for positive in-person activities, pitted
    kids against each other, reinforced negative behaviors like bullying
    and exclusion, impeded healthy habits, and undermined the safe and
    supportive environments kids need to thrive.

        This increase in social media use has also contributed to a
    bombardment of messages that undermine this generation's sense of self-
    worth--messages that tell our kids with greater frequency and volume
    than ever before that they're not good looking enough, not popular
    enough, not smart enough, not rich enough.

        Meanwhile, progress on the issues that will determine the world
    they'll inherit, like economic inequality, climate change, racial
    injustice, LGBTQ rights, the opioid epidemic, and gun violence, feels
    too slow. It's undermining their sense of long-term safety, security,
    and opportunity. It's undercutting the fundamental American promise--
    their hope in the possibility of a better future.

        All of these factors affecting youth mental health were true before
    the COVID-19 pandemic. The pandemic has further exacerbated the
    stresses young people already faced, and at worst has pushed many to a
    breaking point. The last 2 years have dramatically changed young
    peoples' experiences at home, at school, and in their communities. It's
    not just the unfathomable number of deaths, or the instability caused
    by increased food insecurity, or the loss of health care, social
    services, or housing. It's also the pervasive uncertainty and the
    nagging sense of fear. It's the isolation from loved ones, friends, and
    communities at a moment when human support systems are irreplaceable.

        At the heart of our youth mental health crisis is a pervasive
    stigma that tells young people they should be embarrassed if they are
    struggling with depression, anxiety, stress, or loneliness. It makes a
    human condition feel inhuman. And it's a reflection of a broader
    societal perspective that mental health is, at best, the absence of
    disease, and at worst, a source of shame to be hidden and ignored. This
    stigma prevents vulnerable kids from seeking help and receiving the
    long-term recovery supports they need.

        I felt that stigma myself, 35 years ago, growing up in Miami as a
    kid who didn't look the same as the other kids, whose immigrant parents
    didn't eat the same food or dress the same way other parents did, who
    didn't live in the biggest house or get picked up after school in a
    fancy car. And when that led me to feel persistently lonely, isolated,
    and anxious--when it led me to get bullied and called racial slurs by
    classmates who constantly told me that I didn't belong, I felt a deep
    sense of shame. Like it was somehow my fault that I was alone and
    hurting. Like I had nowhere to go and no one, even my unconditionally
    loving and supportive family, to turn to for help.

        A world of shame and stigma, where children can't get the help they
    need, is not the world I want for my kids, your kids, and kids across
    our country. But, Senators, we are on the verge of beating back one
    public health crisis in COVID-19, only to see another grow in its
    place.

        In 2019, the year before the pandemic, one in three high school
    students reported persistent feelings of sadness or hopelessness, up 40
    percent from a decade prior; one in six made a suicide plan, a 44-
    percent increase over the same 10-year period. From 2011 to 2015, youth
    psychiatric visits to emergency departments for depression, anxiety,
    and behavioral challenges increased by 28 percent. And between 2007 and
    2018, suicide rates among youth ages 10-24 increased by 57 percent--a
    total of 65,026 young people lost.

        As devastating as these numbers are, the real tragedy is that we
    are failing to adequately respond to them. Even before the pandemic, we
    were not doing enough to provide adequate care and treatment options in
    every community--and COVID has only made this disparity worse. We are
    not doing enough as a country to build and maintain a sufficient and
    diverse mental health-care workforce. We are not doing enough to
    integrate the mental health-care system with the rest of the health-
    care system, to say nothing of the millions who still lack adequate and
    affordable insurance coverage. We are not doing enough to provide
    sufficient access to remote counseling.

        And we are not doing enough to prevent, and not just treat, this
    crisis. Many mental health challenges first emerge early in life--half
    of all lifetime mental health issues begin by age 14, and 75 percent
    begin by age 24. We are not doing enough to give young people the tools
    to prevent these challenges during a critical period of development,
    and the long-term impact is incalculable.

        As a result, the average delay between the onset of mental health
    symptoms and treatment is 11 years--11 long, isolating, confusing, and
    painful years.

        We have the opportunity and the responsibility to make change
    happen now. Late last year, I released my Surgeon General's Advisory,
    which outlines the policy, institutional, and individual changes it
    will take to reframe how we view, prioritize, treat, and prevent mental
    health challenges.

        Out of the many recommendations in the advisory, I'd like to
    highlight four today.

        First, ensuring that every child has access to high-quality,
    affordable, and culturally competent mental health care. To do this, we
    must make sure that children are enrolled in health coverage--far too
    many children in our country are eligible for coverage under Medicaid
    and the Children's Health Insurance Program, but aren't enrolled. We
    need to do better here. We also need to expand our mental health
    workforce, from clinical psychologists, school counselors, and
    psychiatrists, to recovery coaches and peer specialists. We have too
    few providers to meet the growing demand. And we need to make sure care
    is delivered at the right place and time, whether that's in health-care
    settings like primary care practices, or community-based settings like
    schools, and whether it's in-person or through telehealth. We know
    States and school districts are already using funds from the American
    Rescue Plan Elementary and Secondary Education Emergency Relief Fund to
    provide more counselors, other mental health providers, and nurses in
    schools. Those funds are available now to help meet our young peoples'
    critical mental health needs.

        Second, focusing on prevention, by investing in school and
    community-based programs that gave been shown to improve the mental
    health and emotional well-being of children at low cost and high
    benefit. Every dollar we spend on prevention is a dollar we won't have
    to spend on treatment--in fact, one study estimated that investment in
    early prevention offered a fourfold return down the line. These
    programs give kids tools to manage their emotions in healthy ways,
    build supportive relationships, and get help when they need it. They
    support families, teaching parents how to recognize challenges as they
    emerge, find available resources, and offer support and care.

        We've seen the extraordinary potential of certain strategies and
    programs--Project AWARE, Beyond Differences, and Family Check-Up, for
    example. We need to invest in scaling these programs across the
    country. And that must go hand in hand with continuing to address the
    systemic economic and social barriers, like safety, housing, food and
    economic insecurity, that contribute to and create the conditions for
    poor mental health for young people, families, and caregivers.

        Third, we need to better understand the impact that technology and
    social media has on mental health. At a minimum, if technology
    companies are going to continue to conduct a massive, national
    experiment on our kids, then public health experts and the public at
    large must be the ones to analyze the data, to draw the conclusions,
    and draft the recommendations--not the companies alone. That's how we
    give parents and caregivers the ability to make informed choices about
    their kids' use of technology. We should also act to ensure that these
    platforms are built to help and not harm the mental health of our
    youth, and are designed in an age appropriate way, with the health and
    well-being of all users, especially younger users, coming before profit
    and scale. Other countries, like the UK and Australia, are already
    taking innovative steps to protect their children, and so should the
    United States.

        The final recommendation concerns individual and community
    engagement--the role we each have to play in overcoming the stigma
    associated with seeking help. No child should feel ashamed of their
    hurt, confusion, or isolation, and no one should feel too ashamed to
    ask for help.

        If we don't keep working towards a culture that normalizes and
    promotes mental health care, that celebrates and finds hope in stories
    of people seeking help, getting treatment, and successfully recovering,
    then the consequences of our inattention and neglect will continue to
    ripple across generation, class, and geography. It's something we each,
    as parents, siblings, teachers, friends, and leaders, have the power to
    start changing today, by choosing to reach out to the kids in our
    lives, by letting them know that they are not alone in their struggles,
    and by sharing our own stories.

        I look forward to discussing these recommendations and
    possibilities with you today. Mitigating this crisis is possible, but
    it will take a bipartisan, all-of-society coalition of young people and
    their families, schools and health-care systems, technology and media
    companies, employers, community organizations, and governments alike. I
    thank you for recognizing this, and for your shared commitment to
    action.

        Our obligation to act is not just medical--it's moral. It's not
    only about saving lives. It's about listening to our kids, who are
    concerned about the state of the world they're set to inherit, and it's
    about our opportunity to rebuild the world we want to give them--a
    world that fundamentally refocuses our priorities on people and
    community, and builds a culture of kindness, inclusion, and respect.

        My job as Surgeon General is to help lay the foundation for a
    healthier Nation. That foundation isn't just built by putting warning
    labels on cigarette packs. It's built by focusing our attention on our
    Nation's most pressing public health concerns, and by fostering
    connection, community, and resilience. A house where people are
    isolated; where they feel left behind economically, socially, and
    professionally; where they feel unsafe; and where they feel like they
    don't matter, is a house that cannot stand.

        But I believe that, if we seize this moment, and step up for
    children and families in their moment of need, we can lay that
    foundation now. Throughout our history, progress has been born in the
    wake of tragedy. I'm eager to partner with you to make it happen again.

        Thank you for having me, and for giving this critical issue the
    attention it needs and deserves.

                                     ______

     Questions Submitted for the Record to Hon. Vivek H. Murthy, M.D., MBA
                  Questions Submitted by Hon. Thomas R. Carper
                       preventative services and schools
        Question. I want to thank you so much for your testimony today. I'd
    also like to thank Chairman Wyden for the opportunity to serve as a co-
    chair of this bipartisan working group on mental health. I'm thrilled
    to be chairing the Pediatrics and Young People portion of this effort
    with my friend and colleague, Senator Cassidy.

        The pediatric mental health crisis is not a challenge that this
    committee can meet alone. But those of us in this room, working with
    others who share our vision, like you, Dr. Murthy, can forge the way.
    And I believe we will.

        In one of my first acts as Governor, I established a Family
    Services Cabinet Council devoted to strengthening families. The goal of
    the council was to focus on prevention, so that rather than spending
    our resources treating the symptoms of our problems, we attack the root
    causes of those problems.

        Surgeon General Murthy, in your opening testimony, you mention that
    investing in school and community-based programs that have been shown
    to improve mental health and emotional well-being of children at low
    cost and high benefit.

        How can Congress further build on these preventative and effective
    services?

        Answer. It's essential to invest in prevention and early
    intervention--75 percent of the time, mental health symptoms emerge
    before age 24. To effectively support the mental health and emotional
    well-being of young people, we must act early and meet young people
    where they are. School- and community-based programs can and should
    play a critical role here. In the recent Surgeon General's advisory and
    in previous statements, I've highlighted programs such as Family Check-
    Up as an example of a promising and evidence-based intervention that
    has been shown to improve the mental health and emotional well-being of
    children at low cost and high benefit, as well as Project AWARE, an HHS
    grant program for State and tribal education agencies to advance
    wellness and resiliency for children and youth in school-based
    settings. We also should be thinking about reducing silos between
    schools and health-care organizations, for example by bringing mental
    health services to school campuses and providing sufficient funding so
    that these services can be sustained over time. Undergirding all of
    these efforts, we must continue to address the systemic economic and
    social barriers that contribute to poor mental health for young people,
    their families, and caregivers, including poverty.

        Primary prevention, which can address the root causes of mental
    health in children, is key. Toxic stress and other effects that result
    from exposure to Adverse Childhood Experiences (ACEs) can change brain
    development and affect how the body responds to stress. ACEs are
    strongly linked to mental illness, substance use, and chronic health
    conditions in adulthood. Research shows that preventing ACEs could have
    substantial positive impacts on public health and health outcomes and
    can enhance our public safety. For example, preventing ACEs could
    reduce the number of adults with depression by as much as 44 percent.
    CDC funds 6 recipients for Preventing Adverse Childhood Experiences:
    Data to Action \1\ to implement two or more prevention strategies from
    CDC's ACEs prevention resource, Preventing Adverse Childhood
    Experiences (ACEs): Leveraging the Best Available Evidence.\2\
    ---------------------------------------------------------------------------
        \1\ https://www.cdc.gov/violenceprevention/aces/preventingace-
    datatoaction.html.
        \2\ https://www.cdc.gov/violenceprevention/pdf/preventingACES.pdf.

        Secondary prevention, which includes screening to identify health
    concerns in their earlier stages, is also important. HRSA's Bright
    Futures Program develops
    evidence-driven guidelines for preventive care screenings and routine
    primary care visits for newborns through adolescents up to age 21. The
    Guidelines were recently updated to add universal screening for suicide
    risk to the current Depression Screening category for individuals ages
    12 to 21, and new guidance for behavioral, social, and emotional
    ---------------------------------------------------------------------------
    screening.

        In addition, schools play an essential role in the health and well-
    being of children and youth. Primary prevention in schools that focuses
    on improving emotional well-being for all students is very much in line
    with CDC's public health approach. Creating healthy and supportive
    school environments--from how teachers manage classrooms, to programs
    that promote social and emotional learning, to policies and practices
    that support LGBTQ youth--have a strong and lifelong impact on mental
    health. CDC's unique role is to lead the Nation's prevention efforts to
    protect and improve the health of adolescents. CDC collects data that
    drive action and partners with schools to implement a comprehensive
    public health approach that helps protect against negative outcomes
    among youth. For example, CDC's ``What Works in Schools'' approach to
    primary prevention in local school districts improves health education,
    connects youth to the services they need, and creates safer and more
    supportive school environments for students and educators alike. This
    approach has demonstrated positive impacts on substance use, sexual
    risk, exposure to violence, public safety, and mental health among
    students in schools that implement the approach. It represents an
    important tool to address the current mental health crisis among our
    young people. In addition, CDC's Whole School, Whole Community, Whole
    Child (WSCC) model, is a comprehensive, student-centered, school health
    approach that emphasizes the role of the community in supporting the
    school, the connections between health and academic achievement and the
    importance of evidence-based school policies and practices.

        Research demonstrates that healthy and supportive school
    environments, school connectedness, and parent engagement positively
    affect health behaviors, and improve emotional well-being for students
    and enhance the safety of school communities for educators and students
    alike.

        Congress can fund programs through legislation that supports a
    public health model which would include all three levels of
    intervention. This model provides both preventive and effective
    services for children who are in need across setting (i.e., schools,
    communities, or health care), risk factors (i.e., poverty or substance
    misuse) or concern (i.e., suicide or depression). This public health
    model would enhance public safety outcomes as well.

        The first level is universal, providing education on mental health
    literacy and suicide prevention to children (as age appropriate) and
    school personnel. These tools assist school personnel in recognizing
    those children who need additional help. The second level identifies
    children at risk and assessing, in conjunction with their families, if
    they need clinical assistance. The third level is referring children
    who need more intensive mental health treatment to qualified providers
    in their community.

        It is critical that we acknowledge the grief and loss that children
    and youth have faced and help both students and adults engage in
    meaningful activities of resilience in the face of the pandemic and its
    effects of social isolation as well as the loss of caring adults in
    their lives. Therefore, ensuring that the school climate, for all
    children, is nurturing and supportive to address their needs.

        Some children have additional risk factors (e.g., death of a care
    giver, loss of parental employment, etc.) that need additional
    attention. It is important to support educators' efficacy in
    identifying the mental health needs of their students by providing
    ongoing opportunities and incentives for training in mental health
    literacy and referral strategies. Providing Youth Mental Health First
    Aid has been a successful strategy for SAMHSA's Project Advancing
    Wellness and Resiliency in Education (AWARE) grantees.

        Finally, Congress can work to ensure that children that need
    intensive specialty mental health services quickly gain access to
    services with providers specialized to provide care. Our educators play
    an important role in the health and well-being of all our
    children.These educators are critical in fostering a supportive
    classroom climate, supporting all children at risk for behavioral
    health conditions and who need good working knowledge of treatment
    resources.
                          public-private partnerships
        Question. Thank you for your Surgeon General's advisory on the
    youth mental health crisis. We are seeing this crisis play out in
    Delaware. At Nemours Children's Hospital, Delaware, from 2020 to 2021,
    there was an 80-percent increase in patients in the ED with chief
    concerns of suicidality or intentional harm. And this trend can be seen
    across the country.

        What are some specific areas where you think philanthropy, private
    business, and health systems leaders can partner with the Federal
    Government to make short-term and long-term impact in addressing the
    youth mental health crisis? What do you see as low-hanging fruit and
    more challenging issues that could be addressed through a public-
    private partnership, and what might some early action steps be?

        Answer. I see at least four opportunities for public-private
    partnerships to support youth mental health.

        First, we should think creatively about how to sustainably finance
    new mental health care delivery models, such as school-based programs
    that enroll children in health coverage and make services more
    accessible and convenient for young people and their families. Multiple
    funding sources could be used to support these models, including
    Federal Medicaid funding, State funding, private insurance, and private
    and philanthropic funding.

        Second, public-private partnerships can improve our understanding
    of how technology and social media affect mental health. For example,
    technology companies could partner with academic researchers,
    governments, and community organizations to foster and enable more
    research, develop best practices around and encourage healthy online
    behavior, and help parents and caregivers make informed choices about
    their children's use of technology.

        Third, public-private partnerships can create sustained investments
    in addressing the social and economic barriers, such as poverty,
    discrimination, food insecurity, and adverse childhood experiences,
    that affect children's healthy development and mental health. The scale
    and complexity of mental health challenges among young people require
    collaborative approaches across stakeholders.

        And fourth, public-private partnerships can educate others about
    mental health through education, information sharing, and story-telling
    campaigns to help overcome the stigmatization associated with seeking
    help. For example, members of the sports and entertainment industry
    could partner with governments, community organizations, and schools to
    share stories about mental health challenges, raise awareness, and
    reduce negative biases and beliefs about mental health care. The
    President's Council on Sports, Fitness and Nutrition could be involved
    to foster partnerships, as they have a focus under this administration
    on mental health and physical activity and good nutrition. In addition,
    private businesses and employers could partner with health systems to
    provide support for employees and families who are affected by mental
    health challenges.

        For additional recommendations for funders and foundations, please
    see the Surgeon General's Advisory on Protecting Youth Mental Health.
                           national response to grief
        Question. My staff and I have heard from behavioral health
    providers in Delaware that dealing with grief from the loss of family
    members due to COVID-19 has been particularly challenging for the
    pediatric population.

        What strategies do you see as most effective in helping to support
    our Nation's children and youth cope with grief, and is there
    additional support needed from Congress to bolster our response?

        Answer. It's critical to support young people coping with grief and
    trauma, including those who tragically lost a parent or caregiver to
    COVID-19. These young people may be at risk for long-term mental health
    consequences as a result of these experiences. SAMHSA's National Child
    Traumatic Stress Initiative (NCTSI) works to improve treatment and
    services for young people and families experiencing traumatic events.
    The initiative has a national network of grantees that work
    collaboratively to promote effective community practices for those
    exposed to trauma. In addition, the initiative includes education
    materials for families and other stakeholders, as well as technical
    assistance for professionals.

        Additionally, title IV-E of the Social Security Act provides
    Federal reimbursement to States for a part of the cost of providing
    foster care, adoption assistance, and kinship guardianship assistance
    on behalf of each child who meets Federal eligibility criteria.
    Reimbursements provide foster care maintenance payments, adoption
    assistance, and, at the agency's option, a guardianship assistance
    program. While some children are entitled to receive Social Security
    survivors' benefits that provide access to financial support, not all
    children who are eligible receive these benefits.

        In addition to providing Federal funding to support youth who have
    lost family members due to COVID-19, we should continue building
    partnerships across health-care providers, educators, community
    organizations, and others to provide trauma-informed support to these
    young people. Moreover, additional funding and partnerships are needed
    to address disparities in maternal mortality and support youth and
    families affected by these losses.

        It may also be useful to frame mental health as wellness, and
    proactively identify students or staff in need of extra support.
    Additionally, an effective strategy is to support educators' efficacy
    in identifying the mental health needs of their students by providing
    ongoing opportunities and incentives for training in mental health
    literacy and referral strategies. As stated above, providing Youth
    Mental Health First Aid has been a successful strategy for our Project
    AWARE grantees. It is also helpful to connect youth to individuals with
    lived experience. One way to do this is to engage with trainers who
    have lived experience with mental illness and dedicate classroom and/or
    staff time to hearing their stories.

        There are several ways to ensure that children receive mental
    health services for grief, for anxiety, and for depression. One is to
    provide them in age-appropriate settings. Another is to meet them where
    they are, thereby creating a no-wrong door approach to accessing
    services by integrating mental health screening, robust referral
    pathways, and culturally responsive and developmentally appropriate
    approaches into all settings in which children, youth, and their
    families spend the most time. Strategies that are implemented should
    strive to serve young people and caregivers where they are, in a
    language that they speak, with a provider that understands their lived
    experience. Additional strategies include those that teach and model
    mental health as wellness from an early age and integrate positive
    mental health stories into curricula across subjects.

        Additional actions that are effective include providing
    professional development to classroom educators on the academic impact
    of mental health literacy and trauma, teaching them that student
    performance is linked to mental health and wellness as a strategy to
    increase their commitment to promoting trauma-informed, and grief-
    sensitive frameworks. Key clinical practices that have a strong
    evidence-base or are promising practices to address child traumatic
    grief include interventions such as Child Parent Psychotherapy (CPP),
    Parent-Child Interaction Therapy (PCIT),
    Trauma-Focused Cognitive Behavioral Therapy (TF-CBT), and Combined
    Parent-Child Cognitive Behavioral Therapy (CPC-CBT).

        Finally, strategies should ensure that postvention initiatives that
    help children and youth recover from pandemic-related grief and create
    resilience for facing future grief and loss are provided to children,
    teachers, and families.

                                     ______

                   Questions Submitted by Hon. Sherrod Brown
                             continuous eligibility
        Question. Together, Medicaid and the Children's Health Insurance
    Program (CHIP) provide health-care coverage to nearly 40 million \3\
    children. Unfortunately, eligible Medicaid and CHIP beneficiaries--
    including many kids--periodically ``churn'' or lose coverage only to
    regain it again just weeks or months later. These children do not lose
    coverage because they become long-term ineligible for the program--
    instead, they are often disenrolled from the program due to
    administrative burdens, bureaucratic snafus, or when their parents
    experience short-term changes in income. This leads to a vicious cycle
    where kids get kicked off the program, interrupting their treatment
    programs, severing their continuity of care, and undermining quality
    monitoring efforts. These disruptions to care can be particularly
    challenging for children with behavioral health needs.
    ---------------------------------------------------------------------------
        \3\ https://www.kff.org/medicaid/state-indicator/total-medicaid-
    and-chip-child-enrollment/?cur
    rentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22as
    c%22%7D.

        Despite being eligible for the program, on average, kids enrolled
    in Medicaid are only covered for less than 10 months out of the year.
    Churning in and out of health coverage has a direct, negative effect on
    beneficiaries as well as the ability of doctors, hospitals, and health
    plans to provide effective, continuous care--not just for kids'
    ---------------------------------------------------------------------------
    physical health, but for their mental health as well.

        Under current law, States have the option to provide 12-months of
    continuous coverage for children. States that elect this option have
    helped eliminate coverage gaps caused by slight fluctuations in income
    over the course of the year.

        In your opinion, would requiring States to extend 12-month
    continuous coverage--as proposed in my Stabilize Medicaid and CHIP
    Coverage Act (S. 646) for children who rely on Medicaid and CHIP for
    their health insurance coverage help increase stability in coverage and
    improve access to essential mental health services for those children
    in need?

        Are there other advantages to requiring continuous coverage for
    children in Medicaid and CHIP?

        Answer. Medicaid and CHIP are incredibly important lifelines for
    almost 87 million individuals who are enrolled in these programs,
    including over 40 million children as of January 2022. The Biden-Harris
    administration is committed to ensuring that every eligible person can
    access the coverage and care to which they are entitled.

        According to a report released by the Assistant Secretary for
    Planning and Evaluation (ASPE) in April 2021, individuals who
    experience coverage disruptions are more likely to delay care, receive
    less preventive care, refill prescriptions less often, and have more
    emergency department visits. Children with interruptions in coverage
    also are more likely to have delayed care, unmet medical needs, and
    unfilled prescriptions. Continuous coverage or allowing beneficiaries
    to maintain Medicaid coverage for a set period of time irrespective of
    changes in their circumstances, helps prevents disruptions in health
    care for beneficiaries and provides States more predictable and
    efficient spending.

        Federal law provides States with the option to implement a variety
    of strategies to promote continuity of coverage, including continuous
    eligibility for children. States have the option to provide children
    with 12 months of continuous coverage under CHIP and Medicaid, even if
    the family experiences a change in income during the year. Continuous
    eligibility is a valuable tool that helps States ensure that children
    stay enrolled in the health coverage for which they are eligible and
    have consistent access to needed health-care services.

        In addition to this flexibility, CMS is using every available tool
    to expand access to coverage and care. In January, supporting President
    Biden's 2021 Executive Order 14009 \4\ on Strengthening Medicaid and
    the Affordable Care Act, CMS committed $49.4 million to fund
    organizations that can connect more eligible children, parents, and
    pregnant individuals to health-care coverage through Medicaid and CHIP.
    Awardees--including State/local governments, tribal organizations,
    Federal health safety net organizations, non-profits, schools, and
    others--will receive up to $1.5 million each for a 3-year period to
    reduce the number of uninsured children by advancing Medicaid and CHIP
    enrollment and retention. Funded organizations will provide enrollment
    and renewal assistance to children and their families, as well as
    pregnant people.
    ---------------------------------------------------------------------------
        \4\ https://www.govinfo.gov/content/pkg/FR-2021-02-02/pdf/2021-
    02252.pdf.

        In November 2021, through its Medicaid and CHIP Coverage Learning
    Collaborative, CMS published an issue brief, Connecting Kids to
    Coverage: State Outreach, Enrollment, and Retention Strategies,
    highlighting effective and practical strategies that States, providers
    and health plans can use to ensure eligible individuals are able to
    enroll in and retain Medicaid and CHIP coverage, including adopting
    ---------------------------------------------------------------------------
    continuous eligibility for children.

        In February 2022, CMS also issued a Request for Information (RFI)
    \5\ on access to care and coverage for people enrolled in Medicaid and
    CHIP. Feedback obtained from the RFI will aid in CMS's understanding of
    enrollees' barriers to enrolling in and maintaining coverage and
    accessing needed health-care services and support through Medicaid and
    CHIP. This information will help inform future policies, monitoring,
    and regulatory actions, helping ensure beneficiaries have equitable
    access to high-quality and appropriate care across all Medicaid and
    CHIP payment and delivery systems, including fee-for-service, managed
    care, and alternative payment models. The RFI submissions will also
    inform CMS's work to ensure timely access to critical services, such as
    behavioral health care and home and community-based services.
    ---------------------------------------------------------------------------
        \5\ https://cmsmedicaidaccessrfi.gov1.qualtrics.com/jfe/form/
    SV_6EYj9eLS9b74Npk.

        I look forward to working with Congress and partners across the
    Federal Government to expand on this important work and connect
    eligible children, parents, and pregnant individuals to health-care
    coverage through Medicaid and CHIP.
               senate finance committee mental health initiative
        Question. As part of the Senate Finance Committee (SFC)'s work on
    mental health, the committee has identified five focus areas for
    improving the mental health-care system. Two of these focus areas are:
    (1) strengthening the workforce, and (2) increasing integration. I have
    a couple questions specific to each focus area.

        Our country is experiencing a shortage of mental and behavioral
    health providers. It is clear we need to do more to strengthen this
    essential health-care workforce.

        What steps should the SFC working group/Congress take to strengthen
    and address the gaps in our behavioral health workforce pipeline?

        Answer. The SFC working group/Congress may consider some of the
    Health Resources and Services Administration's (HRSA's) most successful
    programs for sustaining the workforce pipeline across various medical
    disciplines that are listed below. Many of them help health-care
    professionals continue their training and education or assist in
    placing providers in areas of greatest need by providing financial
    incentives through scholarship and loan repayment programs.

            The Nurse Corps SP offers scholarships to nursing students in
    exchange for an agreement to work in a Critical Shortage Facility (CSF)
    for at least 2 years upon graduation from an accredited school of
    nursing. CSFs are located in Health Professional Shortage Areas
    (HPSAs), which include rural communities and other identified
    geographic areas with populations that lack access to both primary care
    and behavioral health services.
            The National Health Service Corps (NHSC) SP provides financial
    support through scholarships, including tuition, other reasonable
    education expenses, and a monthly living stipend to health professions
    students committed to providing primary care in underserved communities
    of greatest need. Awards are targeted to individuals who demonstrate
    characteristics that are indicative of success in a career in primary
    care in underserved communities
            The NHSC Students to Service LRP provides loan repayment
    assistance of up to $120,000 to students in their last year of
    allopathic or osteopathic medical, dental, physician assistant, or
    nursing school in return for a commitment to provide primary health
    care in rural and urban HPSAs of greatest need for 3 years. This
    program was established to increase the number of physicians and
    dentists in the NHSC pipeline.

        HRSA has several other programs which work to place students into
    the primary and behavioral health pipeline, including the Area Health
    Education Centers (AHEC), the Centers of Excellence (COE) Program, and
    the Health Careers Opportunity Program (HCOP). All of these programs
    focus on developing a primary care and behavioral health workforce that
    is equipped to provide quality services to underserved and rural areas
    and enhancing cultural competency in the provision of services.

        Question. Are there ways that Medicare and/or Medicaid can better
    support the training of mental health professionals--including, but not
    limited to--psychiatrists, clinical psychologists, nurses, licensed
    professional counselors, licensed marriage and family therapists,
    licensed counselors, social workers, and certified peer specialists,
    across settings of care, including community settings such as certified
    community behavioral health clinics, community health centers, and
    schools?

        Answer. The training and retention of physicians and other health-
    care professionals is critical to ensuring access to health care in
    underserved communities that have historically experienced workforce
    challenges, including with delivering culturally competent care. In
    December, CMS issued a final rule that will enhance the health-care
    workforce and fund additional medical residency positions in hospitals
    serving rural and underserved communities, including areas with a
    shortage of mental health-care providers. The Fiscal Year (FY) 2022
    Inpatient Prospective Payment System (IPPS) final rule with comment
    period establishes policies to distribute 1,000 new Medicare-funded
    physician residency slots to qualifying hospitals, phasing in 200 slots
    per year over 5 years. CMS estimates that funding for the additional
    residency slots, once fully phased in, will total approximately $1.8
    billion over the next 10 years. In implementing a section of the
    Consolidated Appropriations Act (CAA), 2021, this is the largest
    increase in Medicare-funded residency slots in over 25 years. In
    allocating these new residency slots, CMS will prioritize hospitals
    with training programs in areas demonstrating the greatest need for
    providers, as determined by Health Professional Shortage Areas (HPSA).
    The first round of 200 residency slots will be announced by January 31,
    2023 and will become effective July 1, 2023. In addition, under the
    HPSA Physician Bonus Program, CMS pays a 10-percent bonus to
    psychiatrists who deliver services to Medicare patients in the areas
    that have a geographic mental health HPSA designation.

        In September 2019, CMS awarded $50 million in planning grants to 15
    States to increase the capacity of Medicaid providers to deliver
    substance use disorder (SUD) treatment or recovery services, including
    through recruitment, training, and technical assistance for such
    providers. In September 2021, CMS selected five States (of those that
    received planning grants) to participate in 36-month demonstrations
    that provide enhanced Federal reimbursement for increases in Medicaid
    expenditures for SUD treatment and recovery services.

        Question. What impact does integrating primary and behavioral
    health care have on improving children's mental health and development?

        Answer. Research has shown that the integration of mental health
    and primary care makes a difference for infants, children, and
    adolescents by expanding access to mental health care, improving health
    and functional outcomes, increased satisfaction with care, cost
    savings, and improved coordination among primary care clinicians and
    behavioral providers in clinics and school-based and community
    settings. Integration further destigmatizes help-seeking and creates
    the opportunity for whole-child, whole-family care. When treatment is
    delivered in the school setting, youth are far more likely to be
    identified early, and to initiate and complete care.

        Co-location of services in schools reduces health-care disparities
    and ensures that all children, regardless of socioeconomic
    circumstances, have more equitable access to behavioral health care.
    When students are provided with mental health promotion education and
    accessible mental health interventions in schools, the result is
    positive steps toward remedying student inequities in both education
    and health care.

        Additionally, the integration of primary care and behavioral health
    services allows for the provision of whole-patient care in a timely and
    accessible manner. A recent report from the Milbank Memorial Fund
    revealed:

            Nearly one in seven children aged 2 to 8 years in the United
            States has a mental, behavioral, or developmental disorder.
            Among children and adolescents aged 9 to 17 years, as many as
            one in five may have a diagnosable psychiatric disorder. Yet no
            State in the country has an adequate supply of child
            psychiatrists, and 43 States are considered to have a severe
            shortage.\6\
    ---------------------------------------------------------------------------
        \6\ Tobin Tyler, Elizabeth, Hulkower, Rachel, and Kaminski,
    Jennifer. (2017). ``Behavioral Health Integration in Pediatric Primary
    Care: Considerations and Opportunities for Policymakers, Planners, and
    Providers.'' Milbank Memorial Fund.

        For many, primary care is the first point of entry into the health-
    care system and children routinely access primary care for well child
    examinations, vaccinations and routine care. Therefore, primary care
    providers are well-situated to identify and address substance misuse
    among their patients. In this way, the integration of primary and
    behavioral health-care facilitates timely access to services that
    directly impact mental health and development. Primary care providers
    are skilled in the identification and triage of childhood mental health
    developmental issues. Integration of primary and behavioral health care
    allows for the rapid provision of comprehensive services that
    positively impact the child's development. Additionally, addressing
    behavioral health routinely within primary care settings is likely to
    reduce stigmatization of families with children who need these
    ---------------------------------------------------------------------------
    services.

        Integrating behavioral health into primary care helps improve
    behavioral and physical health outcomes, as it increases access to
    care, reduces stigmatization, and allows patients to receive
    comprehensive care. The American Academy of Child and Adolescent
    Psychiatry (AACAP) drafted a policy on the importance of collaborating
    with pediatric medical professions. The data shows that approximately
    half of all pediatric primary care office visits involve behavioral,
    psychosocial, and/or educational concerns. In a joint paper, AACAP and
    The American Academy of Pediatrics (AAP) notes integrated behavioral
    health in pediatric primary care has the potential to reduce health
    disparities and improve service utilization. HRSA includes the
    integrated behavioral health into primary care model in several
    workforce development, service, and technical assistance programs.

        Additionally, this approach enables pediatric primary care
    providers to support early identification, diagnosis, treatment and
    referral for children and adolescents with behavioral health
    conditions. Providing services such as tele-consultation, training,
    technical assistance, and care coordination to pediatric primary care
    providers can help providers make behavioral health support a routine
    part of children's health-care services. For example, HRSA's Pediatric
    Mental Health Care Access (PMHCA) Program supports behavioral health
    integration in pediatric primary care through new or expanded State or
    regional pediatric mental health-care access telehealth programs. The
    PMHCA program addresses nationwide shortages of psychiatrists,
    developmental-behavioral pediatricians, and other behavioral health
    clinicians who can identify behavioral concerns in children and
    adolescents by enhancing the capacity of pediatric primary care in
    addressing the behavioral health needs of their patients.

        Question. What steps should the SFC working group/Congress take to
    ensure more families have access to pediatric integrated primary and
    behavioral health care?

        Answer. The SFC working group and Congress should consider
    mechanisms to increase training in behavioral health care among
    professional schools, medical schools and specialist/residency
    programs. This will expand the workforce, while also augmenting the
    training that medical specialists and primary care providers undertake
    in the provision of behavioral health care.

        Additionally, traditional fee-for-service billing practices have
    created barriers to innovations in behavioral health integration by
    limiting or prohibiting reimbursement for behavioral health specialist
    consultation, care coordination, or physical and mental health services
    provided on the same day. Another obstacle to integration has been
    mental health carve-outs, in which an insurer or managed care
    organization contracts separately for behavioral and physical health
    services and will only pay for behavioral health services provided by a
    specified behavioral health organization.\7\
    ---------------------------------------------------------------------------
        \7\ O'Donnell, A.N., Williams, M., and Kilbourne, A.M. ``Overcoming
    roadblocks: Current and emerging reimbursement strategies for
    integrated mental health services in primary care.'' J Gen Intern Med.
    2013;28(12):1667-1672.

        Although changes to fee-for-service payment structures could
    facilitate pediatric behavioral health integration, the most promising
    opportunities for behavioral health integration initiatives might occur
    through health-care system and payment reform. A striking example can
    be found in the Affordable Care Act's adoption of mental health and
    substance use disorder services, including behavioral health treatment,
    as an essential health benefit. This has reduced the stigmatization and
    isolation of behavioral health services. Also, Medicaid expansion in
    some States has helped drive behavioral health integration by
    increasing the funding available to Medicaid managed care programs and
    community health centers to broaden and better integrate services.\8\
    ---------------------------------------------------------------------------
        \8\ Searing, A., Hoadley, J. ``Medicaid expansion: driving
    innovation in behavioral health integration.'' Health Affairs Blog.
    http://healthaffairs.org/blog/2016/07/05/medicaid-expansion-driving-
    innovation-in-behavioral-health-integration/. Published July 5, 2016.

        We need to provide a full spectrum of primary care wellness
    including both physical and mental health care in schools. The Hopeful
    Futures Campaign \9\ produces report cards that provide data on the
    provision of mental health care in all 50 States and in the District of
    Columbia.
    ---------------------------------------------------------------------------
        \9\ https://hopefulfutures.us/.

        Ensuring that our rural and frontier communities have the trained
    and supported work force that they need to meet the needs of their
    children is critically important. We need to provide care, relief, and
    support to those already in the field and expand the pipeline of new
    providers through workforce development activities such as training
    grants, fellowship programs, scholarships, and loan forgiveness.
    Building a distributive workforce is key to ensuring that we provide
    ---------------------------------------------------------------------------
    the services and supports at all levels of the public health model.

        It is also critical to promote and support programs that integrate
    behavioral health-care services into primary and preventative health
    care. COVID-19 has highlighted the critical need for expanded access to
    mental health services, particularly for children whose lives and
    educations were acutely impacted by COVID-19. One lever we can pull to
    affect change in this space is HRSA's Health Center Program. HRSA funds
    nearly 1,400 health center organizations that serve as the primary care
    medical home for nearly 8 million children nationwide, providing access
    to comprehensive and preventive primary health care--including mental
    health services--critical to the overall health of America's youth.

        The following are examples of programs that have a direct focus on
    increasing integrated care in community-based settings: the Children's
    Hospital Graduate Medical Education (CHGME) payment program, the
    Teaching Health Center Graduate Medical Education (THCGME) program, and
    the Preventive Medicine Residency (PMR) program.

        The Children's Hospitals Graduate Medical Education (CHGME) payment
    program provides funds to freestanding children's teaching hospitals.
    This program supports the education and training of resident physicians
    and helps to increase access to quality care.

        The Teaching Health Center Graduate Medical Education (THCGME)
    program supports the training of primary care physician and dental
    residents, increasing the overall number of these primary care
    providers.

        The Preventive Medicine Residency (PMR) program provides support
    for residents in medical training in preventive medicine, including
    stipends for residents to defray the costs associated with living
    expenses, tuition, and fees.

        Continued support from Congress to increase the reach of programs
    such as the Pediatric Mental Health Care Access (PMHCA) program and
    further expand resources such as the Bright Futures guidelines will
    help ensure more families have access to integrated pediatric primary
    and behavioral health care. The PMHCA program works to address the
    shortages of psychiatrists, developmental-behavioral pediatricians, and
    other behavioral health clinicians who can identify behavioral concerns
    in children and adolescents using telehealth technologies. HRSA's
    Bright Futures program develops evidence-driven guidelines for
    preventive care screenings and routine primary care visits for newborns
    through adolescents up to age 21.

        Question. How can we help to increase access to integrated care
    within
    community-based settings, including schools?

        Answer. Addressing the mental health needs of students requires
    reaching them where they are most likely to gather and spend the
    majority of their time. Schools, community centers, and other venues
    offer important touchpoints for those who may need services, but often
    the availability of resources can be uneven. Enhancing mental health
    training for school health officials may be helpful. Additionally,
    implementing policies for more widespread Screening, Brief Intervention
    and Referral to Treatment (SBIRT) can be helpful in identifying those
    at risk for substance use disorders. Staff should also receive mental
    health training to identify those at risk so that they may mitigate
    adverse outcomes.

        Additionally, we need to reframe mental health as wellness to
    acknowledge and invest in child wellness promotion strategies that
    recognize that wellness exists on a continuum and is impacted by
    factors both within and outside of the individual--underscoring the
    need for engagement by educators, family, and the greater community.
    Comprehensive school mental health systems that consist of partnerships
    between the education and behavioral health sectors that support a full
    continuum of mental health services, are needed to ensure that children
    receive the level of care that they need--from promotion, prevention,
    early identification, to treatment. Using a three-tiered model ensures
    that children receive the individualized and comprehensive help that
    they need. The first level is universal, providing education, mental
    health literacy, and suicide prevention to children (as age-
    appropriate) and trained school personnel to provide support. These
    services assist school personnel in recognizing those children who need
    additional help. The second level identifies children at risk and
    assesses, in conjunction with their families, if they need clinical
    assistance. The third level is referring children who need more
    intensive mental health treatment to accessible qualified providers in
    their community.

        We can educate school and other child-serving leaders on the
    connection between mental health and academic, social, and economic
    success and ensure that school personnel are trained in mental health
    literacy and suicide prevention strategies so that we build the
    capacity of the broad child-serving workforce to identify needs and
    refer children to behavioral health care. Having school-based
    behavioral health professionals and adequate and accessible treatment
    resources in the community is key to ensuring that children receive the
    kind of supports and services that they need.

        We need to ensure that we have robust school-community
    partnerships. We can incentivize schools to establish formal
    partnerships (such as memoranda of understanding) with community
    behavioral health providers to offer on-site school mental health
    services and supports and to facilitate referrals, access, and
    coordination of community-based mental health services. As wellness
    partners with community-based providers, school-based staff have
    greater knowledge and confidence that students will receive high-
    quality and culturally competent care, making them more likely to refer
    to community-based programs. Co-location in schools makes it easier to
    connect caregivers with needed services and builds trust between
    providers and children and their families.

        For example, HRSA continues to address the comprehensive health-
    care needs of communities across the Nation through the Health Center
    Program. These 1,400 health centers operate more than 14,000 service
    sites that serve nearly 29 million people nationwide, including one in
    three people living in poverty, one in five people living in rural
    communities, and one in eight children. These community-based and
    patient-directed organizations ensure access to affordable, high-
    quality, and cost-
    effective primary health care regardless of the patients' ability to
    pay.

        HRSA funds more than 3,200 school-based health centers and section
    330 school-based service sites in 52 States and territories. In 2020,
    despite the temporary closures of many schools due to COVID-19, such
    sites served more than 650,000 pediatric patients. Both kinds of
    service sites are access points for comprehensive primary health-care
    services that extend well beyond the band-aid or ice pack of the
    traditional school nurse. Across the country, HRSA is funding a full
    range of age-appropriate health-care services, typically including
    primary medical care, mental/behavioral health care, dental/oral health
    care, health education and promotion, substance abuse counseling, case
    management, and nutrition education. The specific services provided at
    a site vary based on community needs and resources; the services also
    consider collaborations between the community, the health center, and
    school districts.

        HRSA, in collaboration with CDC, leads the National Coordinating
    Committee on School Health and Safety (NCCSHS), which supports student
    well-being and ensures that school facilities are healthy and safe
    environments.

        In addition, HRSA's Collaborative Improvement and Innovation
    Network (CoIIN) on School-Based Health Services (SBHS) improves
    children and adolescents' access to high-quality, comprehensive health
    care by expanding use of evidence-based models of school-based health
    (SBH) services, including SBH centers and comprehensive school mental
    health systems (CSMHSs). The CoIIN-SBHS provides trauma-
    informed, behavioral health technical assistance to State partners
    (such as title V Maternal and Child Health programs, State Medicaid
    programs, child mental health agencies, education agencies, State-level
    non-profit organizations), school districts, CSMHSs, and SBH centers.

        Furthermore, investments in programs that have a direct focus on
    integrated care can help increase access to care in community-based
    settings. Examples of HRSA programs in this area include the Children's
    Hospital Graduate Medical Education (CHGME) payment program, the
    Teaching Health Center Graduate Medical Education (THCGME) program, and
    the Preventive Medicine Residency (PMR) program.

                                     ______

                Question Submitted by Hon. Robert P. Casey, Jr.
        Question. Because Medicaid is the single largest health insurer for
    children in the U.S., improvements to the program can have a
    significant impact on children's mental health. It's important to align
    payment and delivery models with our aims of increasing children's
    access to mental health support. In the advisory, you mentioned the
    ``Integrated Care for Kids'' (InCK) model demonstration, which aims to
    reduce spending and improve care for children covered by Medicaid
    through prevention, early identification, and treatment of behavioral
    and physical health needs. I look forward to learning the effects of
    that model on mental health outcomes for children. But, today, that
    model is only in seven States.

        How can we scale successful models of integrated care, and do you
    have any other recommendations for how Medicaid can better integrate
    physical and behavioral health for children?

        Answer. The Biden-Harris administration is committed to partnering
    with States to improve and strengthen Medicaid and CHIP, including by
    encouraging States to increase efforts that integrate physical and
    behavioral health services for children. In addition to the Integrated
    Care for Kids (InCK) model, CMS administered the Medicaid Innovation
    Accelerator Program (IAP) from July 2014 through September 2020. The
    goal of IAP was to improve the health and health care of Medicaid
    beneficiaries and to reduce costs by supporting States' ongoing payment
    and delivery system reforms. Medicaid IAP supported Medicaid agencies
    with building capacity in key program and functional areas by offering
    targeted technical assistance, tool development, and cross-State
    learning opportunities. Among other efforts, the IAP provided nine
    State Medicaid agencies with technical support and resources to assist
    them in expanding or enhancing physical and mental health integration
    efforts in their States. Based on this work, CMS developed and released
    several tools and resources States can use to align State policies to
    support physical and mental health integration and promote provider
    capacity for physical and mental health integration.

        The partnership between States and the Federal Government is
    central to Medicaid, and the Biden-Harris administration is committed
    to supporting State innovation and States' ability to test different
    models that meet the unique needs of their residents. I look forward to
    working with Congress and partners across the Federal Government to
    continue to expand efforts to integrate physical and mental health
    services.

                                     ______

                 Questions Submitted by Hon. Sheldon Whitehouse
        Question. One of my constituents, Mara, living in Bristol, RI,
    shared with me that she nearly lost her 14-year-old daughter to
    anorexia. Her daughter was hospitalized for weeks at Hasbro Children's
    Hospital. Her doctors and parents believe that social media content
    contributed to her illness. Your advisory calls on the Federal
    Government to ensure safe online experiences for kids.

        What do we know about social media's role in mental illness among
    children? What are possible guard rails that could prevent social media
    algorithms from feeding kids harmful content?

        Answer. In recent years, there has been growing concern about the
    impact of digital technologies, particularly social media, on the
    mental health and well-being of children and young people. Since
    technology and social media involve such a vast range of devices,
    platforms, products, and activities, it's difficult to generalize.
    These platforms have too often exacerbated feelings of loneliness,
    futility, and low self-
    esteem for some youth. They have also contributed to a bombardment of
    messages by both traditional and social media that undermine this
    generation's sense of self-worth--messages that tell our kids with
    greater frequency and volume than ever before that they're not good
    looking enough, not popular enough, not smart enough, not rich enough.
    These platforms are often designed to be addictive. Using algorithms,
    they can manipulate what people see online in order to keep them
    addicted to ``liking'' and scrolling through nonstop ads and content.
    The problem with manipulative algorithms and addictive design is that
    they can not only direct harmful and extreme content to those uniquely
    vulnerable such as children, adolescents, and teens, but that they also
    can adversely affect young people's habits of sleep and social
    interaction, for example, and paradoxically lead to more social
    isolation and mental health challenges.

        We need far more transparency from technology companies on their
    data and algorithmic processes to better understand the effects of
    social media on youth mental health. As a doctor, I can't diagnose a
    problem if I can't talk to my patient and understand what their lab
    tests and X-rays show. Data helps us understand what's really going on.
    With social media, companies aren't providing the data that would let
    us understand the real impact their products are having on our children
    and on all of us. Companies know an enormous amount about their users
    and their platforms and aren't sharing much of that information with
    the public or with researchers. In fact, right now the technology
    platforms know a lot more about us than we know about them. To get a
    clearer picture of what specific guardrails are needed, companies have
    to provide researchers with useful data to inform their research, with
    user consent. At a minimum, if technology companies are going to
    continue to conduct a massive, national experiment on our kids, then
    public health experts and the public at large must be the ones to
    analyze the data, to draw the conclusions and draft the
    recommendations--not the companies alone. President Biden has called
    for a range of measures to address the impact of social media on young
    people, including investing in research, strengthening children's
    privacy online, and requiring companies to prioritize and ensure the
    health, safety and well-being of children and young people above profit
    and revenue in the design of their products and services.

        Companies can choose to minimize negative impacts, including on
    children. One example of a measure taken to address the effects of
    social media, is that CDC has conducted research related to the impact
    of how suicide is reported in the media. For example, CDC has conducted
    research related to the impact of how suicide is reported in the media.
    Media's reporting of a suicide can have either positive or negative
    effects. For example, when a suicide death is sensationalized, there
    can be an increased risk of suicide contagion. On the other hand, when
    media outlets adhere to the standards on how to report a suicide, it
    raises the importance of suicide prevention, without an increased risk
    of additional suicide deaths. To promote responsible reporting of
    suicide by the media, CDC provides guidance to media around the safest
    ways to cover deaths from suicide.

        Question. How can we effectively recruit and retain pediatric
    mental health professionals?

        Answer. As the committee is aware, there is a shortage of pediatric
    mental health providers, particularly in rural and underserved areas
    who can offer culturally competent, evidence-based mental health care.
    HRSA has several workforce initiatives that are designed to help
    prepare, train and build pediatric mental health workforce capacity to
    help recruit and retain pediatric mental health professionals.
    Expanding existing HRSA workforce programs could help to recruit and
    retain pediatric mental health professionals.

        In order to effectively recruit and retain pediatric mental and
    behavioral health professionals, HRSA recommends the following
    strategies:

            Recruiting and retaining providers to choose careers in rural
    and underserved areas, including training students in rural and
    underserved communities and enhancing access to culturally competent,
    evidence-based mental health care;
            Leveraging loan repayment and scholarship programs;
            Recruiting a workforce that reflects the communities HRSA
    serves;
            Training interprofessional and collaborative teams;
            Integrating behavioral health into primary care; and
            Establishing community-based partnerships and training to
    ensure participation in institutional programs.

        For example, HRSA's Pediatric Mental Health Care Access (PMHCA)
    program promotes behavioral health integration in pediatric primary
    care by providing tele-consultation, training, technical assistance,
    and care coordination to enable pediatric primary care providers to
    provide early identification, diagnosis, treatment and referral for
    children and adolescents with behavioral health conditions. HRSA's
    Developmental-Behavioral Pediatrics (DBP) training program trains
    leaders in
    developmental-behavioral pediatrics and builds capacity to address the
    broad range of child and adolescent behavioral, psychosocial and
    developmental issues. Additionally, HRSA's Leadership Education in
    Adolescent Health Program prepares health professionals in adolescent
    and young adult health by building workforce capacity to address the
    unique health needs of adolescent and young adults, including mental
    health. If expanded, programs could help to fill the gap in the
    shortage of pediatric mental health providers.

        HRSA's Behavioral Health Workforce Development (BHWD) programs,
    including the Behavioral Health Workforce and Education and Training
    (BHWET) program, work to develop and expand the behavioral health
    workforce serving populations across the lifespan, including in rural
    and medically underserved areas. The BHWD programs support a number of
    activities to expand the behavioral workforce as well as enhance the
    training of the pipeline and current workforce, including offering
    education and training to ensure professionals are ready to enter and
    remain in the workforce and providing financial support through loan
    repayment or scholarships to remove financial barriers to furthering
    education to enter the workforce.

        Additionally, HRSA's Nurse Corps Loan Repayment Program (LRP) and
    Scholarship Program (SP) are critical to ensuring both children and
    adults have access to a high-quality, adequate behavioral health
    nursing care. The nurse corps programs address the current
    maldistribution of nurses and expand access to behavioral health
    services by increasing funding for scholarships and loan repayment
    assistance for behavioral health training and service for Nurse
    Practitioners (NPs) specializing in psychiatric mental health. Nurse
    corps members receive scholarship and loan repayment incentives in
    exchange for an agreement to work in Critical Shortage Facilities
    (CSFs), which are located in Health Professional Shortage Areas (HPSAs)
    around the Nation. The nurse corps LRP reserves up to 20 percent of
    annual funding for awarding psychiatric NPs, covering all age groups
    and settings, including children.

        Finally, HRSA's National Health Service Corps (NHSC) programs offer
    both scholarship and loan repayment opportunities to clinicians,
    including pediatricians and psychiatrists, in exchange for an agreement
    to serve in a HPSA. The current NHSC field strength is over 20,000
    clinicians, including over 600 pediatricians and over 240
    psychiatrists.

        Continued congressional support and investment in these strategies
    moving forward is critical for addressing the various challenges in
    access, supply, distribution, and quality associated with behavioral
    health workforce shortages.

        Question. Since pediatricians and psychiatrists are among the
    lowest-compensated physician specialties, how can we encourage medical
    students to pursue these professions?

        Answer. Noting that primary care providers, including pediatricians
    and psychiatrists, generally earn less than specialists, HRSA offers a
    number of scholarship and loan repayment programs to primary care
    providers who commit to serve in underserved areas throughout the
    country, through the National Health Service Corps (NHSC) programs.
    HRSA also makes awards through several graduate medical education
    programs that provide support for training for primary care providers,
    including pediatricians and psychiatrists.

        The NHSC programs offer both scholarship and loan repayment
    incentives to clinicians in exchange for an agreement to serve in a
    Health Professional Shortage Area. For example, the NHSC scholarship
    program provides financial support through scholarships, including
    tuition, other reasonable education expenses, and a monthly living
    stipend to health professions students committed to providing primary
    care in underserved communities of greatest need. Additionally, since
    FY 2018, funding has been appropriated to the NHSC for the express
    purpose of expanding and improving access to quality opioid and
    substance-use disorder treatment in rural and underserved areas
    nationwide.

        The Children's Hospitals Graduate Medical Education (CHGME) payment
    program provides funds to freestanding children's teaching hospitals.
    This program supports the education and training of resident physicians
    and helps to increase access to quality care. These hospitals are
    regional and national referral centers for very sick children, often
    serving as the only source of care for many critical pediatric
    services.

        The Teaching Health Center Graduate Medical Education (THCGME)
    program supports the training of primary care physician and dental
    residents, increasing the overall number of these primary care
    providers. THCGME payments support training in community-based
    ambulatory patient care centers, as opposed to inpatient care settings
    in hospitals. In addition to increasing the number of primary care
    residents training in these community-based patient care centers, the
    THCGME program meets the administration's priority of increasing
    health-care quality and expanding Americans' overall access to care.

        Question. How can we ensure children receive mental health services
    in age-
    appropriate settings?

        Answer. The key to ensuring that children receive mental health
    services in age-appropriate settings is to meet them where they are--
    create a no-wrong-door approach to accessing services by integrating
    mental health screening, robust referral pathways, and culturally
    competent and responsive and developmentally appropriate approaches
    into all settings in which children, youth, and their families spend
    the most time.

        Examples of age-appropriate settings for children include:

            Pediatric and primary care settings.
            Centers of early learning and education.
            K-12 education settings.
            Community settings (such as churches, community centers, and
    recreational facilities).

        To further meet the need for increased services in school settings,
    this past September HRSA awarded over $5 million to 27 health centers
    to expand services at new or existing Health Center Program school-
    based service delivery sites. These health centers are using this
    funding to expand the provision of general primary medical care,
    behavioral health (mental health and substance use) services, oral
    health, vision, and enabling services such as transportation, outreach,
    and translation and interpretation services at school-based service
    sites, both in-person and through telehealth. By funding health centers
    that offer these critical services on school grounds, HHS provides
    convenient access to high quality health care for underserved students,
    their families, and the larger community.

        Schools and primary care settings are two age-appropriate systems
    with which nearly all children interface and where identification of
    mental health needs are most likely to occur.\10\ To ensure that
    children receive mental health services in these settings, HRSA
    promotes integration of behavioral health into primary care and schools
    to ensure early identification and intervention.
    ---------------------------------------------------------------------------
        \10\ Jensen, P.S., E. Goldman, et al. (2011). ``Overlooked and
    Underserved: Action signs for identifying children with unmet mental
    health needs.'' Pediatrics 128(5): 970-979.

        HRSA's Bright Futures program develops evidence-driven guidelines
    for preventive care screenings and routine primary care visits for
    newborns through adolescents up to age 21 and recommends routine
    behavioral/social/emotional screening, depression screening, and
    suicide risk screening during certain preventive checkups.
    Pediatricians play a unique role in mental health care as they
    typically see patients over time, giving them opportunity to develop
    trusting relationships with patients and their families. HRSA's
    Collaborative Improvement and Innovation Network (CoIIN) on School-
    Based Health Services (SBHS) improves children and adolescents' access
    to high-quality, comprehensive health care by expanding use of
    evidence-based models of school-based health (SBH) services, including
    SBH centers and comprehensive school mental health systems (CSMHSs).
    The CoIIN-SBHS provides trauma-informed, behavioral health technical
    assistance to State partners (such as title V Maternal and Child Health
    programs, State Medicaid programs, child mental health agencies,
    education agencies, State-level non-profit organizations), school
    districts, CSMHSs, and SBH centers. The program helps States promote
    the quality, sustainability and growth of SBHs, which increase
    students' access to behavioral health care and address adverse effects
    ---------------------------------------------------------------------------
    of social determinants of health on students and their families.

        Question. Can you speak to the connection between justice
    involvement and mental health?

        Answer. Data indicate that a significant number of individuals who
    come in contact with law enforcement and the criminal justice system
    have a mental disorder. According to a survey of prison inmates, about
    43 percent of State and 23 percent of Federal prisoners have a history
    of a mental health problem.\11\ Approximately 250,000 individuals with
    serious mental illness (SMI) are incarcerated at any given time--about
    half arrested for non-violent offenses, such as trespassing or
    disorderly conduct. In addition, during street encounters, police
    officers are almost twice as likely to arrest someone who appears to
    have a mental illness as those who do not. A Chicago study of thousands
    of police encounters found that 47 percent of people with a mental
    illness were arrested, while only 28 percent of individuals without a
    mental illness were arrested for the same behavior.\12\ The costs
    associated with incarceration are high: State corrections budgets alone
    account for $39.0 billion in taxpayer costs.\13\, \14\ There
    is a clear and largely unmet need for effective behavioral health
    services and supports that are accessible before, during, and after
    incarceration and continue in the community as needed for this high-
    need, population. Identifying and addressing these needs enhances
    individual and community public health and public safety outcomes.
    ---------------------------------------------------------------------------
        \11\ U.S. Department of Justice, Office of Justice Programs.
    (2006). ``Mental health problems of prison and jail inmates.''
    Retrieved, March 25, 2011, from https://bjs.ojp.gov/content/pub/pdf/
    mhppji.pdf.
        \12\ ``The Role of Mental Health Courts in System Reform.'' (2003).
    The Bazelon Center for Mental Health Law. http://heinonline.org/HOL/
    LandingPage?handle=hein.journals/udclr7&div=
    10&id=&page=.
        \13\ Pew Center on the States. (2011). ``State of recidivism: The
    revolving door of America's prisons.'' Washington, DC: The Pew
    Charitable Trusts. http://www.pewtrusts.org/en/research-and-analysis/
    reports/0001/01/01/state-of-recidivism.
        \14\ Henrichson, C., and Delaney, R. (2012). ``The price of
    prisons: What incarceration costs taxpayers.'' New York: Vera Institute
    of Justice.

        Question. How can schools recognize and support the mental health
    needs of children, especially as kids recover from the effects of
    ---------------------------------------------------------------------------
    COVID-19 on their families and communities?

        Answer. Schools have the infrastructure to provide critical support
    to youth and families, including opportunities to engage in academic,
    social, mental health, and physical health services, and mental health
    promotion activities, all of which can mediate stress and lessen
    negative outcomes. Many students and school staff have been adversely
    impacted by the pandemic. While mental health services are necessary,
    they alone are not sufficient to promote mental health and well-being.
    School connectedness is an important approach to promoting mental
    health. Connectedness can impact many students simultaneously,
    promoting positive student mental health outcomes and buffering the
    impact of traumatic experiences. We can build school connectedness
    through classroom-specific and school-wide programs as well through
    improved classroom policies, management and disciplinary strategies,
    and activities within the broader community environment to promote
    parent and family involvement. Examples include providing adequate seat
    time for school meals to foster peer connection and increasing
    opportunities for physical activity in the classroom.

        CDC's Whole School, Whole Community, Whole Child (WSCC) model is a
    comprehensive, student-centered, school health approach that is
    comprised of the following 10 components: (1) physical education and
    physical activity; (2) nutrition environment and services; (3) health
    education; (4) health services; (5) counseling, psychological, and
    social services; (6) employee wellness; (7) social and emotional school
    climate; (8) physical environment; (9) family engagement; and (10)
    community involvement. These components address barriers to learning
    through a coordinated framework that centers on the whole child.

        The CDC ``What Works in Schools'' approach to primary prevention in
    local school districts improves health education, connects youth to the
    services they need, and creates safer and more supportive school
    environments. This approach has demonstrated positive impacts on
    substance use, sexual risk, experience of violence, and mental health
    among students in schools that implement the approach.

        Schools can recognize and support the mental health needs of
    children by employing aspects of the public health model. The first
    tier of the model is universal efforts that apply to all children
    within the school climate. The second would be identifying children at
    particular risk. The third would be referring children in need of
    mental health treatment to qualified providers.

        Some children have additional needs (such as death of a caregiver,
    or loss of parental employment, etc.) that require additional
    attention. It is important to support educators' efficacy in
    identifying the mental health needs of their students by providing
    ongoing opportunities and incentives for training in mental health
    literacy and referral strategies. Providing Youth Mental Health First
    Aid has been a successful strategy for SAMHSA Project AWARE grants. Our
    educators play an important role in the health and well-being of all of
    our children. They are critical in fostering a supportive classroom
    climate, supporting all children at risk for serious emotional
    disturbances and need good working knowledge of how to get kids into
    treatment. Finally, it is important to ensure that children who need
    intensive specialty mental health services quickly gain access to
    services with providers specialized to provide care.

        Schools can play a key role in supporting healthy social and
    emotional development of children and their families by providing a
    comprehensive system of supports for children where they learn and
    play. The school environment offers access to children and youth
    recovering from the effects of COVID-19 where school personnel can
    provide consistent support and stability, identify concerns early, and
    offer additional services when needed.

        HRSA administers various school-based initiatives that optimize the
    role schools play in children's mental health and well-being. The HRSA-
    funded School-Based Health Alliance maintains and updates resources for
    the field and the public to learn about school-based health. HRSA's
    Collaborative Improvement and Innovation Network (CoIIN) on School-
    Based Health Services (SBHS) increases students' access to behavioral
    health care by promoting evidence-based models of school-based health
    services, including Comprehensive School Mental Health Systems (CSMHS).
    Core features of a CSMHS are training educators, family-school-
    community collaboration and teaming, resource mapping, multi-tiered
    system of support, mental health screening, evidence-based practice,
    data, and funding. Current funding supports the provision of technical
    assistance to interested local education authorities. Expanding support
    for CSMHS and other evidence-based models of school-based health
    services, including implementation support and technical assistance
    such as that provided by HRSA's SBHS-CoIIN could help promote mental
    health needs of children in school, including early identification,
    intervention, and treatment.

        HRSA, in collaboration with CDC, leads the National Coordinating
    Committee on School Health and Safety (NCCSHS). NCCSHS was formed in
    1994 by the Secretaries of Education and Health and Human Services and
    has grown to include several Federal departments and nearly 100 non-
    governmental organizations (NGOs) that work to improve the health of
    children and their ability to achieve in school. With increased
    support, NCCSHS could provide additional resources and coordination of
    communication strategies to State education authorities regarding their
    ability to address the mental health needs of their students. NCCSHS
    members coordinate communication and support implementation at the
    State/local levels of school-based approaches that protect student's
    mental health and well-being. This is done through expanding
    comprehensive, trauma-informed mental health services in schools and
    the Whole Child and Whole Community Model. Additional investment would
    expand the reach of the NCCSHS, leveraging the strength of this
    existing, long serving public/private collaboration.

                                     ______

               Questions Submitted by Hon. Catherine Cortez Masto
        Question. How specifically are you making sure the information and
    recommendations contained in the advisory get to schools? How are you
    helping to make sure they can put these recommendations into action?

        Answer. Our office is actively working with a range of stakeholders
    to disseminate the advisory. For example, we are working across HHS and
    the Federal Government to develop and publicize the advisory, including
    with Federal grantees. Recently, Education Secretary Cardona and I
    answered questions submitted from people across the country about the
    importance of vaccinations, kid and school safety, vaccine mandates,
    misinformation, and youth mental health. In addition, we are engaging
    with students, educators, and school leaders across the country on a
    regular basis to share the recommendations in the advisory and help
    them address youth mental health challenges in local communities. Other
    stakeholders we have engaged with include the American Academy of
    Pediatrics, the American College of Obstetricians and Gynecologists,
    members of the entertainment industry, and philanthropists and
    foundations. We have also participated in events with Nick News, Time
    for Kids, and Teen Vogue Twitter Spaces to target younger audiences. We
    would be happy to discuss further opportunities to support schools in
    implementing the recommendations in the advisory.

        CDC works closely with the Department of Education to communicate
    recommendations with schools by email, by website updates, on calls,
    and through webinars. CDC also directly funds State education agencies
    to implement school health programs, and support local school districts
    and communities. Information about the recommendations contained in the
    Advisory have been disseminated through these education agencies.
    Additionally, local health departments are providing support to schools
    as needed and over 500 school health staff, including mental health
    services staff, have been hired through the CDC Foundation's School
    Support Initiative.

        CDC's Healthy Schools program has funded partnerships with national
    non-
    governmental organizations that provide professional development and
    technical assistance in support of creating healthy and supportive
    environments for students and staff. CDC's extensive partner-
    stakeholder list can support the advisory by distributing the
    recommendations through their networks. Finally, through the CARES Act,
    CDC provided supplemental funding to school districts and non-
    governmental organizations to conduct activities in schools which would
    help mitigate adverse impacts of the COVID-19 pandemic on student
    mental health while enhancing mental health support and linkages to
    services for students. CARES Act funding was also provided to the
    National Parent Teacher Association to strengthen the engagement and
    information sharing with schools and communities, and to increase the
    availability of resources focused on the mental health of students and
    their families during the COVID-19 pandemic. CDC disseminated the
    Advisory to funded local educational agencies and non-governmental
    partners working with schools. Additionally, agencies and partners are
    conducting webinars in partnership with the Department of Education as
    part of their Lessons from the Field series that highlights the
    strategies contained in the Surgeon General's Youth Mental Health
    Advisory. Finally, CDC expanded the Youth Risk Behavior Surveillance
    System and launched the Adolescent Behaviors and Experiences Survey to
    be able to track and monitor youth mental health more effectively.

        Question. Some of these recommendations may require some pressure--
    on stakeholders like social media companies, for example--who may not
    be quick to implement your recommendation to consider kids' mental
    health over profits. What do you envision as next steps to hold these
    folks to account for keeping the kids healthy?

        Answer. We need more transparency from technology companies on
    their data and algorithmic processes to better understand the effects
    of social media on youth mental health. As a doctor, I can't diagnose a
    problem if I can't talk to my patient and understand what their lab
    tests and X-rays show. Data helps us understand what's really going on.
    With social media, companies aren't providing the data that would let
    us understand the full impact their products are having on our children
    and on all of us. In fact, right now the technology platforms know a
    lot more about us than we know about them. We have to give people--
    especially the parents and caregivers of children who use these
    platforms--the ability to make informed choices about their use of
    technology. If technology companies are going to conduct a massive,
    national experiment on our children, then we have to make sure that
    public health experts and the public at large have at least an equal
    opportunity to analyze the data, draw conclusions, and respond. We
    cannot just rely on the companies alone; they simply do not have the
    right incentives to optimize for mental health over maximizing users'
    attention and their own profits.

        Companies can choose to prevent and minimize negative impacts,
    including on children. For example, CDC has conducted research related
    to the impact of how suicide is reported in the media. When a suicide
    death is sensationalized, there can be an increased risk of suicide
    contagion. On the other hand, when media outlets adhere to the
    standards on how to report a suicide, it raises the importance of
    suicide prevention, without an increased risk of additional suicide
    deaths. To promote responsible reporting of suicide by the media, CDC
    provides guidance to media around the safest ways to cover deaths from
    suicide.

        President Biden has called for a range of measures to address the
    impact of social media on young people, including investing in
    research, strengthening children's privacy and protections online, and
    requiring companies to prioritize and ensure the health, safety and
    well-being of children and young people above profit and revenue in the
    design of their products and services. The Department of Health and
    Human Services is also launching a national Center of Excellence on
    Social Media and Mental Wellness, which will develop and disseminate
    information, guidance, and training on the full impact of adolescent
    social media use, especially the risks these services pose to their
    mental health.

        Question. How can we empower parents and even kids themselves to
    understand the distinction between healthier behaviors like FaceTimeing
    relatives versus consuming stressful content, and make informed choices
    about the content they're consuming?

        Answer. The Surgeon General's Advisory on Protecting Youth Mental
    Health includes several recommendations for young people and their
    families around engaging with technology and social media.

        Young people should be intentional about use of social media, video
    games, and other technologies. Here are some questions that can help
    guide one's technology use: How much time are you spending online? Is
    it taking away from healthy offline activities, like exercising, seeing
    friends, reading, and sleeping? What content are you consuming, and how
    does it make you feel? Are you online because you want to be, or
    because you feel like you have to be?

        Although it's not realistic or fair to put the burden on parents or
    caregivers to control or supervise everything their children are seeing
    or doing online, there are ways they can support children and youth in
    having healthier online experiences. Having open conversations with
    one's children is a great place to start. On page 18 of the advisory, I
    provide a list of questions parents and families can consider when it
    comes to their child's use of technology. And technology companies
    should make it as easy as possible in their products for kids and their
    caregiving to protect their privacy, prevent addictive use, and avoid
    harmful content.

        Question. Are there examples of Federal programs serving kids and
    young people that should have some sort of youth advisory panel but
    don't currently?

        Answer. Elevating the voices of children, young people, and their
    families should be critical components of any program that serves them.
    Youth advisory panels or similar structures offer programs, and those
    working in those programs, an important way to solicit youth insights
    or feedback on program design, implementation, and evaluation. They can
    also help define outcomes that are relevant to young peoples' needs;
    deepen existing youth engagement strategies and understanding on what
    is and isn't working; and provide young people the opportunity to
    directly support program processes. I would be happy to further discuss
    opportunities for the Federal Government to better engage with youth.

        Question. Can you speak to the impact of the investments Congress
    has made over the course of the pandemic and what the landscape may
    have looked like if we hadn't sought to mitigate mental health
    challenges?

        Answer. Congress has made major investments over the course of the
    pandemic to mitigate the effects of COVID-19, support the health of
    youth and families, and promote economic recovery. One of the most
    significant investments was the American Rescue Plan Act (ARP), which
    provided critical support and immediate economic relief to children and
    families. Many provisions included in the ARP helped address the myriad
    of challenges facing children and families, including the 1-year
    expansion of the Child Tax Credit; direct cash payments for individuals
    and their dependents; childcare funding; the expansion of nutrition
    assistance; funding to ensure schools and higher education institutions
    can operate safely and support students; and supports to help families
    avoid housing insecurity, homelessness, or foreclosure.

        Other significant investments include the Extending Government
    Funding and Delivering Emergency Assistance Act and the Families First
    Coronavirus Response Act, among many others. As a result of Congress
    and the administration working together, young people and their
    families have benefited in a number of ways, including avoiding the
    negative health consequences of COVID-19, receiving food assistance and
    unemployment benefits, accessing care via telehealth, and receiving
    additional mental health services and supports through their schools.
    These and other investments have supported the mental health of young
    people and families.

        Question. The burden of COVID-19 has disproportionately impacted
    Latino and other children of color. Over the course of the pandemic,
    children of color were more likely to have experienced the death of a
    primary caregiver, and more likely to have been infected by COVID
    themselves. This is on top of the already disproportionate health
    disparity faced by children of color.

        What specific policies are necessary to help advance mental health
    equity and begin to close some of the racial disparities that preceded
    or have been exacerbated by COVID-19 on this issue?

        Answer. Addressing the disproportionate mental health disparities
    faced by Latino and other children of color and advancing mental health
    equity requires a multifaceted approach, including policy actions to
    mitigate key barriers. In broad terms, barriers to mental health equity
    are related to the workforce, access to care, including culturally
    competent care, data disaggregation, education, and stigmatization and
    discrimination. Recent presidential actions support policy efforts to
    advance equity--for example, Executive Order 13985 ``Advancing Racial
    Equity and Support for Underserved Communities Through the Federal
    Government'' calls for the Federal Government to pursue a comprehensive
    approach to address barriers to opportunities and benefits for
    underserved groups, and Executive Order 13995 ``Ensuring an Equitable
    Pandemic Response and Recovery'' directs the Federal Government to
    prevent and remedy differences in COVID-19 care and outcomes within
    communities of color and other underserved populations.

        Additionally, there are a number of policies that can advance
    mental health equity and address racial disparities, including:

            Developing increased capacity for behavioral health services
    in under-resourced communities where racial and ethnic groups facing
    health disparities are overrepresented.
            Addressing social determinants of health and mental health
    (e.g., housing, nutrition, exposure to trauma) that have
    disproportionate negative impact on racial and ethnic groups facing
    health disparities.
            Building a mental health workforce that includes more
    representation from racial and ethnic groups facing health disparities,
    including focused recruitment, training, and professional development
    efforts.
            Training for the general mental health workforce in the
    importance of recognizing and responding to the cultures of people
    being served and how to approach services with cultural humility.
            Using data to identify disparities in access across programs
    and then engaging in tailored and intentional efforts to provide
    outreach to racial and ethnic groups facing health disparities.
            Using data to identify disparities in outcomes among racial
    and ethnic groups and then engaging in quality improvement efforts to
    address these disparities Adaptation of programs and models, including
    evidence-based practices, to address the needs of specific racial and
    ethnic groups facing health disparities and supporting uptake of these
    tailored approaches.
    Workforce:
        Promoting mental health equity requires a diverse workforce in
    clinical, community, and school settings that can address the specific
    cultural and linguistic needs of all youth. Currently, the mental
    health profession is facing workforce shortages, due in part to
    challenges in recruitment and retention among those who are bilingual
    and/or bicultural. Policies that can address these workforce challenges
    include establishing/enhancing scholarships and loan repayment programs
    for diverse students pursuing mental health careers; establishing/
    enhancing mental health career pathway programs; financing and
    sustaining a peer workforce (such as community health workers, peer
    navigators, recovery support specialists); incentivizing practice in
    underserved communities; and building cultural and linguistic
    competency among mental health professionals. Through its Think
    Cultural Health \15\ website, the HHS Office of Minority Health (OMH)
    offers resources and online educational programs to help build capacity
    among health professionals to provide culturally and linguistically
    appropriate care, including a program designed specifically for
    behavioral health professionals.
    ---------------------------------------------------------------------------
        \15\ https://thinkculturalhealth.hhs.gov/.
    ---------------------------------------------------------------------------
    Access to care:
        There are a number of factors limiting the ability of children of
    color to access quality and affordable health care, including the lack
    of availability of culturally and linguistically appropriate services
    (CLAS) in their communities, as well as lack of health insurance
    coverage and mental health parity in health-care plans for children
    that are enrolled in coverage. Policies that can improve access to care
    could support and finance service models that address access barriers
    (e.g., co-location of primary and behavioral health services, school-
    based mental health services, family-centered interventions); enhance
    broadband infrastructure to allow access to telehealth services; expand
    interjurisdictional tele-psychological services across State lines to
    meet mental health needs of underserved communities; improve
    accountability of health plans to cover behavioral health services at
    parity with medical services; increase coverage for CLAS in health
    plans; and improve health insurance enrollment among families of color.

        OMH has developed the National Standards for Culturally and
    Linguistically Appropriate Services in Health and Health Care \16\
    (National CLAS Standards) to provide a blueprint for individuals and
    organizations to implement CLAS. Adherence to the National CLAS
    Standards can contribute to improving access to and the quality of care
    and thus help to improve health outcomes. OMH also includes a
    requirement for adoption of the National CLAS Standards in its Notices
    of Funding Opportunity, which aligns with legal and regulatory
    requirements (e.g., title VI of the Civil Rights Act of 1964) for
    federally funded entities to provide language assistance for
    individuals who are limited English proficient.
    ---------------------------------------------------------------------------
        \16\ https://thinkculturalhealth.hhs.gov/clas/standards.
    ---------------------------------------------------------------------------
    Data Disaggregation:
        Data that are collected or aggregated in broad racial and ethnic
    categories often mask disparities and differences experienced among
    subgroups of children of color. Policies that support the collection
    and use of disaggregated data, using granular racial and ethnic
    categories, are critical to the ability to identify and effectively
    address mental health disparities and equitably allocate resources.
    Such policies align with Executive Orders 13994 and 13995, which calls
    on Federal agencies to strengthen equity data collection, reporting,
    and use related to COVID-19 and to assess pandemic response plans and
    policies to determine whether resources have been or will be allocated
    equitably.

        OMH contributed to the development and promotion of guidelines \17\
    for implementation of section 4302 of the Affordable Care Act, which
    included more granular racial and ethnic categories than are in the
    current OMB government-wide standard.
    ---------------------------------------------------------------------------
        \17\ https://aspe.hhs.gov/reports/hhs-implementation-guidance-data-
    collection-standards-race-ethnicity-sex-primary-language-disability-0.
    ---------------------------------------------------------------------------
    Education, Stigmatization, and Discrimination:
        Limited mental health literacy and discrimination or stigmatization
    related to mental health issues can prevent youth of color from seeking
    and receiving help when needed. Policies to increase awareness of
    mental health and reduce stigmatization can support culturally and
    linguistically appropriate educational campaigns; delivery of services
    in non-specialty settings (e.g., primary care, schools, community-based
    organizations); and engagement and utilization of the peer workforce
    and community leaders.

                                     ______

                   Questions Submitted by Hon. Chuck Grassley
        Question. In 2019, I passed the bipartisan Advancing Care for
    Exceptional (ACE) Kids Act. Currently, CMS is working on implementation
    in coordination with State Medicaid programs for a start-date of
    October 1, 2022. ACE Kids Act establishes a pediatric health home for
    children with complex medical conditions providing a designated lead to
    coordinate care across a team of providers. CMS released guidance to
    State Medicaid directors in fall 2021 (hyperlink: https://
    www.medicaid.gov/federal-policy-guidance/downloads/cib102021.pdf). It
    aligns Medicaid rules and payment to incentivize care coordination,
    including mental health care, for kids with complex medical conditions.
    The Surgeon General's Advisory, Protecting Youth Mental Health, lists
    the type of children at higher risk of mental health challenges during
    the pandemic.

        Are children with complex medical conditions part of the higher
    risk group? If so, please describe how critical it is for children with
    complex medical needs to have mental health support services as part of
    a coordinated pediatric medical home.

        Answer. Complex medical conditions (CMCs), such as serious
    congenital heart defects, cerebral palsy, congenital anomalies, and
    genetic disorders, have many implications for the behavioral health of
    children and their families, putting them at risk of mental health
    challenges.\18\, \19\ Children with CMCs tend to have
    multiple chronic health conditions and frequently utilize health-care
    services. When children's behavioral health needs are not met or
    services are not coordinated with their other medical and social needs,
    they are at higher risk for poor health and other outcomes. Children
    and youth with CMCs may require care across multiple systems, including
    primary care, behavioral health care, schools, community-based
    organizations, and other social service programs. A coordinated medical
    home model can optimize services for children, especially if services
    are collocated, with behavioral health and other services. Using a
    coordinated, comprehensive, and family-centered network of services and
    supports that is organized to meet the needs of children and youth with
    complex medical needs, has been shown to improve outcomes for children
    and families, ensure continuity and improve quality of care.\20\
    Children with CMCs, especially those who require behavioral health
    treatment, often have to go outside of their insurance plans' provider
    networks for care. Almost one in five children with complex, chronic
    medical conditions such as cystic fibrosis, who also need behavioral
    health care, are seen by specialists who are out of network.\21\
    Limited access to mental health services for children with CMCs, may
    compromise their chronic health conditions, negatively impact
    functioning and overall quality of life, or exacerbate their mental
    health problems. We must recognize that both mental and physical health
    are critical for children's well-being and optimal functioning and
    should be available concurrently in one medical home for children with
    CMCs.
    ---------------------------------------------------------------------------
        \18\ Mueller, A.E., Georgiopoulos, A.M., Reno, K.L., Roach, C.M.,
    Kvam, C.M., Quittner, A.L., Lomas, P., Smith, B.A., and Filigno, S.S.
    (2020). ``Introduction to Cystic Fibrosis for Mental Health Care
    Coordinators and Providers: Collaborating to Promote Wellness.'' Health
    and Social Work, 45(3), 202-210. https://doi.org/10.1093/hsw/hlaa009.
        \19\ Gonzalez, V.J., Kimbro, R.T., Cutitta, K.E., Shabosky, J.C.,
    Bilal, M.F., Penny, D.J., and Lopez, K.N. (2021). ``Mental Health
    Disorders in Children With Congenital Heart Disease.'' Pediatrics,
    147(2), e20201693. https://doi.org/10.1542/peds.2020-1693.
        \20\ https://uofuhealth.utah.edu/notes/postings/2022/images/
    stanford-case-study-neurobehav
    ior-home-program.pdf.
        \21\ Xu, W.Y., Li, Y., Song, C., Bose-Brill, S., and Retchin, S.M.
    (2022). ``Out-of-Network Care in Commercially Insured Pediatric
    Patients According to Medical Complexity.'' Medical Care, 60(5), 375-
    380. https://doi.org/10.1097/MLR.0000000000001705.

        Question. I asked a similar question during our hearing. I was not
    sure if you were familiar with my bipartisan work on the ACE Kids Act
    and Accelerating Kids' Access to Care Act (hyperlink: https://
    www.grassley.senate.gov/news/news-releases/grassley-bennet-introduce-
    bipartisan-bicameral-bill-to-increase-health-care-access-for-children).
    You discussed the importance of telehealth in your response to my
    question. My bipartisan work on improving the lives of children with
    complex medical conditions requires in-person medical visits with
    specialty providers, sometimes out-of-State. Telehealth certainly is an
    important tool to improving care especially in a coordinated manner.
    While I agree with you on the importance of telehealth, as I am strong
    supporter of telehealth, I wanted to give you the opportunity to
    respond to my question in writing. I will restate my question. This
    Congress, I am working with Senator Bennet to pass the Accelerating
    Kids' Access to Care Act to streamline access to out-of-State providers
    for these same kids and their families. The Surgeon General advisory
    discusses the importance of improving access to high-quality health
    care as well as breaking down economic barriers. The Accelerating Kids'
    Access to Care Act builds onto ACE Kids Act by cutting red tape for
    ---------------------------------------------------------------------------
    providers and families.

        Is access to an out-of-State provider a challenge for families who
    have children with complex medical needs? How does timeliness of care,
    or lack thereof, impact a child with complex medical condition's
    physical and mental health outcome?

        Answer. The Biden-Harris administration is committed to making
    quality mental health services available to all Americans, including
    children with complex medical conditions. In October 2021, CMS issued
    guidance aimed at assisting State Medicaid programs as they develop
    protocols, procedures, and agreements that will help to ensure that
    children with medically complex conditions receive prompt, high-quality
    care from out-of-State providers when needed. The Guidance on
    Coordinating Care Provided by Out-of-State Providers for Children With
    Medically Complex Conditions \22\ provides a description of best
    practices and other implementation considerations related to
    coordination of care from out-of-State providers for children with
    medically complex conditions. CMS also released guidance to States on
    implementation of the Medicaid health homes option under the ACE Kids
    Act (which ultimately became section 1945A of the Social Security Act).
    Section 1945A(b)(1) of the Social Security Act requires that section
    1945A health home providers demonstrate to the State their ability to
    coordinate prompt care for children with medically complex
    conditions.\23\
    ---------------------------------------------------------------------------
        \22\ https://www.medicaid.gov/federal-policy-guidance/downloads/
    cib102021.pdf.
        \23\ https://www.medicaid.gov/federal-policy-guidance/downloads/
    smd22004.pdf.

        Question. The Surgeon General's advisory, ``Protecting Youth Mental
    Health,'' lists youth in rural areas as higher risk of mental health
    challenges individuals during the pandemic. The report provides
    specific resources, but it does not list any rural-focused
    organizations such as university extension and outreach offices, 4-H,
    or Future Farmers of America (FFA). These organizations all provide
    rural-focused mental health awareness and resources. I'm glad during
    the hearing you agreed we need more mental health resources for rural
    youth. You specifically cited the development of 988 and Crisis Text
    ---------------------------------------------------------------------------
    Line. I will restate my question, so you can elaborate on your answer.

        What efforts should be taken to address unique rural mental health
    needs? Are there specific organizations you are working with to raise
    awareness and provide resources? Can you issue rural-focused resource
    guide?

        Answer. It is important that rural residents have the ability to
    access mental health services. This ability will differ based on the
    geography and proximity to services for each community. Increasing
    access to mental health services, either in-person or virtually, is key
    to addressing unique rural mental health needs. Additionally, once
    access is established, linkages to services through a provider, health
    worker, or other resource are essential to making sure that residents
    know that these services exist.

        To that end, HRSA's Federal Office of Rural Health Policy (FORHP)
    administers a number of rural community-based grant programs that can
    be leveraged to address rural mental health-care access and workforce
    needs. For example, FORHP anticipates awarding approximately $13
    million to benefit rural communities later this year under the Rural
    Communities Opioid Response Program-Behavioral Health Care Support,
    which aims to improve access to behavioral health care for individuals
    with substance use disorder and/or co-occurring mental disorders.

        HRSA leads the Agricultural Mental Health Coalition, a joint effort
    between HRSA, USDA, and CDC, that focuses on developing and providing
    mental health resources for the agricultural community which tend to be
    in rural areas. HRSA also supports programs that aim to increase access
    to telehealth for mental health services in rural and underserved
    areas, and funds the Rural Health Information Hub (RHIhub), a national
    clearinghouse on rural health issues. RHIhub provides free access to
    many resources related to mental health, including funding
    opportunities, evidence-based and promising practice programs models,
    toolkits, webinars, and more. Currently, RHIHub maintains a ``Mental
    Health in Rural Communities'' toolkit on its website that provides
    guidance on how to develop, implement, sustain, and evaluate rural
    mental health programs (https://www.ruralhealthinfo.org/toolkits/
    mental-health). Additionally, over the past 25 years, FORHP has
    supported over 90 policy briefs, fact sheets, journal articles, and
    other publications pertaining to mental and behavioral health care in
    rural America through the Rural Health Research Centers Program. These
    products are available for reference on the Rural Health Research
    Gateway (https://www.ruralhealthresearch.org/topics/mental-and-
    behavioral-health/publications).

        Question. I helped pass the bipartisan Farmers First Act in the
    2018 farm bill and the bipartisan Seeding Rural Resilience Act in the
    2020 NDAA. Both bills addressed suicide rates among farmers and the
    agriculture community. The Farmers First Act made grants available for
    helplines and support groups. The Seeding Rural Resilience Act created
    a voluntary stress management program that helps train U.S. Department
    of Agriculture (USDA) employees to detect stress. USDA is also required
    to be working with HHS, including the Surgeon General, to raise mental
    health public awareness among farmers and ranchers, this includes rural
    youth. You indicated in the hearing that you will work with the USDA to
    ensure this effort is developing as urgently as possible and report
    back to me.

        I ask again in writing, can you work with your USDA colleagues to
    ensure this effort is developing as urgently as possible and report
    back to me? I request you report back timely on this request. It is
    important the USDA is coordinating across the interagency to
    appropriately implement the Seeding Rural Resilience Act.

        Answer. During the Committees hearing, you requested I work with my
    colleagues at the U.S. Department of Agriculture (USDA) to ensure that
    the Seeding Rural Resilience Act is developing. We have reached out to
    colleagues within USDA and are eager to collaborate with them to
    support this goal.

        Through our discussions, we learned that over 95 percent of the
    nearly 22,000 employees in USDA's Farm Production and Conservation
    Mission Area have completed the training laid out in the Seeding Rural
    Resiliency Act. From our understanding, public facing employees of the
    Rural Development Mission Area may also be completing these trainings
    to better serve their rural customer base that do not have access to
    mental health services in the same way that people in more populated
    areas often do. However, the $3 million authorized in the bill for a
    public service announcement campaign (PSA)--in consultation with the
    Department of Health and Human Services--to address the mental health
    of farmers and ranchers, to date, has not received an appropriation. As
    a result, it has not yet been implemented. We are continuing to explore
    opportunities for collaboration with USDA and hope to share more in the
    coming months.

        While this PSA has not been implemented, I have been encouraged by
    other initiatives and recent investments to address and support mental
    health in rural America such as the availability of $13 million in
    funding to increase access to behavioral health-care services through
    the Health Resources and Services Administration's (HRSA) Rural
    Communities Opioid Response Program--Behavioral Health Care
    Support;\24\ nearly $48 million to expand public health capacity in
    rural and tribal communities under HRSA's Rural Public Health Workforce
    Training Network;\25\ and the Centers for Medicare and Medicaid
    Services' Rural Health Strategy \26\ which outlines a goal to advance
    telemedicine and telehealth which is critical to improve access to care
    and help meet the needs of rural areas that lack sufficient mental
    health-care services.
    ---------------------------------------------------------------------------
        \24\ U.S. Department of Health and Human Services. HHS Announces
    Availability of $13 Million to Increase Behavioral Health Care Access
    in Rural Communities. Accessed on April 1, 2022. Retrieved from https:/
    /www.hhs.gov/about/news/2022/01/18/hhs-announces-availability-13-
    million-increase-behavioral-health-care-access-rural-communities.html.
        \25\ U.S. Department of Health and Human Services. HHS Announces
    Availability of Nearly $48 Million to Increase the Public Health
    Workforce in Rural and Tribal Communities. Accessed on April 1, 2022.
    Retrieved from https://www.hhs.gov/about/news/2021/12/23/hhs-announces-
    availability-nearly-48-million-to-increase-public-health-workforce-
    rural-tribal-communities.html.
        \26\ U.S. Department of Health and Human Services, Centers for
    Medicare and Medicaid Services (2018). CMS Rural Health Strategy.
    Retrieved from https://www.cms.gov/About-CMS/Agency-Information/OMH/
    Downloads/Rural-Strategy-2018.pdf.

        I hope that all of us--civic leaders, researchers, members of the
    health-care community, families, and concerned Americans alike--can
    work together to protect the mental health of our Nation's youth. I
    remain confident that through our collective efforts, we can address
    this youth mental health crisis and support the health of our children,
    ---------------------------------------------------------------------------
    adolescents, and young adults and their families.

        Question. In December 2021, The Wall Street Journal, documented
    (hyperlink: https://www.wsj.com/articles/fentanyl-invades-more-illicit-
    pills-with-deadly-consequences-11639650605?mod=e2tw) a growing trend
    among youth obtaining counterfeit illicit pills believing they are
    prescription pills (e.g., benzodiazepines) to treat anxiety. The Drug
    Enforcement Administration (DEA) reported the United States seized 20
    million fake pills in 2021. Much of these counterfeit illicit pills
    turn out to contain fentanyl resulting in accidental overdose deaths,
    especially among youth. Young people are increasingly obtaining these
    fake pills through social media platforms like SnapChat and TikTok.
    According to the CDC, these pill-related overdose deaths are growing
    increasingly common. In September 2021, DEA issued (hyperlink: https://
    www.dea.gov/press-releases/2021/09/27/dea-issues-public-safety-alert) a
    public safety alert on the sharp increase in fake prescription pills
    containing fentanyl and meth. At the same time, a recent study
    published (hyperlink: https://www.nih.gov/news-events/news-releases/
    suicides-drug-overdose-increased-among-young-people-elderly-people-
    black-women-despite-overall-downward-tren) in the American Journal of
    Psychiatry and the National Institutes of Health found suicides by drug
    overdose increased among young people from 2015 to 2019 despite an
    overall downward trend. In young men, suicides by drug overdose
    increased by 33 percent and among young women by 66 percent. Whether a
    young person is dying by suicide or accidental drug overdose, we have a
    deeply concerning trend driven by mental health challenges.

        Question. Do you agree with the DEA that counterfeit illicit pills
    are a public safety issue? What efforts should be taken by the Federal
    Government to review e-
    commerce and social media platform use by drug trafficking
    organizations in the sale and distribution of counterfeit pills laced
    with illicit substances, particularly as youth use of social media
    increases? Should we bring together public- and private-sector leaders
    to address the alarming trend of youth obtaining counterfeit illicit
    pills through social media platforms, and resulting in accidental
    overdose deaths and suicides by drug overdose?

        Answer. Counterfeit pills represent an area of particular risk that
    is difficult to quantify but needs attention. The increase in
    counterfeit pills containing fentanyl products represents significant
    overdose risk for individuals who are opioid naive (not yet tolerant).
    Synthetic opioids, including illicitly manufactured fentanyls (IMFs),
    were involved in 64 percent of >100,000 estimated U.S. drug overdose
    deaths during May 2020-April 2021, and the continued proliferation of
    counterfeit pills is enabling IMF spread into communities across the
    U.S.\27\ Almost half of individuals who illicitly use opioids gets them
    from a friend of family member. In addition to Federal law
    enforcement's investigative and enforcement resources, in terms of
    public health, the Federal Government should support an education
    campaign that focuses on illicit pills. For example, CDC recently
    launched four complementary education campaigns intended to reach young
    adults ages 18-34 years. The campaigns provide information about the
    prevalence and dangers of fentanyl, the risks and consequences of
    mixing drugs, the life-saving power of naloxone, and the importance of
    reducing stigmatization around drug use to support treatment and
    recovery.
    ---------------------------------------------------------------------------
        \27\ https://www.cdc.gov/mmwr/volumes/70/wr/mm7050e3.htm.

                                     ______

                    Questions Submitted by Hon. John Cornyn
                                   marijuana
        Question. Your advisory recommends avoidance of substances like
    alcohol, marijuana, and tobacco among steps youth can take to protect
    and improve their mental health. Is that correct?

        Answer. Young people should take care of body and mind, which
    includes sticking to a schedule, eating well, staying physically
    active, getting quality sleep, staying hydrated, and spending time
    outside. This also includes avoiding substances that are addictive and
    can ultimately make one feel tired, down, or depressed, such as
    alcohol, marijuana, vaping, and tobacco.

        Question. Your predecessor, Dr. Adams, in his advisory on marijuana
    use noted that, ``The risks of physical dependence, addiction, and
    other negative consequences increase with exposure to high
    concentrations of THC and the younger the age of initiation. Higher
    doses of THC are more likely to produce anxiety, agitation, paranoia,
    and psychosis.''\28\ Do you agree with that assessment?
    ---------------------------------------------------------------------------
        \28\ https://www.hhs.gov/surgeongeneral/reports-and-publications/
    addiction-and-substance-misuse/advisory-on-marijuana-use-and-
    developing-brain/index.html.

        Answer. Even though more research is needed, we do know that
    marijuana use may have a wide range of effects on the brain and the
    body, including the effects mentioned in the Surgeon General's Advisory
    on Marijuana Use and the Developing Brain. We also know that
    individuals who start using substances during adolescence often
    experience more chronic and intensive use, and they are at greater risk
    of developing a substance use disorder compared with those who begin
    use at an older age. In other words, the earlier the exposure, the
    ---------------------------------------------------------------------------
    greater the risk.

        Question. Given these recommendations, it is striking that as a
    candidate, President Biden supported decriminalization and descheduling
    of marijuana.

        How do you reconcile the President's position on increasing access
    to marijuana given the advisories from the Dr. Adams and yourself?

        Answer. When it comes to decriminalization, I don't believe there
    is value to individuals or society to incarcerate people for non-
    violent drug use alone. Instead, we should prioritize getting people
    access to evidence-based treatment and support. In addition, the
    President has never supported--and no jurisdiction that legalizes
    marijuana allows--recreational use of marijuana by youth. Rather, in
    terms of our approach to marijuana, we have to let science guide us.
    The National Academies of Medicine report on marijuana, published in
    2017, offers a rigorous review of scientific research about what is
    known about the health impacts of both the medical and recreational use
    of marijuana, ranging from its therapeutic effects to its risks. The
    Centers for Disease Control and Prevention (CDC) has a website that
    describes what we know and don't know about marijuana, and the National
    Center for Complementary and Integrative Health (NCCIH) at the National
    Institutes of Health (NIH) has a website on the harms and potential
    benefits of cannabis and cannabinoids. As surgeon general my role is to
    provide the American people with the best, science-based information to
    help them make informed health decisions and work with policymakers to
    help people understand what science tells us and, where there are gaps,
    to help fill those gaps with research and honest inquiry.

        Given the changing perceptions of risk associated with cannabis use
    and the continually evolving nature of policies legalizing and
    decriminalizing medical and nonmedical adult cannabis use at the State
    level, research and evaluation studies are warranted to improve our
    understanding of outcomes associated with cannabis use among youth. For
    example, CDC has developed both a Cannabis Strategic Plan and Research
    Agenda, with particular focus on populations at increased risk for
    negative outcomes, including youth. The Strategy describes actions that
    will foster a public health approach, improve messaging, and secure
    dedicated resources to address the health risks of cannabis. One of the
    six pillars in the Strategy is focused around partnering with public
    safety, schools, and community coalitions to offer opportunities for
    community-based coalitions to learn about evidence-based substance use
    prevention strategies addressing youth cannabis use.
                                  social media
        Question. CDC noted in a Morbidity and Mortality Weekly Report \29\
    that from March 2020 to March 2021, emergency department visits related
    to a suspected attempted suicide were nearly 51 percent higher among
    girls aged 12-17 years than during the same period in the preceding
    year.
    ---------------------------------------------------------------------------
        \29\ https://www.cdc.gov/mmwr/volumes/70/wr/mm7024e1.htm.

        Among boys of the same age range and during that time frame,
    suspected suicide emergency department visits increased 3.7 percent.
    Any increase in suicidal ideation or suicide attempts is tragic and we
    must understand as to why those rates increased. And as the father of
    two daughters, I am truly saddened to see this large increase in
    ---------------------------------------------------------------------------
    suicide attempts by young women. And we must help.

        With school closures, increased isolation and anxiety, a lack of
    focus on enhancing emotional well-being in schools due to limited
    infrastructure, resources, and other factors like certain social media
    use influencing young people, it is clear to see why some individuals
    feel despair and hopelessness.

        I agree with your advisory that we need to better understand how
    social media use can negatively impact mental health, especially that
    of our youth. It has been noted that specific actions and interactions
    with users and accounts can illicit negative body-image issues, severe
    sadness and bouts of depression, and otherwise severely impact a
    person's mental health.

        What are specific functions on social media you believe lawmakers
    should look at getting a clearer picture of and their effects on mental
    health?

        Answer. To get a clearer picture of social media's effects on
    mental health, I believe technology companies should provide public
    interest researchers and the public with information they request and
    share data in ways that protect user privacy and ensure user consent.
    This would help us understand questions like:

            Which groups of users are being negatively affected in terms
    of their mental health? Are there subsets of people who seem to be more
    susceptible to the negative mental health effects of social media than
    others, and why?
            What characteristics of social media use affect users' mental
    health (e.g., length of use, type of use, type of content, device)?
            How often are young people exposed to harmful content, such as
    content that may increase risk of eating disorders, anxiety, isolation,
    etc.? How much of this is due to algorithms serving content to users or
    users seeking out this content on their own?

        I have concerns about how social media and other technology and
    gaming platforms deliberately work to produce addictive user and about
    how their algorithms can direct young folks to harmful content and
    deliver harmful content to young people, e.g., self-harm content and
    eating disorders.

        Question. How do you intend to work with social media companies to
    either curb harmful content or advise parents about harmful social
    media behaviors?

        Answer. Over the last year I have been clear about the essential
    role technology companies must play in helping us understand harms
    caused by platforms and how they should act to address those harms
    upstream. Most recently, I have been in touch with technology companies
    about a Request for Information \30\ on the impact of health
    misinformation during the pandemic. I look forward to partnering with
    Congress and other stakeholders to find ways to increase transparency
    and reduce the impact of harmful content and social media behaviors. In
    addition, our office is regularly meeting with local community
    organizations, including groups of parents and caregivers, to identify
    opportunities to support children in engaging online in age-appropriate
    ways. As new information becomes available, I plan to continue
    providing the public with accurate scientific information to help them
    make informed decisions and to policymakers to ensure they can act
    appropriately.
    ---------------------------------------------------------------------------
        \30\ https://www.hhs.gov/surgeongeneral/health-misinformation-rfi/
    index.html.
    ---------------------------------------------------------------------------
                                    big act
        Question. Last week our colleagues in the Senate HELP Committee
    held a similar hearing on youth mental health. One exchange I found
    particularly compelling was between Chairwoman Murray and Dr. Mitch
    Prinstein of the American Psychological Association.

        Dr. Prinstein's response to Chairwoman Murray's question about best
    practices for identifying trauma gets to the heart of the issue: how
    and where we deliver care. As part of his response, Dr. Prinstein said,
    ``We need the opportunity to be able to teach what we know to all those
    teachers, counselors, and administrators so we can help them to
    identify kids before they reach a moment of trauma.''

        Based on your advisory, I take it you agree with Dr. Prinstein's
    response. In particular, on page 19 of your advisory you recommend that
    educators should learn to recognize signs of change in mental and
    physical health among students, including trauma and behavior changes
    and to take appropriate action when necessary.

        I introduced the Behavioral Intervention Guidelines Act or BIG Act
    to address this exact problem. We must equip our educators with basic
    tools of recognizing youth who may be experiencing a mental health
    issue and help them get the care they need. These guidelines would
    provide best practices for schools to create and implement behavioral
    intervention teams, which help identify students who are at-risk and
    exhibiting signs of physical or mental distress.

        These voluntary guidelines developed by SAMHSA would take into
    account perspectives from the boots on the ground: teachers, parents,
    law enforcement, school psychologists, and other groups. Behavioral
    intervention teams and best practices from the BIG Act could serve as
    another tool for schools to maintain healthy campuses and provide their
    students with the best learning environment. Every student deserves a
    safe learning environment and we have an obligation to help provide
    that opportunity wherever possible.

        How do you envision behavioral intervention teams in schools
    playing a role in addressing the mental health crisis among our youth?

        Answer. School districts often have multidisciplinary teams,
    sometimes within frameworks such as Multi-Tiered Systems of Support
    (MTSS) or Positive Behavioral Interventions and Supports (PBIS) that
    work to put into place a system of behavioral supports for students
    that include universal supports for all students in a given grade or
    school (Tier 1), or for small groups of students (Tier 2) who need
    additional support, such as children of parents going through divorce,
    and Tier 3 supports for those who need individual support. These teams,
    and their ability to function effectively, is vitally important. State
    departments of education and school districts can also provide
    resources and training, but local school teams are vital to
    implementation and ensuring that the appropriate supports are provided
    for each student and evidence-based policies and practices are being
    implemented by school staff.

        As a start, schools need to develop partnerships with their
    community mental health centers, Certified Community Behavioral Health
    Clinics, and Federally Qualified Health Centers so there are robust
    referral pathways for students to obtain needed clinical services. In
    order for behavioral prevention and intervention teams to be effective
    in schools, they must be more than referral pathways--but be true
    partners to enable them to come together quickly before a student is in
    crisis and/or needs intensive intervention.

        When students are in crisis, they (and their families) need
    immediate support from teams that are trauma-informed, culturally
    competent, person-centered, and work well together. Schools and health-
    care providers need to work together so their teams are well-
    functioning before they are needed. In that working together, it is
    important to adopt destigmatizing language, build the capacity of the
    team to recognize when a student is in crisis, and ensure that
    qualified clinical providers are available to help school personnel
    when needed.
                                     access
        Question. Emerging data is demonstrating that telehealth--
    particularly telehealth for mental health and substance use care--can
    maintain and even improve the quality and comprehensiveness of patient
    care while expanding access to evidence-based care. Many of the changes
    proved to be a critical lifeline for the rising numbers of very young
    children experiencing mental and emotional challenges by offering ways
    to support their mental health needs including acute care, early
    intervention services, and continued operation of family courts. These
    supports are essential to families in rural, underserved, and low-
    income communities who continue to face the most barriers to care. The
    massive surge in telehealth use during the pandemic demonstrates the
    significance continued access to telehealth offers for reducing
    barriers to mental and behavioral health care.

        What is the administration's plan to ensure that beyond the
    pandemic, telehealth, particularly for mental health and substance use
    treatment for very young and families, will continue to be part of a
    comprehensive set of care options available to provide the right care
    in the right place at the right time?

        Answer. HHS continues to evaluate telehealth flexibilities and has
    engaged
    agency-wide workgroups to assess their impact and possible
    continuation. Indeed, the telehealth flexibilities have been well
    received by the treatment community, since they offer: flexibility in
    service delivery, improved access to care for those living in rural or
    remote areas, improved provider-client relationships through more
    trusting relationships, and improvement in care coordination
    activities. SAMHSA is also working closely with the Centers for
    Medicare and Medicaid Services to ensure appropriate recognition and
    remuneration of services.

        Telehealth services are an important tool to improve health equity
    and access to health care for the very young and families including for
    mental health and substance use treatment. Throughout the pandemic,
    telehealth services have filled an urgent need to maintain access to
    care while social distancing was necessary. Beyond the pandemic, HHS
    will continue to support telehealth services programs and activities
    for youth and families. For example, HRSA's Office for the Advancement
    of Telehealth will continue to provide support through resources like
    the Telehealth.HHS.gov website and the Telehealth Resource Centers so
    patients and providers have access to tele-behavioral technical
    assistance.

        HRSA has observed an increase in telehealth utilization since the
    start of the COVID-19 pandemic, which has been beneficial in the
    delivery of care across various medical fields. To the extent allowable
    by law, HRSA has extended flexibilities allowing programs and awardees
    to adopt telehealth and incorporate it into everyday delivery of care.
    To maintain this utilization, it would be necessary to further consider
    additional flexibilities needed by practitioners to ensure patient
    access to telehealth services.

            The Medical Student Education (MSE) Program provides grants to
    public institutions of higher education to expand or support graduate
    education for medical students preparing to become physicians in the
    top quintile of States with a projected primary care provider shortage
    in 2025. Awardees are using telehealth modalities and telemedicine
    networks to connect clinicians to rural patients and to provide care
    and education through telemedicine. Seventy percent of MSE trainees
    received training in telehealth and 46 percent of sites offered
    telehealth services.
            The Graduate Psychology Education (GPE) Program supports
    innovative
    doctoral-level health psychology programs that foster an
    interprofessional approach to providing behavioral health and substance
    use prevention and treatment services in high-need and high-demand
    areas through academic and community partnerships. In AY 2019-2020,
    grantees partnered with 210 sites (e.g., hospitals, ambulatory practice
    sites, and academic institutions), of which approximately 77 percent
    offered substance use treatment services and 83 percent offered
    telehealth services.
            In response to the COVID-19 pandemic, the National Health
    Service Corps (NHSC) has enabled the program's clinicians to be
    increasingly flexible in their use of telemedicine. More than 40
    percent of NHSC awardees indicate that their site currently uses
    telemedicine.
            HRSA's Substance Use Disorder Treatment and Recovery (STAR)
    Loan Repayment Program (LRP) recruits and retains medical, nursing,
    behavioral/mental health clinicians and paraprofessionals who provide
    direct treatment or recovery support of patients with or in recovery
    from a substance use disorder. The program enables mental health
    providers serving in mental health Health Professional Shortage Areas
    (HPSAs) to provide mental health services via telehealth to patients
    located outside of a HPSA.
            The Pediatric Mental Health Care Access (PMHCA) Program
    promotes behavioral health integration in pediatric primary care by
    supporting the development of new, or the improvement of existing,
    statewide or regional pediatric mental health care telehealth access
    programs. These programs provide tele-consultation, training, technical
    assistance, and care coordination for pediatric primary care providers
    to diagnose, treat and refer children with behavioral health
    conditions. Telehealth strategies, like the ones supported by the PMHCA
    Program, connect primary care providers with specialty mental and
    behavioral health-care providers, and can be an effective means of
    increasing access to mental and behavioral health services for children
    and adolescents, especially those living in rural and other underserved
    areas. PMHCA programs also support resilience strategies among families
    and clinicians.
                                   investment
        Question. The COVID-19 pandemic has placed families and children in
    challenging situations that have caused persistent stress and
    uncertainty. While this has certainly contributed to the crisis in
    child and adolescent mental health, we know that this problem and its
    root causes, such a lack of youth-specific mental health infrastructure
    and a shortage of pediatric mental health professionals, predate the
    pandemic.

        What upstream investments should we be making now to promote
    children's healthy social-emotional development and to build a stronger
    system of care to meet children's needs far into the future?

        Answer. Prior to the pandemic, we knew that about half of children
    with mental health disorders did not receive care. Although trends in
    pediatric mental health were worrying before the COVID-19 public health
    emergency, demand over the past 18 months for pediatric inpatient
    mental health services, partial hospitalization, step-down programs and
    other levels of crisis care has risen significantly.

        Promotion of healthy social and emotional development of children
    and their families will require investment in upstream, comprehensive
    system of supports for children where they live, learn, and play, such
    as schools and other community settings. The school environment offers
    access to children and youth where school personnel can provide
    consistent support and stability, identify concerns early, and offer
    additional services when needed. Additional investments in the
    community could support community members who engage regularly with
    mothers and children with the foundational knowledge to integrate
    support for social and emotional development and identify mental and
    behavioral health needs.

        HRSA's upstream approach includes promoting children's mental
    health and well-being across the lifespan, and preventing behavioral
    health conditions from occurring or getting worse. Early engagement in
    a child's life helps promote optimal health and well-being and
    decreases the likelihood of mental and behavioral health problems later
    on in life. Additionally, HRSA integrates behavioral health-care
    services into primary and preventative health care.

        To promote children's healthy social-emotional development and to
    build a stronger system of care, HRSA's title V Maternal and Child
    Health (MCH) Services Block Grant (title V) program can play a key
    role. It is a Federal-State partnership that awards formula grants to
    59 States and jurisdictions to address the health needs of mothers,
    infants, and children, including children with special health-care
    needs. Title V strategies to promote mental and behavioral health and
    well-being across the MCH population include workforce training and
    education, cross-sector collaborations, public health campaigns, and
    evidence-based approaches to address substance use disorders. For
    example, the Texas title V program supports ongoing health education
    for Texas providers on mental and behavioral health. In FY 2020, 16,983
    early childhood development and screening modules were completed by
    providers via Texas Health Steps-Online Provider Education (THS-OPE)
    modules. The education module topics addressing mental and behavioral
    health included adverse childhood experiences, attention-deficit/
    hyperactivity disorder, autism spectrum disorder, behavioral health
    screening and intervention, depression, anxiety, developmental
    surveillance and screening, and using developmental screening tools.

        In addition, HRSA's Bright Futures program supports State title V
    Maternal and Child Health (MCH) and clinical health professionals to
    use evidence-based strategies that increase access to, and the quality
    of, preventive health-care visits for children, adolescents and young
    adults. Mental health can be affected at many critical times in
    development, beginning prenatally with the mental health of the mother,
    through infancy with the importance of attachments, through early
    childhood, and beyond. Accordingly, promoting mental health through
    activities that are aimed at prevention, risk assessment, and diagnosis
    and offering an array of appropriate interventions is essential.\31\
    The Bright Futures Periodicity Schedule recommends what screening
    should occur with what frequency, including routine behavioral/
    social/emotional screening and the Bright Futures Guidelines chapter
    titled, ``Promoting Mental Health,'' educates pediatricians on how to
    improve children and adolescents' mental development within the well
    child visit. Each Bright Futures primary care visit addresses the
    physical and mental health of the child or adolescent. This theme
    highlights opportunities for promoting mental health in every child,
    including specific suggestions for each age and stage of
    development.\31\
    ---------------------------------------------------------------------------
        \31\ Hagan, J.F., Shaw, J.S., and Duncan, P.M., eds. Bright
    Futures: Guidelines for Health Supervision of Infants, Children, and
    Adolescents. 4th ed. Elk Grove Village, IL: American Academy of
    Pediatrics; 2017.

        Additional investments in primary care pediatricians and other
    pediatric mental health providers should be considered to build a
    stronger system of care to meet children's socio-emotional development
    needs. Investments in provider resiliency are also critical to building
    a stronger system of care and maintaining the broader health-care
    ---------------------------------------------------------------------------
    workforce, including the pediatric care workforce.

        The pandemic has also exacerbated risk factors for negative mental
    health impacts including financial stress and instability, housing and
    food insecurity, and isolation. Knowing that suicide risk factors,
    overdoses, and violence have increased throughout the pandemic raises
    concerns for not only mitigating the impacts of Adverse Childhood
    Experiences (ACEs) in the immediate and long-term but underscores the
    importance of scaling up effective prevention efforts to prevent the
    risk for additional Adverse Childhood Experiences (ACEs). The science
    is clear, ACEs are strongly linked to mental health and substance use
    challenges in adolescence and later in life and preventing ACEs could
    have substantial positive impacts on the
    social-emotional health of young people. The evidence tells us that
    ACEs can be prevented by connecting children and families to safe,
    stable, nurturing relationships and environments with demonstrated
    broad and sustained benefits. CDC has been a leader in ACEs prevention
    work. Through the Preventing Adverse Childhood Experiences: Data to
    Action \32\ cooperative agreement, CDC supports communities to
    implement strategies based on the best available evidence including:
    ---------------------------------------------------------------------------
        \32\ https://www.cdc.gov/violenceprevention/aces/preventingace-
    datatoaction.html.

            Strengthening economic supports for families, which help
    increase household incomes for working families while offsetting the
    costs of child care and have demonstrated impacts on maternal stress,
    mental health problems, and child behavioral problems.
            Promoting social norms that protect against violence and
    adversity including norms that prevent violence of all forms against
    women and girls.
            Ensuring a strong start for children and paving the way for
    them to reach their full potential including family-friendly leave
    policies, paid family leave and access to high-quality child care, and
    preschool enrichment programs which include family engagement.
            Teaching skills to help parents and youth handle stress,
    manage emotions, and tackle everyday challenges.
            Connecting youth to caring adults and activities which
    includes connecting to coaches, neighbors, and other community members,
    as well as extended family members; mentoring; after-school programs;
    and other opportunities to help children and youth develop and practice
    leadership, informed decision-making, self-management, and social
    problem-solving skills.
            Intervening to lessen immediate and long-term harms in
    instances where ACEs have occurred including referrals to community
    supports, primary care providers and trauma-informed care.

        Investing as early as possible in the life cycle of children is
    critical. This can be accomplished through promoting mental health
    literacy, early screening, ensuring that (if needed) parents and
    children have access to evidence-based interventions for the 0-5
    population.

        For example, SAMHSA's Mental Health Awareness Training grant
    program promotes mental health literacy by training school personnel,
    emergency first responders, law enforcement, veterans, armed services
    members and their families to recognize the signs and symptoms of
    mental disorders, particularly serious mental illness (SMI) and/or
    serious emotional disturbances (SED).

        For children of all ages, but especially young children,
    relationships with primary caregivers have the greatest effect on a
    child's healthy social-emotional development. CDC's Whole School, Whole
    Community, Whole Child model emphasizes the role of connectedness among
    parents and family members, peers, teachers and the community, as well
    as creating healthy and supportive environments for students to thrive.
    Investments in programs and policies that support human development in
    the first 5 years of life is one of the most effective ways to promote
    social-emotional development and minimize the prevalence of mental and
    behavioral health issues in adulthood. Along with healthy
    relationships, a two-generation strategy for promoting health social-
    emotional development, by creating policies and programs that provide
    services and supports to young children and their parents (or
    caregivers) at the same time. Supporting parents' and caregivers' well-
    being is a critical prevention activity in ensuring children's mental
    health. Early childhood systems must be focused on the prevention end
    of the mental health continuum, but not to the exclusion of providing
    treatment as necessary. Appropriate screening, assessment, and
    diagnosis so children and families who need more intensive supports
    receive them.

        SAMHSA's Project Linking Actions for Unmet Needs in Children's
    Health (LAUNCH) program and Children's Mental Health Initiative
    (Systems of Care) grants are focused on early childhood. The purpose of
    the Project LAUNCH initiative is to promote the wellness of young
    children, from birth to 8 years of age, by addressing the physical,
    social, emotional, cognitive, and behavioral aspects of their
    development. Project LAUNCH pays particular attention to the social and
    emotional development of young children and works to ensure that the
    systems that serve them (including childcare and education, home
    visiting, and primary care) are equipped to promote and monitor healthy
    social and emotional development. The program also ensures that the
    systems intervene to prevent, recognize early signs of, and address
    mental, emotional, and behavioral disorders in early childhood and into
    the early elementary grades. SAMHSA's Children's Mental Health
    Initiative Systems of Care grants support children and youth with
    serious emotional disturbances and their families to increase their
    access to evidence-based treatment and supports. Additionally, SAMHSA's
    Infant and Early Childhood Mental Health grantees improve outcomes for
    children through training early childhood providers and clinicians to
    identify and treat behavioral health disorders of early childhood,
    including in children with a history of in utero exposure to substances
    such as opioids, stimulants or other drugs that may impact development,
    and through the implementation of evidence-based multigenerational
    treatment approaches that strengthen caregiving relationships.

        Question. What steps can we take to ensure we are providing enough
    resources director to children's mental health during the current
    crisis and how can we plan for future pandemics?

        Answer. Congress can support Federal efforts to develop Emergency
    Preparedness, Resilience, and Response (EPRR) plans that address the
    mental health needs of children, their families, and the adults who
    support them. For example, through greater investments in and scaling
    up SAMHSA's Infant Early Childhood Mental Health (IECMH) programming,
    we can prevent long-term challenges resulting from pandemic-related
    stressors. Increasing our investment in IECMH Consultation, we can
    ``care for the caregiver'' through professional, evidence-based
    support. The FY 2023 budget request is $37.5 million. This funding will
    support 30 continuation grants and the National Center of Excellence
    for Infant and Early Childhood Mental Health Consultation (CoE-IECMHC)
    to improve health outcomes for young children and support children at
    high risk for mental illness and their families in order to prevent
    future disability. This funding request will provide continued
    screening, prevention, early intervention for behavioral health issues
    and referrals to high quality treatment for children and families in 30
    communities across the U.S.

        CDC's Healthy Schools Program is taking several steps to ensure
    schools and the children, families and communities they serve are
    equipped and supported in handling the mental health challenges brought
    on by the COVID-19 pandemic. These include:

            Emphasizing the Whole School, Whole Community, Whole Child
    \33\ framework to implement evidence-based strategies that improve
    physical and mental health, encompassing healthy in-school and out-of-
    school time programs and staff wellness. The model is comprised of 10
    components that work synergistically, including two related to mental
    health: Counseling, Psychological and Social Services and Social and
    Emotional School Climate.
    ---------------------------------------------------------------------------
        \33\ https://www.cdc.gov/healthyschools/wscc/index.htm.
    ---------------------------------------------------------------------------
            Supporting 15 geographically diverse State education agencies
    (SEAs) through the CDC Healthy Schools FY21 COVID-19 Supplemental
    Funding. This support is designed to address COVID-19 within K-12
    settings by supporting the implementation of COVID-19 prevention
    strategies and additional COVID-19 needs of local education agencies
    (LEAs) and schools. This includes supporting social, emotional, mental
    health and well-being of students and teachers and school staff as they
    returned to in-person learning this school year. The supplement funds
    this cooperative agreement for the 12-month budget/performance period
    from June 30, 2021, to June 29, 2022, to allow for the acceleration of
    activities.
            Developing resources like the social and emotional climate and
    learning webpage, \34\ which houses the Toolkit for Schools: Engaging
    Parents and Families to Support Social and Emotional Climate and
    Learning \35\ and Tools \36\ for school employee wellness.
    ---------------------------------------------------------------------------
        \34\ https://www.cdc.gov/healthyschools/sec.htm.
        \35\ https://www.cdc.gov/healthyschools/sec/sec_toolkit.htm.
        \36\ https://www.cdc.gov/healthyschools/employee_wellness.htm.
    ---------------------------------------------------------------------------
            A social media campaign and videos to promote school health
    champions, including Supporting the Well-being of School Employees on
    the Frontlines to help maintain healthy schools.\37\
    ---------------------------------------------------------------------------
        \37\ https://www.youtube.com/watch?v=vfA52EohO8o.
    ---------------------------------------------------------------------------
            Funding 4 non-governmental organizations to support State
    educational agencies, local school districts, parents, and community
    partners with return to school after COVID-19 closures. This work
    involves training to address the social, emotional, and mental health
    needs of students as well as school faculty and staff related to
    reopening after long school closures due to COVID-19.
            In FY22 (estimated start of June 1, 2022), CDC's Healthy
    Schools program will start a new NGO cooperative agreement cycle. The
    FY22 NOFO includes two new priority areas that specifically aim to
    improve access to health services and the emotional well-being of
    students and staff in disproportionately affected communities.
            In response to mounting mental health concerns among students,
    families and school staff, CDC Healthy Schools is further emphasizing
    emotional well-being and connectedness in its programs by creating and
    publishing tools and resources that reflect the needs from the field on
    our website. These tools are for educators, administrators, and
    parents.

        We can make sure that mental health services are seen similarly to
    physical health by leveraging campaigns that SAMHSA and CMS host to
    promote mental health-care access. We can work with the Department of
    Education to build mental health into the health education curriculum
    to de-stigmatize the utilization of mental health services and provide
    psychoeducation. We can require early child-care settings and other
    educational settings to support the provision of mental health services
    through access to technical assistance and increasing the behavioral
    health workforce in these settings. Ensure funding is consistently
    allocated for tele-
    behavioral health, tele-consultation, and tele-psychiatry services to
    assist with improving access to behavioral health care.

        Children have unique emergency care needs, especially during
    serious or life-threatening emergency situations. The majority of the
    Nation's children are treated in community and rural emergency
    departments (EDs) close to where they live. Hospital EDs and emergency
    medical services (EMS) agencies often lack the necessary equipment and
    resources to treat children adequately. To ensure we are providing
    enough resources directed to children's mental health during current
    and future crises, HRSA's Emergency Medical Services for Children
    (EMSC) program focuses its resources on ensuring that seriously ill or
    injured children have access to high-
    quality pediatric emergency care, no matter where they live in the U.S.
    EMSC agencies are a critical resource in responding to childhood
    trauma, youth suicide (now the second leading cause of death for people
    aged 10-34), and the health and social/
    emotional impact of the COVID-19 pandemic on children. In 2020, HRSA's
    Pediatric Emergency Care Applied Research Network (PECARN) completed
    two studies with over 10,000 adolescents and found that a brief,
    computerized adaptive screening tool accurately predicted risk for
    attempted suicide. In addition, the EMSC program continued to promote
    the Critical Crossroads: Pediatric Mental Health Care in the Emergency
    Department Pathways Toolkit, a clinical decision tool and resource
    guide. State Partners are also improving emergency care systems for
    children in mental health crises. For example, the New England Regional
    EMSC network developed a Behavioral Health Toolkit to assist with the
    care of pediatric patients who present with a behavioral health
    complaint and are awaiting placement or further evaluation.

        According to workforce projections from the HRSA's National Center
    for Health Workforce Analysis (NCHWA), by 2030, there is also a
    projected maldistribution of pediatricians in particular States. For
    example, Texas is projected to have enough pediatricians in 2030 to
    meet only 72 percent of projected demand. Texas would need an
    additional 1,940 pediatricians to meet the projected demand in 2030. In
    addition, there is projected maldistribution with respect to metro and
    non-metro settings. While the projected supply of pediatricians in
    metro areas in the U.S. is sufficient to meet 101 percent of projected
    demand in 2030, that figure is only 67 percent for non-metro areas.
    These projections do not take into account the effects of the pandemic
    particularly those related to changes in demand for mental health
    services.

        HRSA also offers several programs that invest in recruiting and
    retaining clinicians and nurses in the mental health, primary care and
    pediatric fields. HRSA also offers resiliency programs, stemming from
    the COVID-19 pandemic, that support the planning, developing,
    operating, or participation of health professions and nursing training
    activities, using evidence-based or evidence-informed strategies, to
    reduce and address burnout, suicide, mental health conditions, and
    substance use disorders and to promote resiliency among public safety
    officers and health-care professionals, health-care students,
    residents, trainees, and paraprofessionals in rural and medically
    underserved communities. These programs include the Health and Public
    Safety Workforce Resiliency Training Program, as well as the Promoting
    Resilience and Mental Health Among Health Professional Workforce
    program.
                                return to school
        Question. For almost 2 years, children have been forced to toggle
    between virtual and in-person learning. The medical experts at the
    University of Texas Health Science Center report that social distancing
    has played a significant role in the rise in mental health issues among
    adolescents. Consequently, mental-health related visits to hospital
    emergency rooms have had sharp increases. These experts highlight the
    strain on relationships amongst family members, but also teachers,
    school administrators, and peers. This inability to find a sense of
    belonging and grounding within the community break down the social
    connections that provide an important source of resiliency.

        Now that children are primarily back in the classroom, how can
    schools play a role in lowering mental health outcomes and identifying
    children who are struggling with anxiety, depression, or behavioral
    health issues to ensure they receive the help they need?

        Answer. Schools can take the following actions to recognize and
    support the mental health needs of children:

            Implement proven universal mental health promotion strategies,
    such as Social Emotional Learning (SEL), to all students grades K-12.
    The need for mental health support resulting from the collective
    experience of COVID-19 for many students is so pervasive that services
    alone are necessary, but not sufficient, to promote recovery and well-
    being. Universal prevention strategies are a critical complement to
    more intensive services for those who need them. These prevention
    strategies include health education and also entail strategies to
    improve o school climate or student sense of connectedness or belonging
    to school, which is associated with positive mental health and academic
    outcomes. Students who feel connected to their school are less likely
    to experience depression, anxiety, suicide ideation or to engage in
    sexual activity. The effects of school connectedness are long-lasting.
    Students who feel connected to their school are, as adults, less likely
    to have emotional distress, suicidal ideation, physical violence
    victimization or perpetration, multiple sex partners, sexually
    transmitted diseases, or prescription drug misuse or illicit drug use.
    School connectedness represents a public health approach to mental
    health promotion because of its potential to impact many students
    simultaneously and evidence of its relationship to promoting positive
    student mental health outcomes and buffering the impact of traumatic
    experiences. Effective school connectedness strategies include
    classroom specific and school-wide programs, school climate change or
    management and disciplinary strategies, and activities within the
    broader community environment to promote with parent and family
    involvement.
            Increase the number of school mental health professionals.
    Schools are one of the leading settings for delivery of mental health
    services, with 15.4 percent of students receiving mental health
    services in schools, surpassed only slightly by specialty mental health
    settings (16.7 percent). However, significant gaps remain between those
    who need mental health services and those who receive them. In 2019,
    nearly 57 percent of adolescents ages 12-17 with major depressive
    impairment did not receive any treatment in the year prior to the
    survey. On average, U.S. school systems have only 1 counselor per 491
    students and 1 psychologist per 1,400 students, far below recommended
    ratios. Estimates prior to the COVID-19 pandemic project a potential
    dire shortage of school counselors, with a projected deficiency of more
    than 10,000 personnel, relative to projected need by 2025.
            Facilitate partnerships between schools and community
    providers. Increasing mental health staff may help schools implement
    more comprehensive approaches to mental health screening.
            Support the mental health of school staff members. School
    staff are hampered in their ability to provide mental health support to
    students in they are experiencing mental health challenges. As noted in
    the U.S. Department of Education Handbook,\38\ schools can consider
    eliminating or reducing administrative duties and non-critical meetings
    for school mental health staff or teachers. Integrate wellness into
    professional development approaches by providing adequate planning time
    for staff that includes opportunities for collaboration, training, peer
    coaching, and supportive performance feedback.
    ---------------------------------------------------------------------------
        \38\ https://www2.ed.gov/documents/students/supporting-child-
    student-social-emotional-behavioral-mental-health.pdf.
    ---------------------------------------------------------------------------
            Provide tools and resources to parents and caregivers. CDC
    developed a set of resources, called Parents for Healthy Schools,\39\
    to assist schools, school groups, and school wellness committees with
    encouraging parent involvement in school health. Parents for Healthy
    Schools uses evidence-based strategies for parent engagement.
    ---------------------------------------------------------------------------
        \39\ https://www.cdc.gov/healthyschools/parentsforhealthyschools/
    p4hs.htm?msclkid=bc3b367f
    cfab11eca77127cce216be93.
    ---------------------------------------------------------------------------
            Implement equitable, trauma-informed disciplinary policies.

        While schools play an important role in addressing the behavioral
    health needs of children and youth, it is equally important to also
    integrate efforts outside of schools as part of a holistic and
    comprehensive approach to addressing the well-being and resilience of
    children and youth. Doing so enhances public health and public safety
    outcomes for individuals and communities. CDC's Preventing Adverse
    Childhood Experiences: Leveraging the Best Available Evidence \40\
    guide recommends universal preschool with an emphasis on social
    emotional learning as a form of prevention intervention. Programs such
    as child parent centers are also associated with lower rates of
    substantiated reports of child abuse and neglect and out-of-home
    placements; youth depression and substance use; and arrests for violent
    and nonviolent offenses, convictions, and incarceration well into
    adulthood and systematic reviews of the evidence for social emotional
    learning approaches finds that they significantly reduce peer violence
    across grade levels, school environments, and demographic groups, and
    improve other outcomes such as reducing substance use. In addition to
    impacts on aggression and violent behavior, programs that include these
    ACEs prevention strategies, such as Life Skills Training, the Good
    Behavior Game, and Promoting Alternative Thinking Strategies (PATHS)
    have demonstrated other benefits as well, including reductions in youth
    alcohol, tobacco, and drug use, depression and anxiety, suicidal
    thoughts and attempts, delinquency, and involvement in crime. CDC's
    ACEs strategy also promotes connecting youth to caring adults through
    mentorship opportunities which help them to develop and practice
    leadership, decision-making, self-management, and social problem-
    solving skills are important components of after-school programs with
    documented benefits. One example is the After School Matters program,
    which offers apprenticeship experiences in technology, science,
    communication, the arts, and sports to high school students.
    ---------------------------------------------------------------------------
        \40\ https://www.cdc.gov/violenceprevention/pdf/preventingACES.pdf.

        Schools can create a shared language around trauma, resilience,
    wellness, and achievement and create trauma-informed schools. Schools
    can also generate clear frameworks, assessments, and referral pathways
    that differentiate between anxiety, depression, grief, trauma, and
    youth development needs so that children access and receive the help
    that is responsive to their needs--not just what is available.
    Additionally, they can increase referral pathways to include culturally
    and linguistically competent and appropriate services. Schools can also
    work to ensure everyone understands and promotes the knowledge that
    ---------------------------------------------------------------------------
    mental health is health, and that grief is not a problem to be solved.

                                     ______

                     Questions Submitted by Hon. John Thune
        Question. Your advisory references physical activity as an
    important component of kids' overall health a few times. I think that
    many would agree that sports and fitness provide an important outlet
    for kids, both in terms of stress and energy release, and in the
    development of communication, leadership, and team-building skills.
    Shutting down sports over the pandemic has been tough on kids and
    families.

        What can the administration and Congress do to ensure that we are
    getting kids and adults back into sports and physical activity, and to
    make it more affordable and accessible?

        Answer. Physical activity is one of the best things we can do for
    both physical and mental health, and playing sports is one way for
    Americans to get the physical activity they need. A 2020 study
    conducted by CDC and SAMHSA found significant associations between
    insufficient physical activity, less healthy dietary behaviors and poor
    mental health-related outcomes, including feeling sad and hopeless, and
    seriously considering suicide, among US high school students. CDC's
    Healthy Schools program funds 16 State education agencies through the
    Improving Student Health and Academic Achievement Through Nutrition,
    Physical Activity, and the Management of Chronic Conditions in Schools
    program. Funded States support local communities in implementing
    evidence-based, comprehensive school health policies, practices, and
    programs designed to improve student and staff health and well-being,
    with a special focus on healthy school nutrition \41\ and physical
    activity \42\ strategies.
    ---------------------------------------------------------------------------
        \41\ https://www.cdc.gov/healthyschools/nutrition/
    school_nutrition_sec.htm.
        \42\ https://www.cdc.gov/healthyschools/school_based_pa_se_sel.htm.

        The National Youth Sports Strategy (NYSS), released in 2019 by
    OASH, is a Federal roadmap designed to unify U.S. youth sports culture
    around a shared vision: that one day all youth will have the
    opportunity, motivation, and access to play sports. It provides a
    framework with actionable steps that communities, organizations,
    decision-makers, and policymakers can use to help improve the U.S.
    youth sports landscape. At launch, the HHS awarded 18 Youth Engagement
    in Sports (YES) Grants with the help of our Office of Minority Health
    and Office on Women's Health, totaling over $6.7 million to help
    increase youth participation in sports and reduce barriers to play,
    especially for youth populations with lower rates of sports
    participation and communities with limited access to athletic
    facilities or recreational areas. These grants provided 3 years of
    ---------------------------------------------------------------------------
    funding which ended in FY 2022.

        There are many organizations across the United States that are
    working in alignment with the National Youth Sports Strategy. The NYSS
    Champions partnership initiative highlights over 190 organizations on
    health.gov.

        We have heard from NYSS Champions that they face a range of
    barriers, including lack of funding sources, limited formal training
    for coaches and difficulty recruiting and retaining volunteers, limited
    access to facilities and infrastructure, low awareness of sports
    programs and offerings among the public, and competition outweighing
    fun and youth development in many programs. Despite these challenges,
    organizations have found new and creative ways to engage their
    communities in physical activity and sports during the pandemic and
    continue to seek support for their efforts to create safe, fun,
    inclusive, developmentally appropriate, and accessible sports
    opportunities for all youth.

                                     ______

                    Questions Submitted by Hon. Richard Burr
        Question. Your advisory on protecting youth mental health includes
    a number recommendations for State, local, and tribal governments. A
    few that stuck out to me include: support the mental health needs of
    youth involved in the child welfare system; ensure all children and
    youth have comprehensive and affordable coverage for mental health
    care; and improve coordination across all levels of government to
    address youth mental health needs.

        The advisory also identifies kids in the child welfare system as a
    group at higher risk of mental health challenges during the pandemic.

        Senator Feinstein and I have introduced a bill to directly help
    vulnerable youth in the child welfare system in a manner supported by
    all three of these recommendations. Our bill would ensure that children
    placed in qualified residential treatment programs (QRTPs) with more
    than sixteen beds would not lose eligibility for Medicaid because of an
    antiquated law often called the ``IMD exclusion.''

        QRTPs are required by law to have a trauma-informed treatment model
    designed to address the clinical needs of foster children with serious
    emotional disturbances or behavioral disorders. In other words, these
    programs are legally required to provide a clinically appropriate level
    of care for vulnerable foster children who are in serious need of such
    care.

        Do you believe that children in QRTPs with more than 16 beds should
    be able to keep their Medicaid coverage?

        If not, please be specific as to how losing that coverage would
    improve the mental health of those children.

        If you believe that these foster children--among whom racial and
    ethnic minorities are overrepresented relative to the population \43\--
    should lose their Medicaid coverage, please explain in detail how such
    policy aligns with Executive Order 13985, in which President Biden
    declares it is ``the policy of my administration that the Federal
    Government should pursue a comprehensive approach to advancing equity
    for all, including people of color and others who have been
    historically underserved, marginalized, and adversely affected by
    persistent poverty and inequality.''\44\
    ---------------------------------------------------------------------------
        \43\ https://www.childwelfare.gov/pubpdfs/
    racial_disproportionality.pdf.
        \44\ https://www.federalregister.gov/documents/2021/01/25/2021-
    01753/advancing-racial-equity-and-support-for-underserved-communities-
    through-the-federal-government.

        Do you support and commit to working with me to pass my
    legislation, which will ensure that vulnerable foster children across
    the country have access to the medical and mental health services they
    ---------------------------------------------------------------------------
    need?

        Answer. The issues surrounding QRTPs are important and complex.
    Children in foster care should receive the medical care that they need
    and to which they are entitled, without disruption, in a safe and
    nurturing setting that fosters their growth and development. Placement
    in a QRTP that is an IMD does not impact Medicaid eligibility. The
    Medicaid statute prohibits States from receiving Federal financial
    participation for services delivered to most individuals residing in an
    IMD. However, on October 19, 2021, CMS informed States that they can
    request to modify the terms of an existing Medicaid section 1115
    demonstration, or seek approval of a new demonstration to allow States
    to receive Federal funding for Medicaid services delivered to title IV-
    E foster children residing in a QRTP that is an IMD for longer than
    currently allowed under that demonstration model. States will be
    required to provide a plan for transitioning children out of QRTPs that
    are IMDs. Although I was not personally involved in this waiver
    opportunity, I understand that it was developed to provide much needed
    relief to States seeking to receive Federal match for Medicaid services
    provided to foster children residing in QRTPs that are IMDs.

        Question. Children have had their worlds upended by responses to
    the COVID-19 pandemic. Prolonged school closures and virtual learning
    have starved children of the social interaction necessary for healthy
    mental and emotional development. The pandemic has had a devastating
    impact on the mental health of American children and adolescents.

        Your advisory on protecting youth mental health talks about the
    importance of schools in helping children find a sense of purpose and
    fulfillment, as well as serving as a critical resource in managing
    mental health challenges.

        Your advisory includes eight recommendations for school districts,
    educators, and other school staff. Not one of them is ``stay open.''
    Why?

        Answer. As I have said numerous times publicly, it is critical for
    schools to stay open. In addition to providing core educational
    services, schools can also be an essential source of nonacademic
    supports in the way of health and mental health services, food
    assistance, and intervention in cases of homelessness and maltreatment.
    The Federal Government has taken strong action to ensure that schools
    remain open, including providing more than $120 billion of American
    Rescue Plan funding to support safe school reopening and providing
    guidance and technical assistance to States and local communities.
    Ninety-nine percent of schools \45\ are open for full-time, in-person
    learning as of late February 2022.
    ---------------------------------------------------------------------------
        \45\ https://www.ed.gov/news/press-releases/statement-us-secretary-
    education-miguel-cardona-cdc-guidance-and-keeping-schools-safely-open.

        CDC offers guidance on strategies to support in-person learning.
    CDC does not recommend school closures as a public health strategy.
    When schools close, they largely do so due to operational issues--too
    many people (students/staff) are out because they are sick or
    quarantining, or because they are providing a break for in-person
    school due to mental health concerns. The CDC offers important and
    useful guidance for the school systems and health departments to make
    informed decisions for their jurisdictions. We strongly encourage
    education leaders to work closely with their State and local public
    health partners to assess risks and needs locally and make the best
    decisions based on our science and guidance. The vast majority of
    schools are remaining open for in-person learning. Over the past two
    weeks, more than 99.5 percent of schools were fully open for in-person
    ---------------------------------------------------------------------------
    learning.

        Question. For many students coming from underserved families,
    schools may be their only chance to receive mental health care or other
    social services. Do you think school closures undermine this
    administration's goal of improving health outcomes for underserved
    populations?

        Answer. I agree that schools remaining open is critical not only
    for educational purposes but also so that students can receive mental
    health care and other social services. The administration is committed
    to keeping schools open, and 99 percent of schools are open for full-
    time, in-person learning as of late February 2022.

        From a Health Equity Lens, CDC recognizes that local leaders make
    difficult decisions with community wellness and student mental health
    in mind. It is a priority to provide in-person learning and
    alternatives as necessary to reduce the number of lost learning days
    and provide continuity of mental health and social services that
    students rely on. Limited health-care options, differential access to
    testing, low vaccination rates, exposure of high-risk family members
    and staff have impacted underserved families during this pandemic.
    Schools can play a role in increasing support for continuing mental
    health and social services, increasing access to testing, and promoting
    vaccination.

        Question. In June 2021, the CDC released a study that revealed
    Emergency Department visits for suspected suicide attempts among
    adolescent girls were about 51 percent higher from February to March in
    2021 versus that same time period in 2019. For adolescent boys, visits
    increased about 4 percent.

        How do you square these statistics with your advisory that lacks a
    specific recommendation to safely open schools and keep them schools?

        Answer. As noted above, I believe keeping schools open safely is
    essential. It is why, on numerous occasions over the last year, I have
    urged schools and communities to implement evidence-based measures to
    reduce the risk of COVID and allow children to learn safely. With that
    said, the mental health challenges that children are facing are related
    to multiple factors in addition to the disruption of the educational
    environment. They include the loss of caregivers and other loved ones,
    the economic hardship that many families endured, difficulty in
    accessing mental and physical health-care services, increase in food
    insecurity, and the uncertainty about when the pandemic would end. In
    the advisory, I outline a series of recommendations where we can make
    progress in the short and long term. Examples include ensuring that
    every child has access to high-quality, affordable, and culturally
    competent mental health care, putting more energy and resources toward
    prevention, better understanding the impact that technology and social
    media have on mental health, and recognizing the role each of us can
    play in eliminating the stigmatization associated with seeking help for
    mental health challenges.

        CDC guidance stresses the importance of in-person learning and does
    not recommend school closures as a public health strategy. CDC offers
    guidance on strategies to support in-person learning. When schools
    close, they largely do so due to operational issues--too many people
    (students/staff) are out because they are sick or quarantining, or
    because they are providing a break for in-person school due to mental
    health concerns.

        Question. In response to a question for the record in the HELP
    Committee in February 2021, you committed to working with HHS and my
    office to reopen schools safely nationwide.

        What have you done as Surgeon General to get our students back in
    the classroom?

        Answer. Since the beginning of my service in March 2021, I've
    worked in partnership across the Federal Government and with local
    communities to fight the COVID-19 pandemic and support the safe
    reopening of schools across the country. I've provided parents,
    educators, school leaders, and the American public with up-to-date
    information on the evolving evidence around COVID-19 and measures to
    enable safe reopening of schools such as vaccinations, testing,
    masking, and social distancing. I've encouraged schools and communities
    to make use of funds and technical assistance made available to them
    through the American Rescue Plan Act and use these resources to
    strengthen mental health supports. During the fall 2021, I focused
    efforts on the back-to-school season and how to keep kids, teachers,
    and other school staff safe and in-person. I actively engaged with
    national and local media and on social media to promote a safe return
    to school for kids across the country. Our office has also partnered
    with other offices within the Department of Health and Human Services,
    as well as the Department of Education, to discuss the importance of
    child and family vaccinations, safe reopening, and COVID-19
    misinformation. As of late February 2022, 99 percent of schools are
    open for full-time, in-person learning.

        In April 2021, HHS awarded $10 billion for Reopening Schools, from
    the American Rescue Plan Act of 2021, through CDC's existing
    Epidemiology and Laboratory Capacity (ELC) program to 64 State, local,
    and territorial health departments. The ELC Reopening Schools award
    \46\ supports COVID-19 screening testing and other mitigation
    activities in K-12 schools for teachers, staff, and students to reopen
    and keep schools open safely for in-person instruction. These resources
    have been critical in ensuring that students and staff may safely
    continue in-person learning. As of January 31, 2022, over 37.6 million
    tests have been conducted as a result of ELC Reopening Schools funding.
    In addition, CDC has developed guidance and resources to support the
    safe reopening of schools. These include the Guidance for the
    Prevention of COVID-19 in K-12 Schools,\47\ which has been updated as
    new data become available and the science has evolved. To support the
    implementation of testing programs in schools, CDC launched a
    communications toolkit \48\ with resources for school administrators
    and parents. CDC has provided ongoing technical assistance to State,
    local, and territorial health departments for testing efforts through
    regular office hours, webinars and peer to peer learning opportunities.
    Through partnerships with the Department of Education and the
    Rockefeller Foundation, CDC has supported a Learning Network \49\ for
    schools, with resources available at www.
    openandsafeschools.org. CDC's Healthy Schools Program has supported
    State and school districts (112 total) in implementing the guidance by
    providing funds to train school leaders and staff on the recommended
    prevention strategies, vaccination promotion, and testing initiatives.
    ---------------------------------------------------------------------------
        \46\ https://www.cdc.gov/ncezid/dpei/elc/covid-response/index.html.
        \47\ https://www.cdc.gov/coronavirus/2019-ncov/community/schools-
    childcare/k-12-guidance.html.
        \48\ https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/
    testing.html?CDC_AA_ref
    Val=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-
    ncov%2Fcommunity%2Fschools-childcare%2Fschool-testing.html.
        \49\ https://www.openandsafeschools.org/learning-network.

        On January 12, as Omicron cases were surging and schools were
    struggling to reopen safely, the administration announced the monthly
    distribution of 5 million point-of-care antigen tests for schools to
    support in-person learning. Point-of-care testing uses rapid diagnostic
    tests performed or interpreted by someone other than the individual
    being tested or their parent or guardian and can be performed in a
    variety of settings. These tests have been allocated directly to school
    districts through a partnership between CDC and ASPR and based on
    prioritized lists of school districts from ELC recipients (64 State,
    local, and territorial health departments). Tests are prioritized to
    schools with a high social vulnerability index and the ability to
    immediately implement testing. As of March 1, 5.3 million tests have
    been allocated to more than 1,000 school districts across 50
    ---------------------------------------------------------------------------
    jurisdictions.

        CDC's Operation Expanded Testing \50\ (OpET) program increases
    access to no-cost laboratory-based testing in child care centers, K-12
    schools, Historically Black Colleges and Universities, under-resourced
    communities, and congregate settings. Four regional hubs primarily
    provide laboratory-based nucleic acid amplification tests \51\ (NAATs)
    that use nasal swab collection kits. Facilities directly enroll into
    OpET by contacting their regional hub. These contractor-provided
    laboratory services include specimen collection supplies, shipping
    materials, laboratory testing, and results reporting. Sites contribute
    staff to collect specimens. HHS and FEMA are also working with State
    leaders to consider placement of community-based testing sites \52\
    that can support K-12 school \53\ testing.
    ---------------------------------------------------------------------------
        \50\ https://www.cdc.gov/coronavirus/2019-ncov/testing/operation-
    expanded-testing.html.
        \51\ https://www.cdc.gov/coronavirus/2019-ncov/lab/naats.html.
        \52\ https://www.hhs.gov/coronavirus/community-based-testing-sites/
    index.html.
        \53\ https://www.whitehouse.gov/briefing-room/statements-releases/
    2022/01/12/fact-sheet-biden-harris-administration-increases-covid-19-
    testing-in-schools-to-keep-students-safe-and-schools-open/.

        Vaccinations continue to be our best defense to keep students and
    school staff safe from COVID-19. Everyone eligible for a booster shot
    should also get one right away--this includes educators and school
    staff. Boosters provide an improved level of protection against COVID-
    19. We know that vaccines remain effective in preventing severe
    illness, hospitalization, and death. School leaders play an important
    role when it comes to vaccines: according to a Kaiser Family Foundation
    poll,\54\ parents are approximately twice as likely to get their child
    vaccinated if their school provides information about the vaccine.
    Students ages 5 and up are eligible for the COVID-19 vaccine. CDC
    encourages schools to promote vaccination and provide access to COVID-
    19 vaccines at school clinics.
    ---------------------------------------------------------------------------
        \54\ https://www.kff.org/coronavirus-covid-19/poll-finding/kff-
    covid-19-vaccine-monitor-winter-2021-update-on-parents-views-of-
    vaccines/.

                                     ______

                     Questions Submitted by Hon. Tim Scott
                        a remedy worse than the disease
        Question. Sir Francis Bacon, credited with developing the
    scientific method, famously remarked about remedies being worse than
    the disease. That's certainly the case with lockdowns, and I believe
    that to be the case here with school closures. In fact, CDC published
    in its March 19, 2021 Morbidity and Mortality Weekly Report that
    ``changes in modes of instruction have presented psychosocial stressors
    to children and parents that can increase risks to mental health and
    well-being and might exacerbate educational and health disparities.''
    When discussing children's health risk and the omicron case surge on
    MSNBC, President Biden's Chief Medical Advisor, Dr. Fauci, pointed out
    that pediatric hospitalizations are much lower on a percentage basis
    than adults, especially when compared with the elderly. Now compare
    that with a CDC report which found that mental health-related emergency
    room visits for kids ages 12-17 increased by 31 percent during 2020.
    Diving deeper, between February 21st and March 20th of 2021, emergency
    department visits due to suspected suicide attempts were 3.7 percent
    higher among boys aged 12-17 and a shocking 50.6 percent higher among
    girls aged 12-17 than during the same period in 2019.

        Can you further discuss the damaging impacts school closures have
    either created or exacerbated for children's mental health?

        Answer. During the pandemic, children, adolescents, and young
    adults have faced unprecedented challenges. The COVID-19 pandemic
    dramatically changed how they attended school, interacted with peers
    and educators, and accessed important services, such as special
    education services and health care. The broad societal upheaval,
    including the health impacts of the pandemic, a shift to remote
    learning, and physical distancing from friends and peers, have impacted
    the mental health of many children across the country. With that said,
    the mental health challenges that children are facing are related to
    multiple factors in addition to the disruption of the educational
    environment. They include the loss of caregivers and other loved ones,
    the economic hardship that many families endured, difficulty in
    accessing mental and physical health-care services, increase in food
    insecurity, and the uncertainty about when the pandemic would end.
    That's why it's been so important to ensure that Americans are up to
    date on their COVID-19 vaccines and have easy access to masks, tests,
    and other important public health tools to keep them and their loved
    ones safe, and to ensure that schools are open. As of late February
    2022, 99 percent of schools are open for full-time, in-person learning.

        Findings from a nationwide study of 1290 parents of children ages
    5-12 conducted from October 8-November 13, 2020 and published in a
    March 19, 2021 MMWR, suggest children not receiving full-time, in-
    person instruction and their parents might experience increased risk
    for negative mental/emotional and physical health outcomes.
    Specifically:

            Parents of children receiving virtual-only or combined
    instruction more frequently reported that their child's mental/
    emotional health worsened during the pandemic and that their time
    outside, time in-person with friends, and physical activity decreased.
            Parents of children receiving virtual-only instruction more
    frequently reported their own distress, difficulty sleeping, loss of
    work, concern about job stability, conflict between work and providing
    childcare, and childcare challenges than did parents whose children
    were receiving in-person only instruction.
            Children receiving in-person instruction and their parents
    reported the lowest prevalence of negative indicators of child and
    parent well-being.
            Parents whose children attended school in-person only were
    less likely to report challenges with employment and child care.
    Moreover, findings from a similar nationwide survey of 567 adolescents
    ages 13-19 conducted October-November 2020 and published in the January
    2021 edition of the Journal of Adolescent Health, suggested similar
    results.
            Students attending school virtually reported poorer mental
    health than students attending in-person.
            Racial/ethnic disparities related to mode of school
    instruction were noted, with virtual instruction only more prevalent
    among black (68.2 percent) and Hispanic students (69.0 percent)
    compared to white students (48.1 percent).
            Adolescents receiving virtual instruction reported more
    mentally unhealthy days, more persistent symptoms of depression, and a
    greater likelihood of seriously considering attempting suicide than
    students in other modes (in-
    person or hybrid) of instruction. After demographic adjustments, school
    and family connectedness each reduced the strength of the association
    between virtual versus in-person instruction for all of the examined
    mental health indicators.
                          access to in-person learning
        Question. Early in the pandemic, on a June 17, 2020 episode of the
    U.S. Department of Health and Human Service's Learning Curve podcast
    titled Science Is Truth, Dr. Anthony Fauci said: ``The fact that we
    shut down when we did and the rest of the world did, has saved hundreds
    of millions of infections and millions of lives.'' On the other hand,
    recently, researchers at Johns Hopkins University, the same university
    whose COVID-19 data tracker has been widely considered to be the gold
    standard, published a study indicating that lockdowns did little to
    reduce COVID-19 deaths, but instead, caused enormous damage to society.

        Considering the wrap-around services and support kids receive, in
    addition to the careful instruction received in an in-person school
    setting, if parents are unable to count on their school remaining
    consistently open, how important is it for them to have options to
    ensure their child is able to access a healthy, in-person learning
    environment?

        Answer. It is essential to do everything possible to keep youth
    learning in school, in person, safely. As you state, schools provide
    such a critical role in providing services to youth and we should do
    everything we can to ensure that they don't lose access to these
    services. Over the past year, the Federal Government has taken strong
    action to ensure that schools remain open, including providing more
    than $120 billion of American Rescue Plan funding to support safe
    school reopening and providing guidance and technical assistance to
    States and local communities.
    Ninety-nine percent of schools are open for full-time, in-person
    learning as of late February 2022.

        Students benefit from in-person learning, and safely returning to
    in-person instruction continues to be a priority. Schools also provide
    critical services that help to mitigate health disparities, such as
    school lunch programs, and social, physical, behavioral and mental
    health services. School closure disrupts these critical services to
    children and families and the health of communities. The need for in-
    person instruction is particularly important for students with
    intellectual, learning, and behavioral needs. Students who rely on
    essential educational support services, such as Individual Education
    Plans (IEP), English Language Leaner (ELL) services, special education,
    and learning accommodations are put at greater risk for poor
    educational outcomes when schools are closed. During periods of school
    closures, many students had limited access to these critical services.
    The unique and critical role that schools play in society makes it
    important to consider schools as a priority setting that is the ``first
    to open, and last to close'' within communities. Though COVID-19
    outbreaks have occurred in school settings, multiple studies have shown
    that transmission rates within school settings, when multiple
    prevention strategies are in place, are typically lower than--or
    similar to--community transmission levels. CDC guidance stresses the
    importance of in-person learning and does not recommend school closures
    as a public health strategy. CDC offers guidance on strategies to
    support in-person learning.
                                  bottom line
        Question. Congress recognizes the value of in-person education and,
    in that vein, has authorized more than $190 billion to schools to
    reopen and remain open through the pandemic; yet, schools around the
    country continue to close due to COVID-19.

        Bottom line: given what we now know regarding the damaging impacts
    of school closures on children's mental health, in addition to
    exacerbating the very achievement gaps we are all striving to address,
    should schools be open or closed?

        Answer. It's essential we do everything possible to keep children
    learning in school and in person safely. That's why the Office of the
    Surgeon General has worked in partnership across the Federal Government
    and with local communities to provide parents, educators, school
    leaders, and the American public with up-to-date information on how to
    protect themselves and their family, and how to safely reopen schools
    across the country. I know how stressful uncertainty can be as a
    parent. My wife and I have two small children who are in school. One is
    vaccinated; the other is too young to be vaccinated. So, we're always
    thinking about how to optimize our kids' learning and development and
    look out for their safety. We should continue to do everything we can
    to ensure that schools remain open, and, as of late February 2022, 99
    percent of schools are open for full-time, in-person learning.

        The vast majority of schools are remaining open for in-person
    learning. Over the past 2 weeks from the date of the hearing, more than
    99.5 percent of schools were fully open for in-person learning. CDC
    guidance stresses the importance of in-person learning and does not
    recommend school closures as a public health strategy. CDC offers
    guidance on strategies to support in-person learning. When schools
    close, they largely do so due to operational issues--too many people
    (students/staff) are out because they are sick or quarantining, or
    because they are providing a break for in-person school due to mental
    health concerns.
                                 staying active
        Question. Throughout your December 2021 report, ``Protecting Youth
    Mental Health,'' you emphasize the need for children to keep up with
    routine, including playing outside as well as participating in sports
    activities during school and after-school. Similarly, the CDC released
    a January 2022 report but focused on Americans in all age groups
    becoming more sedentary.

        Knowing both agencies have published alarming data on our Nation's
    mental health crisis 2 years into the pandemic, how important is
    physical activity to solving this problem?

        Answer. Physical activity is a necessary component to improving
    mental health. Physical activity researchers have been saying for years
    that ``if there was a drug that improved all the health outcomes that
    physical activity does, we'd all be taking it and paying millions for
    it.'' And yet, physical activity rates across the United States remain
    extremely low. A few notes below from the Physical Activity Guidelines
    for Americans summarize the importance of physical activity.

        A single session of moderate-to-vigorous physical activity can
    reduce blood pressure, improve insulin sensitivity, improve sleep,
    reduce anxiety symptoms, and improve some aspects of cognition on the
    day that it is performed. Most of these improvements become even larger
    with the regular performance of moderate-to vigorous physical activity.

        A 2020 study conducted by CDC and SAMHSA found significant
    associations between insufficient physical activity, less healthy
    dietary behaviors and poor mental health-related outcomes, including
    feeling sad and hopeless, and seriously considering suicide, among US
    high school students.

        Anxiety and anxiety disorders are the most prevalent mental
    disorders. Participating in moderate-to-vigorous physical activity over
    longer durations (weeks or months of regular physical activity) reduces
    symptoms of anxiety in adults and older adults. Major depression is one
    of the most common mental disorders in the United States and is a
    leading cause of disability for middle-aged adults in the United
    States. The prevalence of depressive episodes is higher among females,
    both adolescents and adults, than among males. Engaging in regular
    physical activity reduces the risk of developing depression in children
    and adults and can improve many of the symptoms experienced by people
    with depression.

        President Biden issued Executive Order 14048, renewing the
    President's Council on Sports, Fitness and Nutrition (PCSFN) under
    Executive Order 13265 until September 30, 2023. This EO calls for the
    work of the President's Council to include a focus on expanding
    national awareness of the importance of mental health as it pertains to
    physical fitness and nutrition. The 2020-2021 PCSFN Science Board
    Benefits of Youth Sports Fact Sheet highlights the mental, emotional,
    and social health benefits of youth sports participation:

            a. Lower rates of anxiety and depression
            b. Lower amounts of stress
            c. Higher self-esteem and confidence
            d. Reduced risk of suicide
            e. Less substance abuse and fewer risky behaviors
            f. Increased cognitive performance
            g. Increased creativity
            h. Greater enjoyment of all forms of physical activity
            i. Improved psychological and emotional well-being for
            individuals with disabilities
            j. Increased life satisfaction

        Despite the multitude of benefits of physical activity, currently
    less than 25 percent of adults and youth get the physical activity they
    need to get and stay healthy.

            CDC's Healthy Schools program supports evidence-based school
    policies, practices, and programs for physical activity, healthy
    eating, managing chronic conditions, health services, and supportive
    school environments.
            There is clear evidence that shows healthy students are better
    learners, and that academic achievement, especially graduating high
    school, translates into lifelong health benefits. Teaching students how
    to be physically active, eat healthy, and manage their chronic health
    conditions will help them develop into healthy adults.
            Physical education and physical activity policies \55\ like
    keeping recess in schools \56\ and integrating physical activity \57\
    in the classroom can help cultivate a supportive school environment by
    recognizing and promoting the value of physical activity for health,
    enjoyment, challenge, self-expression, and social interaction.
    Participation in team sports, being physically active, and attending
    physical education are associated with higher levels of school
    connectedness. All opportunities to move and be active in school,
    including classroom physical activity and recess, can increase school
    and peer connectedness.
    ---------------------------------------------------------------------------
        \55\ https://www.cdc.gov/healthyschools/323219-A_FS_SchoolPE_PA-
    032621-FINAL_1.pdf.
        \56\ https://www.cdc.gov/healthyschools/physicalactivity/pdf/
    Recess_Data_Brief_CDC_Logo_
    FINAL_191106.pdf.
        \57\ https://www.cdc.gov/healthyschools/physicalactivity/pdf/
    Classroom_PA_Data_Brief_CDC-Logo_FINAL_191106.pdf.
    ---------------------------------------------------------------------------
            CDC's School Health Guidelines \58\ to Promote Healthy Eating
    and Physical Activity can assist districts and schools in identifying
    evidence-based policies and practices. This resource identifies 9
    evidence-based guidelines and 33 strategies to improve healthy eating
    and physical activity among students.
    ---------------------------------------------------------------------------
        \58\ https://www.cdc.gov/healthyschools/npao/
    strategies.htm?msclkid=3736bb94cfad11ecadaf
    352fefeabb42.

        Question. Is there a coordinated plan to get Americans more
    ---------------------------------------------------------------------------
    physically active?

        Answer. When the most recent edition of the Physical Activity
    Guidelines for Americans was released in November 2018, HHS also
    released Move Your Way, the Federal Government's consumer-focused
    multichannel physical activity communications campaign.

        The Move Your Way campaign plays a crucial role educating the
    public about physical activity by helping people understand why
    activity is important and how to get more active. It also encourages
    Americans to think about physical activity as something that anyone, in
    any body, can do and enjoy.

        The campaign includes over 80 English and Spanish materials--like
    posters, videos, and interactive tools--for youth, teens, adults,
    parents, people during and after pregnancy, older adults, and health-
    care providers.

        Individuals, health educators, health-care providers, local health
    departments, academics, researchers, and other physical activity
    organizations can use campaign materials to promote physical activity
    in their community.

        Since 2019, ODPHP has supported 15 community pilot implementations
    that have resulted in 191 community events and activities, 300
    partnerships, and 83,000 campaign materials distributed. Evaluation of
    the pilot communities found that those who reported campaign exposure
    had 7.2 times the odds of being aware of the Guidelines compared to
    those who were not exposed. Additionally, they had greater odds of
    identifying the correct aerobic and muscle-strengthening dosages and
    had 1.4 times the odds of meeting both the aerobic and muscle-
    strengthening Guidelines.

        To maximize the impact of the campaign, HHS needs to increase
    audience exposure to its messages and materials. Move Your Way has been
    funded through evaluation funds through OASH.

        The Active People Healthy Nation initiative aims to get 27 million
    Americans moving by 2027. The President's Council on Sports, Fitness,
    and Nutrition is chartered to help communicate science-based messages
    to relevant State, local, and private entities, and share information
    about the work of the Council in order to advise the Secretary
    regarding opportunities to extend and improve physical activity,
    fitness, sports, and nutrition programs and services at the State,
    local, and national levels.

        Question. As the Nation's Surgeon General, can you commit to
    getting the message out on the preventative health benefits associated
    with exercise?

        Answer. Physical activity and exercise have been shown to have
    significant benefits for not only physical health, but also mental
    health. I am committed to emphasizing the importance of physical
    activity and relaying the best scientific information available on the
    health benefits associated with exercise to the American people.

        HHS has a strong legacy of promoting evidence-based messages about
    the importance of physical activity for health promotion and disease
    prevention. On behalf of HHS, the Office of Disease Prevention and
    Health Promotion (ODPHP) within OASH leads the development of the
    Physical Activity Guidelines for Americans along with CDC and NIH. The
    Move Your Way Campaign is specifically designed to promote physical
    activity and encourage more Americans to meet the Physical Activity
    Guidelines for Americans. The campaign includes over 80 English and
    Spanish materials--like posters, videos, and interactive tools--for
    youth, teens, adults, parents, people during and after pregnancy, older
    adults, and health-care providers. The Active People Healthy Nation
    initiative led by CDC aims to get 27 million Americans moving by 2027.
    The President's Council on Sports, Fitness and Nutrition is chartered
    to help communicate science-based messages to relevant State, local,
    and private entities, and share information about the work of the
    Council in order to advise the Secretary regarding opportunities to
    extend and improve physical activity, fitness, sports, and nutrition
    programs and services at the State, local, and national levels.

                                     ______

                   Questions Submitted by Hon. James Lankford
                                gender dysphoria
        Question. At the hearing, we discussed the potential adverse impact
    that medical treatments for gender dysphoria can have on the physical
    and mental health of children. I appreciate your willingness to engage
    in such an important conversation on an issue that is impacting more
    and more children and families.

        During our conversation, I mentioned that other countries are
    seeing the negative effects of medical treatments on children and are
    reversing course. For example, in May 2021, Sweden ended the use of
    puberty blockers and cross-sex hormones for most minors. Finland also
    began prioritizing psychological interventions and support over medical
    interventions. Similarly, in the UK, litigation, which suspended
    medical intervention on children under 16 for a time, has sparked a
    national conversation about the effects of surgical procedures on
    minors.

        Which studies is the United States relying on to determine the
    long-term health implications that medical treatments for gender
    dysphoria have on children? Please reply separately for information
    regarding puberty blockers, cross-sex hormones, and surgical
    treatments.

        What are the known long-term effects of puberty blockers for the
    purpose of responding to gender dysphoria if such treatment begins at 8
    years old? What about 12 years old? What about 16 years old?

        What are the known long-term effects of cross-sex hormones for the
    purpose of responding to gender dysphoria if such treatment begins at 8
    years old? What about 12 years old? What about 16 years old?

        Based on the medical evidence that exists, do you believe that it
    is appropriate for children to receive such treatment?

        If so, at what age do you think it is medically and ethically
    appropriate for a child to give consent to receive a treatment with
    such lasting effects?

        Do you agree that at a minimum, parents need to provide consent for
    their children to engage in any transgender care?

        Would you agree that no taxpayer dollars should be used to perform
    a transition procedure on a child who cannot reasonably provide
    informed consent?

        Answer. HHS would recommend consulting with medical associations
    regarding standards of care. Generally speaking, care is between a
    patient, their family and their health-care provider. HHS has released
    a fact sheet explaining that ``puberty blockers'' refers to ``using
    certain types of hormones to pause pubertal development.'' Research
    demonstrates that gender-affirming care improves the mental health and
    overall well-being of gender diverse children and adolescents. Because
    gender-
    affirming care encompasses many facets of health-care needs and
    support, it has been shown to increase positive outcomes for
    transgender and nonbinary children and adolescents. Gender-affirming
    care is patient-centered and treats individuals holistically, aligning
    their outward, physical traits with their gender identity.
                                  bereavement
        Question. Is the death of a parent a social determinant of health?

        Answer. Social determinants of health (SDOH) are the conditions in
    the environments where people are born, live, learn, work, play,
    worship, and age that affect a wide range of health, functioning, and
    quality-of-life outcomes and risks. SDOH have a major impact on
    people's health, well-being, and quality of life. Examples of SDOH
    include: safe housing, transportation, and neighborhoods; racism,
    discrimination, and violence; education, job opportunities, and income;
    access to nutritious foods and physical activity opportunities;
    polluted air and water; and language and literacy skills.\59\ These
    SDOH are encompassed within the five domains of the Healthy People 2030
    SDOH Framework: Economic Security, Education Access and Quality, Health
    Care Access and Quality, Neighborhood and Built Environment, and Social
    and Community Context. The death of a parent would be considered a
    social determinant of health within the Social and Community Context
    domain.
    ---------------------------------------------------------------------------
        \59\ Health People 2030. https://health.gov/healthypeople/priority-
    areas/social-determinants-health.

        A large body of research that reflects the impact of SDOH on health
    show when these conditions are unstable or not met, individuals are at
    an increased risk for negative health outcomes.\60\ Lack of the sense
    of security provided by social determinants such as a stable home,
    consistent nutrition, and supportive relationships can lead to adverse
    childhood experiences (ACEs). ACEs such as the loss of a parent through
    divorce, death or abandonment can undermine one's sense of safety,
    stability, bonding and well-being.\61\ SDOH are closely intertwined
    with ACEs which can result in prolonged toxic stress and negatively
    impact an individual's lifelong health.
    ---------------------------------------------------------------------------
        \60\ Allen, J., Balfour, R., Bell, R., and Marmot, M. (2014).
    Social determinants of mental health. International review of
    psychiatry, 26(4), 392-407. https://pubmed.ncbi.nlm.nih.gov/25137
    105/.
        \61\ Centers for Disease Control and Prevention. (2021 April 6).
    What are adverse childhood experiences? Retrieved from https://
    www.cdc.gov/violenceprevention/aces/fastfact.html.

        HHS is taking a collaborative, multifaceted approach to address
    SDOH across Federal programs in order to advance health equity and
    improve health outcomes. Addressing the SDOH is very important for the
    health and well-being of the Nation, and addressing SDOH requires
    engagement and coordination across HHS, as well as with other
    ---------------------------------------------------------------------------
    Departments within the Federal Government.

        Within HHS, we have adopted a strategic approach to addressing SDOH
    to advance health and well-being over the life course. ASPE recently
    posted a series of documents that describe this approach: https://
    aspe.hhs.gov/topics/health-health-care/addressing-social-determinants-
    health-federal-programs. The approach includes three goals to: advance
    the data infrastructure needed to support care coordination and
    evidence-based policymaking; improve access to equitably delivered
    health-care services and support partnerships between health-care
    providers, human service providers, and other community-based partners;
    and adopt a whole-of-government approach that supports public-private
    partnerships and leverages community engagement to address SDOH.

        The death of a parent or loved one is an Adverse Childhood Event
    (ACE). ACEs, are potentially traumatic events that occur in childhood
    (0-17 years). Like SDOH, ACEs can have lasting, negative effects on
    health, well-being, and opportunity. However, creating and sustaining
    safe, stable, nurturing relationships and environments for all children
    and families can prevent ACEs and help all children reach their full
    health and life potential. CDC has produced a resource, Preventing
    Adverse Childhood Experiences (ACEs): Leveraging the Best Available
    Evidence, to help States and communities take advantage of the best
    available evidence to prevent ACEs. It features six strategies that
    focus on changing norms, environments, and behaviors in ways that can
    prevent ACEs from happening in the first place:

            1. Strengthening economic supports for families;
            2. Promoting social norms that protect against violence and
            adversity;
            3. Ensuring a strong start for children and paving the way for
            them to reach their full potential;
            4. Teaching skills to help parents and youth handle stress,
            manage emotions, and tackle everyday challenges;
            5. Connecting youth to caring adults and activities; and
            6. Intervening to lessen immediate and long-term harms.
                                  immigration
        Question. Have you or the medical community assessed whether
    children who have been trafficked across the border are more likely to
    use drugs or have mental or physical negative effects later in life?

        Answer. HHS has not conducted such an assessment because HHS does
    not have access to health and other personal information for former
    unaccompanied children once they are no longer in HHS custody.

        Question. Cartels often use children as a way to distract border
    patrol so they can move additional contraband and illicit narcotics
    across the border. What evidence have you seen that children who have
    crossed the border suffered trauma while they made the journey to our
    country? What evidence have you seen that these children have suffered
    at the hands of the cartels? What impact does this trauma have on them
    later in life?

        Answer. All unaccompanied children are screened for physical abuse,
    sexual abuse, indicators of trafficking, and for trauma symptoms on
    entry to HHS care. Unaccompanied children report a wide range of
    negative experiences in their home countries and/or along the journey
    to the United States. Some children witness crimes, injuries, deaths,
    and experience abuse. The impact of these various ACEs depends on the
    age of the child, the nature of the abuse and the number of cumulative
    experiences as well as protective factors such as whether the child is
    alone. The immediate and long-term sequelae of trauma include physical
    complaints, fear, sadness, intrusive images and thoughts of these
    events, difficulty with concentration and memory, trouble sleeping,
    social withdrawal, difficulty forming attachments, inability to
    modulate emotions, and thoughts and acts of self-harm and suicide.
    Victimized children often have trouble maintaining and continuing to
    attain developmental milestones. Childhood trauma is predictive of
    future health problems, psychiatric illness, academic difficulty,
    substance use, relationship problems and economic status.

        Question. Once these drugs are trafficked across the border, who is
    the main recipient? How many American teens have died from drugs
    trafficked into our country?

        What percentage of the drugs interdicted in the interior of the
    U.S. came to the country through the southern border?

        Answer. HHS defers to the Department of Homeland Security and the
    Drug Enforcement Administration.

                                     ______

                     Questions Submitted by Hon. Ben Sasse
                                  social media
        Question. In your testimony you highlight that children today are
    facing unprecedented challenges, in part due to the ubiquity of
    technology platforms. I introduced the Children and Media Research
    Advancement (CAMRA) Act with Senator Markey and Senator Blunt, which
    would authorize NIH to lead a research program on technology and
    media's effects on children, including how social media impacts their
    cognitive, physical, and socioemotional development.

        Are you familiar with this bill and would you support its passage?

        Can you speak more about the existing research on how social media
    impacts children? What gaps in data and knowledge remain?

        Should consumption of these platforms be moderated by parents, or
    does the government need to play a stronger role?

        Answer. The National Institutes of Health (NIH) is committed to
    understanding the impact of technology and digital media use, or TDM,
    including social media, among infants, children, and teens. There are
    several institutes at the NIH that support research relevant to this
    topic. For examples, the Eunice Kennedy Shriver National Institute of
    Child Health and Human Development (NICHD) funds research with regards
    to how TDM exposure and usage impacts child and adolescent development.
    As the lead biomedical Federal agency, NIH's mission is to seek
    fundamental knowledge about the nature and behavior of living systems
    and the application of that knowledge to enhance health, lengthen life,
    and reduce illness and disability. Our focus is research; therefore, we
    do not comment on pending legislation.

        The topic of how social media impacts child development from
    infancy through the transition to young adulthood, as well as family
    and peer relationships, is a high priority for the NIH and NICHD.
    First, one of the priorities of the NICHD 2020 Strategic Plan \62\ is
    to further understand the impact of early and/or prolonged exposure to
    technology and digital media on typical and atypical development from
    infancy through adolescence across multiple domains. These domains
    consist of neurocognitive, behavioral, linguistic, social-emotional,
    and physical, including those from diverse backgrounds and
    subpopulations.
    ---------------------------------------------------------------------------
        \62\ https://www.nichd.nih.gov/sites/default/files/2019-09/
    NICHD_Strategic_Plan.pdf.

        Second, research supported by NICHD explores the impact of TDM on
    social interaction and emotional development, the safe use of social
    media, and negative social media interaction. For example, researchers
    found that the age of exposure to and use of social media might
    increase a child's risk for unsafe social interactions. One study \63\
    supported by NICHD suggests that initiating social media platforms in
    childhood (10 years or younger) was significantly associated with
    problematic digital behavior outcomes compared to either tween (11-12)
    and/or teen (13+) initiation. In another study, researchers found that
    adolescents assigned to receive few (vs. many) likes during a social
    media interaction felt more strongly rejected and reported more
    negative affect and more negative thoughts about themselves. Negative
    responses to receiving fewer likes were associated with greater
    depressive symptoms reported day-to-day and at the end of the school
    year. NICHD also supported research examining negative comments
    received via social media, including cyberbullying. One study
    interviewed 13- to 17-year-olds to understand more about their
    experiences and thoughts on cyberbullying. Teens identified
    cyberbullying as part of a continuum of bullying and peer violence
    experiences. Other ongoing research \64\ will identify strategies
    parents can use to effectively manage their adolescents' use of social
    media sites such as using targeted communication, co-use, modeling,
    limit setting, non-technical monitoring, and technical mediation (e.g.,
    use of parental control software) and examine the effects of these
    strategies on adolescents' positive or negative social media
    experiences and well-being. Additionally, ongoing research supported by
    the National Institute of Mental Health is seeking to identify patterns
    in social media use that predict risk for suicide, \65\ self-harm, or
    depressive symptoms \66\ among youth.
    ---------------------------------------------------------------------------
        \63\ https://reporter.nih.gov/search/_SPeLpEEr0G3mSWpMq5NXw/
    project-details/9442212.
        \64\ https://reporter.nih.gov/search/4VV6uDCPGUKGE79ynYlFCw/
    project-details/10216400.
        \65\ https://reporter.nih.gov/project-details/10373402.
        \66\ https://reporter.nih.gov/project-details/10298070.

        Lastly, in 2021, to increase investment in this area of research,
    NICHD released a funding opportunity announcement,\67\ Impact of
    Technology and Digital Media (TDM) Exposure/Usage on Child and
    Adolescent Development, to solicit multi-project research program
    applications from the field which are intended to be flagships in
    advancing TDM research in early childhood (ages birth-8) and
    adolescence (ages 9-17).
    ---------------------------------------------------------------------------
        \67\ https://grants.nih.gov/grants/guide/rfa-files/RFA-HD-22-
    009.html.
    ---------------------------------------------------------------------------
                              workforce shortages
        Question. Much of the congressional focus on attracting more
    practitioners to work in the mental health space centers on student
    loan forgiveness. I worry this approach can create perverse incentives
    for institutions to continue raising the cost of tuition, and forces
    all taxpayers to take responsibility for a subsect of the population
    and their choices.

        What are some other innovative ways to incentivize individuals to
    go into the field of mental and behavioral health?

        Answer. Some innovative ways to incentivize individuals to enter
    the behavioral health field include:

            Loan repayment or scholarships for students who commit to work
    in the field.
            Expanding paid internships to defray student costs and enable
    students to gain experience.
            Increasing scholarships or offset behavioral health education
    costs.
            Subsidizing clinical supervision at no cost/reduced cost,
    during work hours, to individuals in the field that are pursuing
    licensure where this is a requirement.
            Increasing access to mental health/supportive services for
    individuals working in the field of behavioral health (trainings, EAP,
    mental health resources, recovery groups, etc.).
            Outreach in high school and higher education settings to
    educate people about careers in behavioral health.

        Individuals who go into the field of mental and behavioral health
    most often do so out of a desire to help others and to positively
    contribute to society. They are ultimately hampered by excessive
    patient loads, low rates of reimbursement, and difficulty in
    transferring from State to State. While loan forgiveness helps to
    offset the costs of education, systemic issues that contribute to
    burnout and reduced job satisfaction also must be addressed.

        Another important issue is the need to harmonize certification and
    registration requirements across the United States. Currently, States
    have different rules and regulations around certification. This makes
    it difficult for mental and substance use specialized health-care
    providers to transport their skills to new jurisdictions. Encouraging
    States to harmonize their certification requirements will allow
    individuals who relocate across State lines to continue to work in
    substance use or mental health roles with little difficulty.

        HRSA offers a variety of incentives for students to enter the
    mental and behavioral health fields. The National Health Service Corps
    (NHSC) and Nurse Corps programs offer both scholarships and loan
    repayment awards to incentivize students to choose careers in mental
    and behavioral health and incentivize current mental and behavioral
    health providers to serve in medically underserved communities.

        The NHSC currently has a field strength of over 9,300 behavioral
    health providers serving across the Nation, including providers in the
    NHSC Loan Repayment Program (LRP), NHSC Scholarship Program (SP), NHSC
    Rural Community LRP, NHSC Substance Use Disorder Workforce LRP, and the
    NHSC Students to Service LRP.

        HRSA's Nurse Corps LRP and SP are critical to ensuring both
    children and adults have access to a high-quality, adequate behavioral
    health nursing care. The Nurse Corps programs address the current
    maldistribution of nurses and increase access to behavioral health
    services by increasing funding for scholarships and loan repayment
    assistance for behavioral health training and service for Nurse
    Practitioners (NPs) specializing in psychiatric mental health. Nurse
    Corps members receive scholarship and loan repayment incentives in
    exchange for an agreement to work in Critical Shortage Facilities
    (CSFs), which are located in Health Professional Shortage Areas (HPSAs)
    around the Nation.

        Finally, the Substance Use Disorder Treatment and Recovery (STAR)
    LRP aims to recruit and retain medical, nursing, behavioral/mental
    health clinicians and paraprofessionals who provide direct treatment or
    recovery support of patients with or in recovery from a substance use
    disorder.

        Question. How could Congress potentially use GME slots to try and
    remedy this problem?

        Answer. The training and retention of physicians and other health-
    care professionals is critical to ensuring access to health care in
    underserved communities that have historically experienced workforce
    challenges. In December, CMS issued a final rule that will enhance the
    health-care workforce and fund additional medical residency positions
    in hospitals serving rural and underserved communities, including areas
    with a shortage of mental health-care providers. The Fiscal Year (FY)
    2022 Inpatient Prospective Payment System (IPPS) final rule with
    comment period establishes policies to distribute 1,000 new Medicare-
    funded physician residency slots to qualifying hospitals, phasing in
    200 slots per year over 5 years. CMS estimates that funding for the
    additional residency slots, once fully phased in, will total
    approximately $1.8 billion over the next 10 years. In implementing a
    section of the Consolidated Appropriations Act (CAA), 2021, this is the
    largest increase in Medicare-
    funded residency slots in over 25 years. In allocating these new
    residency slots, CMS will prioritize hospitals with training programs
    in areas demonstrating the greatest need for providers, as determined
    by Health Professional Shortage Areas (HPSA). The first round of 200
    residency slots will be announced by January 31, 2023, and will become
    effective July 1, 2023. In addition, under the HPSA Physician Bonus
    Program, CMS pays a 10 percent bonus to psychiatrists who deliver
    services to Medicare patients in the areas that have a geographic
    mental health HPSA designation.

        Unlike most Federal funding for GME, the Health Resources and
    Services Administration's (HRSA's) Teaching Health Center Graduate
    Medical Education (THCGME) program's payments support primary care
    residency training in community-based ambulatory patient care centers,
    as opposed to in-patient care settings in hospitals. The specialties
    covered include pediatrics and psychiatry. Adding pediatric psychiatry
    as an eligible specialty would support training these specialists in
    community-based settings. Although health centers receive Federal
    funding to improve access to care, they often have difficulty
    recruiting and retaining primary care professionals, in part because
    they are generally smaller organizations with smaller operating margins
    compared to teaching hospitals. The THCGME program is uniquely
    positioned to meet these recruitment and retention needs by providing
    funding to support resident training in underserved communities.
    Without THCGME funding, these additional residency positions would be
    challenging to maintain, resulting in a decrease in physicians and
    dentists available to serve rural and underserved communities.

        Moreover, the Children's Hospitals Graduate Medical Education
    (CHGME) payment program helps eligible hospitals maintain GME programs
    that train resident physicians. The CHGME payment program supports the
    training of residents to provide quality care to vulnerable and
    underserved pediatric populations, and enhances the supply of
    pediatricians, pediatric sub-specialists, and other non-pediatric
    residents. Residency training in these hospitals focus on pediatric
    primary care as well as medical and surgical subspecialties which
    suffer from shortages

        Question. During the pandemic, HHS provided a number of
    flexibilities to help address workforce shortages and allow psychiatric
    facilities to fully utilize their staff. Some of these flexibilities
    allowed hospitals to use nurse practitioners or other providers to
    practice to the fullest extent of their license, particularly in the
    areas of behavioral health care.

        Do you support extending, or even making permanent, these
    flexibilities?

        Answer. HHS has received overwhelming support for many of the
    flexibilities enacted during the COVID-19 public health emergency that
    have been widely supported by patients, payers, and other stakeholders.
    HHS has determined that the benefits of continuing many of these
    flexibilities such as telemedicine delivery of care for those with
    opioid use disorder far outweigh the reported risk. HHS is exploring
    options on making many of the flexibilities permanent.

        During the COVID-19 pandemic, the Health Resources and Services
    Administration (HRSA) worked with its National Health Service Corps
    clinicians to extend maximum flexibility for their statutory
    obligations. HRSA continues to evaluate extending these flexibilities
    within the parameters of the statute and regulations. The additional
    flexibilities provided by the Coronavirus Aid, Relief, and Economic
    Security (CARES) Act to NHSC participants included:

            Giving participants more options as to where they can complete
    their service by allowing NHSC participants to receive service credit
    at certain non-
    traditional sites to address the public health emergency; and
            Allowing participants to adjust their service commitment if
    their work is impacted by the pandemic.

        These flexibilities have served as a very useful additional tool
    for expanding access to high quality health care to populations of
    greatest need across the U.S.

        Question. What is HHS currently doing to ensure practitioners can
    work within the full extent of their license and scope of practice?

        Answer. Ensuring practitioners can work within the full extent of
    their license and scope of practice is critical to removing barriers to
    practice and care. HHS is working across government to address these
    long-standing barriers to strengthening the health workforce. Although
    HRSA does not regulate licensing of health-care practitioners, which is
    primarily done at the State level, HRSA provides funding for faculty
    development opportunities, which allows practitioners to continuously
    improve competencies, provide an awareness of new developments and
    emerging theories. HRSA also incentivizes independently licensed
    providers to practice where needed most through loan repayment
    opportunities.

        Question. One major issue in accessing mental health treatment is a
    lack of providers on insurance networks, with people waiting months on
    waitlists to get an appointment with a new provider.

        How can we update network adequacy standards to get at this
    problem? What other approaches might work?

        How is HHS working to ensure behavioral health providers are well
    represented in provider networks in all federally regulated health
    plans, including Medicaid managed care plans and plans offered on the
    exchanges?

        Answer. Protecting and strengthening access to behavioral health
    providers is a critical priority for the Biden-Harris administration.
    Through the HHS Notice of Benefit and Payment Parameters for 2023
    Proposed Rule, issued in December 2021, CMS proposed policies to
    strengthen and clarify our network adequacy standards, including
    standards based on travel time and distance and appointment wait times
    for numerous provider specialties, including behavioral health
    providers, for Qualified Health Plans (QHPs) offered on the Federal
    Marketplace. Under the proposed rule, CMS would conduct network
    adequacy reviews in all Federally Facilitated Marketplace (FFM) States
    except for States performing plan management functions that adhere to a
    standard as stringent as the Federal standard and elect to perform
    their own reviews. Reviews would occur prospectively during the QHP
    certification process.

        CMS is also working to develop and implement a comprehensive access
    strategy for Medicaid and CHIP. In June 2021, CMS published the
    Promoting Access in Medicaid and CHIP Managed Care: Behavioral Health
    Provider Network Adequacy Toolkit \68\ to help State Medicaid agencies
    and the managed care plans with which they contract meet network
    adequacy requirements for adult and pediatric behavioral health-care
    providers. In addition using regulations and guidance, along with other
    tools, CMS will set forth a multifaceted approach to help ensure
    equitable access to health care for Medicaid and CHIP beneficiaries
    across all care delivery systems. In February 2022, CMS issued a
    Request for Information (RFI) \69\ on access to care and coverage for
    people enrolled in Medicaid and CHIP. Feedback obtained from the RFI
    will aid in CMS's understanding of enrollees' barriers to enrolling in
    and maintaining coverage, accessing health-care services and supports,
    and ensuring adequate provider payment rates to encourage provider
    availability and quality. This information will help inform future
    policies, monitoring, and regulatory actions, helping ensure
    beneficiaries have equitable access to high-quality and appropriate
    care across all Medicaid and CHIP payment and delivery systems,
    including fee-for-service, managed care, and alternative payment
    models. The RFI submissions will also inform CMS's work to ensure
    timely access to critical services, such as behavioral health care and
    home and community-based services.
    ---------------------------------------------------------------------------
        \68\ https://www.medicaid.gov/medicaid/downloads/behavior-health-
    provider-network-adequacy-toolkit.pdf.
        \69\ https://cmsmedicaidaccessrfi.gov1.qualtrics.com/jfe/form/
    SV_6EYj9eLS9b74Npk.

        Question. More generally, can you point to any data that discusses
    potential differences in effectiveness based on provider training
    background? Is there evidence to suggest that counselors can provide
    effective treatment at the same level as psychologists or
    ---------------------------------------------------------------------------
    psychiatrists?

        Answer. There are a variety of roles and practices that comprise
    mental health treatment and services. These include prescribing and
    administering medication, assessment and care planning, individual
    therapy, group therapy, care coordination and case management, peer
    support, rehabilitative supports like supported employment and
    supportive housing, and variety of other services and supports.

        Different levels of training and credentialling are required for
    the delivery of these different roles and practices. For example,
    psychiatrists, medical doctors, nurse practitioners or advance practice
    nurses, and physician assistants, may prescribe medication depending on
    the class and schedule of the medications being prescribed, level of
    supervision needed, and other factors. Psychiatrists have extensive
    training that makes them uniquely able to prescribe certain medications
    effectively and safely or determine the best course of treatment,
    including medication needs, for complex cases. Psychologists may have
    specialized training in administering and completing assessments
    reliably and have extensive training that may assist in treating
    complex cases. Psychiatrists and psychologists often play an important
    role by providing clinical supervision to other providers. There are
    also different individual and group therapeutic models that may be
    administered by a range of mental health professionals. Most models of
    individual and group therapy can be effectively delivered by master's-
    level clinicians, and some models can be effectively delivered by
    mental health professionals without a master's degree. Some roles, such
    as case or care managers are often filled by providers that do not have
    a master's degree.

        In short, it is hard to make a blanket statement about whether
    counselors can fulfill the same roles as psychiatrists or
    psychologists, because they often have different roles within the
    service systems and provide different services according to their
    scopes of practice. There are also a variety of different types of
    counselors, so it is probably best not to generalize across this group.
    In general counselors would lack any prescribing authority and medical
    training.
                                school closures
        Question. I want to turn now to school closures and the effects on
    the mental health of children over the last year. To point to just one
    example, a study published in JAMA \70\ in April found that just 3.6
    percent of kids reported feelings of loneliness before schools were
    shuttered, yet nearly 32 percent reported feeling so when schools were
    closed. Only 4.2 percent of children were labeled agitated or angry in
    previous school years, while this number jumped to nearly a quarter of
    children while schools were closed. We also know \71\ there was an
    increase in emergency room visits among children for mental health
    conditions, suicide attempts, and drug overdoses over the last year and
    a half.
    ---------------------------------------------------------------------------
        \70\ https://time.com/5964671/school-closing-children-mental-
    health-pandemic/.
        \71\ https://jamanetwork.com/journals/jamapsychiatry/fullarticle/
    2775991.

        Are you familiar with the data on how school closures impact
    ---------------------------------------------------------------------------
    children's mental health?

        Answer. Yes, which is why providing guidance on safely returning
    to, and maintaining, in-person instruction continues to be a priority
    for HHS and the Biden-
    Harris administration. Numerous studies have been published, from both
    the U.S. and other countries, on the impact of school closures on
    student mental health and well-being during the first wave of the
    COVID-19 pandemic. For example, a recently published systematic review
    article summarized findings from 36 studies (from 11 countries) that
    assessed the associations between school closures on student mental
    health, health behavior, and well-being. Twenty-five studies (69
    percent) of included studies focused on mental health outcomes and
    identified associations across emotional, behavioral, and restlessness/
    inattention problems. CDC guidance stresses the importance of in-person
    learning and does not recommend school closures as a public health
    strategy. CDC offers guidance on strategies to support in-person
    learning.

        Question. Are you working with the Department of Education and
    others in the administration to ensure that schools are able to stay
    open even with the Omicron surge and any potential variants that may
    arise down the line?

        Answer. CDC has developed guidance and resources to support the
    safe reopening of schools. These include the Guidance for the
    Prevention of COVID-19 in K-12 Schools, which has been updated as new
    data become available and the science has evolved. CDC guidance
    stresses the importance of in-person learning and does not recommend
    school closures as a public health strategy. When schools close, they
    do so due to operational issues--too many people (students/staff) are
    out because they are sick or quarantining, or because they are
    providing a break for in-person school due to mental health concerns.
    CDC and the Department of Education work together closely to develop
    webinars, listening sessions, and tools to support schools in safely
    remaining open for in-person learning.

        To support the implementation of testing programs in schools, CDC
    launched a communications toolkit with resources for school
    administrators and parents. CDC has provided ongoing technical
    assistance to State, local, and territorial health departments for
    testing efforts through regular office hours, webinars and peer to peer
    learning opportunities. Through partnerships with the Department of
    Education and the Rockefeller Foundation, CDC has supported a Learning
    Network for schools, with resources available at
    www.openandsafeschools.org.

        Question. Thus far, are you aware of efforts by schools and
    providers to use COVID-19 pandemic relief funding to increase access to
    and availability of behavioral health services?

        If not, what are the barriers still in place?

        Is the administration formally tracking use of these funds and how
    often they are being used to address the youth mental health crisis?

        Answer. CDC's Healthy Schools Program has provided support to 15
    State education agencies that deliver technical assistance and training
    to school district and school leaders on how to address youth mental
    health. States report on a monthly basis the types of technical
    assistance and training topics on school-based mental health that are
    delivered. Across these 15 States, in the 2021-2022 school year, over
    2,000 school leaders from over 200 school districts have received this
    technical assistance and training, 655 collaborative partners were
    engaged, and 1,220 professional development (PD) events related to the
    prevention of COVID-19 were held by SEAs. Through these PD events, SEAs
    reached 6,198 district contacts (517 individuals per month on average)
    and 8,643 school contacts (720 individuals per month on average).
                                 marijuana use
        Question. I appreciated your comments in the hearing about how we
    need to message that marijuana can cause harm in youth. A 2019 meta-
    analysis by JAMA Psychiatry found that adolescent cannabis use was
    associated with increased risk of developing depression and suicidal
    behavior later in life.

        As the legalized marijuana market and public support for Federal
    legislation continue to grow, what needs to be done in terms of
    research, messaging, and policy to ensure that marijuana use does not
    contribute to a growing youth mental health crisis?

        Answer. Marijuana use among youth and young adults is a major
    public health concern. Early youth marijuana use is associated with:

            Neuropsychological and neurodevelopmental decline.
            Poor school performance.
            Increased school drop-out rates.
            Increased risk for psychotic disorders in adulthood.
            Increased risk for later depression.
            Suicidal ideation or behavior.

        As policy and legalization efforts evolve and the availability of
    legal marijuana increases, communities and families need guidance to
    support the prevention of marijuana use among youth.

        To assist communities and families, the Federal Government is
    developing and disseminating practical guidance resources such as
    SAMHSA's evidence-based guide, Preventing Marijuana Use Among Youth
    \72\ (2021), which covers programs and policies to prevent marijuana
    use among youth aged 12 to 17, including:
    ---------------------------------------------------------------------------
        \72\ https://store.samhsa.gov/product/preventing-marijuana-use-
    among-youth/PEP21-06-01-001.

            Environmental strategies, such as regulating the price of
    marijuana products, where these products are sold, the products
    themselves, and their promotion and advertising.
            School- and community-based substance use prevention programs
    to implement along with environmental interventions as part of a
    comprehensive prevention strategy.

        The guide provides considerations and strategies for key
    stakeholders (including policy makers, community coalitions,
    businesses, school administrators, educators, and other community
    members), States, and the prevention workforce to prevent and reduce
    marijuana use among youth.

        SAMHSA youth marijuana use prevention messaging includes public
    education messages \73\ for use by communities, the ``Talk. They Hear
    You.'' national media campaign which empowers parents and caregivers to
    talk with children early about alcohol and other drug use (e.g.,
    PSAs,\74\ brochures, \75\ mobile app,\76\ community engagement,\77\
    podcast \78\), and fact sheets for teens (English/Spanish).\79\,\80\
    ---------------------------------------------------------------------------
        \73\ https://www.samhsa.gov/marijuana.
        \74\ https://www.samhsa.gov/talk-they-hear-you/partner-resources/
    psas.
        \75\ https://www.samhsa.gov/talk-they-hear-you/parent-resources/
    keep-kids-safe-brochures.
        \76\ https://www.samhsa.gov/talk-they-hear-you/mobile-application.
        \77\ https://www.samhsa.gov/talk-they-hear-you/parents-night-out.
        \78\ https://www.samhsa.gov/talk-they-hear-you/podcast.
        \79\ https://store.samhsa.gov/product/Tips-for-Teens-The-Truth-
    About-Marijuana/PEP19-05.
        \80\ https://store.samhsa.gov/product/Tips-for-Teens-The-Truth-
    About-Marijuana-Spanish-Language-Version/PEP20-03-03-011.

        In addition, SAMHSA's national technical assistance and training
    system for substance use disorder prevention, the Prevention Technology
    Transfer Centers \81\ (PTTCs), has a Cannabis Prevention Working Group
    which develops cannabis prevention education \82\ training and
    technical assistance tools, products, and services, to be deployed to
    communities across the country.
    ---------------------------------------------------------------------------
        \81\ https://pttcnetwork.org/.
        \82\ https://pttcnetwork.org/centers/global-pttc/cannabis-
    prevention.

        To better understand the epidemiology of cannabis use as well as
    the harmful and potential therapeutic effects of use, better
    surveillance data are needed on initiation of use, reason for use,
    modes of use, product types, and cannabis use disorder. Additionally,
    given the changing perceptions of risk associated with cannabis use and
    the continually evolving nature of policies legalizing and
    decriminalizing medical and nonmedical adult cannabis use at the State
    level, research and evaluation studies are warranted to improve our
    understanding of outcomes associated with cannabis use among youth.
    Specifically, research on risk and protective factors for early
    cannabis use initiation and escalation of use among youth and young
    ---------------------------------------------------------------------------
    adults is needed to improve messaging to youth.

        Additionally, we need to better understand the health and social
    outcomes associated with cannabis use among youth and how they differ
    by mode of use, frequency of use, and THC concentration of product.
    Many of the available studies on the effects of cannabis on the
    adolescent brain were done prior to the introduction of the high THC
    concentration products that are now available; in addition, most of the
    primary literature on the mental health effects of cannabis use is
    observational in nature. Comorbidity between substance use and mental
    health disorders directly affects the ability to determine causality
    and directionality in studies of cannabis use and mental health
    outcomes and warrants further investigation. In addition, research on
    the impact of prevention programs, policies, and practices is needed to
    understand what is effective in preventing youth cannabis use. CDC has
    developed both a Cannabis Strategic Plan and Research Agenda, with
    particular focus on populations at increased risk for negative
    outcomes, including youth. The Strategy describes actions that will
    foster a public health approach, improve messaging, and secure
    dedicated resources to address the health risks of cannabis. One of the
    six pillars in the Strategy is focused around partnering with public
    safety, schools, and community coalitions to offer opportunities for
    community-based coalitions to learn about evidence-based substance use
    prevention strategies addressing youth cannabis use. CDC has also
    partnered with the National Council on Mental Wellbeing to create a
    Youth Substance Use Prevention Messaging Guide to address increased
    substance use among youth during the pandemic. In September 2021, CDC
    released a health advisory on increased availability of Delta-8 THC
    products and associated adverse events with recommendations for
    consumers to safely store their cannabis products away from youth.

        Question. Is any use of marijuana in adolescence or pregnancy safe?
    If not, should we message this to the public more firmly?

        Answer. Marijuana has both short- and long-term effects on the
    brain. Marijuana also affects brain development. When youth begin using
    marijuana as teenagers, the drug may impair thinking, memory, and
    learning functions and affect how the brain builds connections between
    the areas necessary for these functions. There is ongoing research to
    determine how long marijuana's effects last and whether some changes
    may be permanent.

        Use of marijuana during and after pregnancy may pose risks to both
    mother and baby. Some research has documented effects of marijuana use
    during and after pregnancy, but much remains to be learned. Pregnant
    individuals should be aware of the realities and serious nature of
    these potential harms. Secondhand marijuana smoke contains delta-9-
    tetrahydrocannabinol (THC) and many of the toxic chemicals found in
    cigarette smoke. THC does accumulate in human breast milk, but its
    effect on infants remains unknown. Because an infant's brain is
    continuing to develop, consuming THC in breast milk could affect brain
    development. Research is limited in this area, but it is a growing
    concern.

        SAMHSA's evidence-based guide, Preventing the Use of Marijuana:
    Focus on Women and Pregnancy,\83\ addresses the established health
    risks of marijuana use to pregnant women and their children, as well as
    the expanding evidence base on other potential harms of use during
    pregnancy. The intent is for prevention practitioners and health-care
    providers to use to the guide to be informed of the adverse health
    consequences and potential effects of marijuana use, and to promote
    healthy decision-making among pregnant and postpartum women.
    ---------------------------------------------------------------------------
        \83\ https://www.samhsa.gov/resource/ebp/preventing-use-marijuana-
    focus-women-pregnancy.

        SAMHSA marijuana use prevention and pregnancy messaging includes
    public education messages \84\ for use by communities. SAMHSA also
    funds a grant program \85\ to provide comprehensive substance use
    disorder (SUD) treatment services, recovery support services, and harm
    reduction interventions to pregnant and postpartum women across a
    continuum of specialty SUD residential and outpatient levels of care,
    based on comprehensive, individualized screenings and assessments that
    inform treatment planning and service delivery in a continuous care
    model.
    ---------------------------------------------------------------------------
        \84\ https://www.samhsa.gov/marijuana/marijuana-pregnancy.
        \85\ https://www.samhsa.gov/grants/grant-announcements/ti-22-003.

                                     ______

                   Questions Submitted by Hon. John Barrasso
                   workforce development in rural communities
        Question. The health-care professionals, along with all front-line
    workers, deserve our gratitude and appreciation. Their dedication to
    our communities during this pandemic is something we must recognize and
    never forget.

        A top concern of Wyoming mental health facilities is making sure
    there are enough staff to care for their patients. It is especially
    challenging to attract and keep health-care providers in rural
    communities.

        Can you discuss solutions related to workforce development you
    believe will improve the ability of mental health facilities to attract
    and maintain staff in rural areas?

        Answer. HRSA manages several programs that either focus on
    workforce development in rural communities or allow communities to
    propose a unique workforce program to meet the needs of a community. In
    FY 2021, HRSA funded the Rural Behavioral Health Workforce Centers--
    Northern Border Region (RBHWCs) as part of the Rural Communities Opioid
    Response Program (RCORP), a multiyear HRSA initiative with the goal of
    reducing morbidity and mortality resulting from substance use disorder
    (SUD). The RBHWCs are advancing RCORP's overall goal by improving
    behavioral health-care services in rural areas through educating and
    training health professionals and community members to care for
    individuals with behavioral health disorders, including SUD. This
    program supports HRSA's collaboration with the Northern Border Regional
    Commission (NBRC) to provide career and workforce training activities
    that assist individuals with behavioral health needs, particularly SUD,
    within the four-State NBRC region. We also note that the Nurse Corps
    Loan Repayment Program (LRP) and the National Health Service Corps
    (NHSC) LRPs, offer loan repayment awards to incentivize current mental
    and behavioral health providers to serve in medically underserved
    communities, including rural areas. The NHSC LRPs currently have a
    field strength of over 9,300 behavioral health providers serving across
    the Nation, and over 3,400 of these providers are located in rural
    areas. The Nurse Corps LRP currently has a field strength of 2,307
    clinicians, with 325 serving as psychiatric Nurse Practitioners (NPs).

        Additionally, several of HRSA's rural community-based programs
    offer non-
    categorical funding that allow applicants to propose and build a
    program in response to an area of need. HRSA has funded many programs
    that focus on workforce development through the Rural Health Network
    Development, Rural Health Care Coordination, Rural Health Care Services
    Outreach, and Delta States Rural Development Network grant programs.
                                 youth suicide
        Question. My wife Bobbi and I are committed to helping families who
    have tragically lost a loved one to suicide. The loss of a loved one is
    always difficult, but as a father I cannot imagine the pain of losing a
    child.

        Many Wyoming communities host Out of the Darkness walks to help
    raise awareness about this crisis. I strongly support raising awareness
    about suicide and making sure we are discussing and addressing this
    very real public health crisis.

        Can you discuss ways Congress can raise awareness about youth
    suicide and solutions we should consider?

        Answer. On July 16, 2022, the U.S. will transition the National
    Suicide Prevention Lifeline to the 988 Suicide and Crisis Lifeline as a
    new, easier way to reach the service formally known as the National
    Suicide Prevention Lifeline. Available 24/7, youth will be able to call
    or text 988 or chat 988lifeline.org if they are in need of crisis
    support. They will have quick access to a trained crisis counselor who
    can help youth experiencing mental health-related distress. SAMHSA put
    forward investments to strengthen and expand the existing Lifeline
    network operations and telephone infrastructure, including centralized
    chat/text response, backup center capacity, and special services.

        SAMHSA's main vehicle for supporting youth suicide prevention is
    the Garrett Lee Smith State and Tribal Youth Suicide Prevention grant
    program. Since its start in 2005, following the tragic death by suicide
    of former Senator Gordon Smith's son, this program has been shown to
    have a demonstrable impact or reducing youth suicide. SAMHSA funded
    evaluations have shown that counties implementing grant-funded youth
    suicide prevention activities have lower rates of youth suicide
    compared to matched counties.\86\ Further, this impact was shown in the
    evaluation to be directly related to years of continued funding.
    ---------------------------------------------------------------------------
        \86\ Godoy Garraza L, Kuiper N, Goldston D, McKeon R, Walrath C.
    Long-term impact of the Garrett Lee Smith Youth Suicide Prevention
    Program on youth suicide mortality, 2006-2015. J Child Psychol
    Psychiatry. 2019 Oct;60(10):1142-1147. doi: 10.1111/jcpp.13058. Epub
    2019 May 8. PMID: 31066462.

    ---------------------------------------------------------------------------
        Two approaches to improving awareness are:

            Supporting the Garrett Lee Smith State and Tribal Youth
    Suicide Prevention grant program to support youth suicide awareness and
    suicide prevention efforts across the country.
            Supporting State capacity to continue youth suicide prevention
    efforts when the Federal grants end. Many States do not even have a
    single FTE devoted to youth suicide prevention except for those funded
    by the Garrett Lee Smith grants.

        Developing and disseminating communication messages and resources
    are critical for advancing awareness and public health action related
    to suicide prevention. Messaging and resources may focus on topics such
    as the scope and magnitude of suicide, suicide as a preventable public
    health problem, the need for a comprehensive approach (and what that
    means), the range of suicide risk and protective factors, suicide
    warning signs and what works to prevent suicide. Health departments
    serve a vital role in tracking and monitoring suicide and suicidal
    behavior and in connecting and coordinating suicide prevention efforts
    across State, local, and tribal governments and on the ground in local
    communities. However, according to a CDC survey of State suicide
    prevention coordinators, there is limited capacity and resources to
    carry out suicide-related surveillance and implementation and
    evaluation of public health prevention activities in States, tribes,
    and territories. In addition, data are critical to defining the problem
    of suicide (including its scope and magnitude), determining who is most
    impacted, tracking trends over time, and informing prevention, program
    evaluation, and timely response. However, the availability and
    timeliness of existing data present challenges. New sources of data and
    enhanced application of data are urgently needed to help identify
    emerging health threats and impacted populations, earlier than more
    traditional data and analytic techniques allow. This would include
    leveraging and expanding novel and timely data from sources such as
    social media, emergency medical services (EMS), and near real-time
    hospital records data and using innovative data science methods like
    data linkage and machine learning to rapidly synthesize these data and
    disseminate them to key partners and decision-makers. This quality,
    timely data and the application of emerging data science methods have
    the potential to strengthen and target data driven suicide prevention
    strategies tailored to communities. Support for two programs could help
    improve State suicide prevention capacity and surveillance, CDC's
    Comprehensive Suicide Prevention Program and CDC's suicide syndromic
    surveillance which provides near-real time data and targeted response
    efforts and new and innovative methods for collecting suicidal behavior
    data.
                             masking young children
        Question. Making sure young people can attend school is vitally
    important. Previously, the Department of Health and Human Services
    issued a rule requiring young children to wear a mask to attend a Head
    Start program.

        As a doctor, I am concerned this policy is not supported by the
    medical evidence. Even the World Health Organization explicitly States
    that ``children aged 5 years and under should not be required to wear
    masks . . . based on the safety and overall interest of the child.''

        Do you believe the scientific data supports the masking of young
    children?

        Answer. When the COVID-19 community level is high, CDC recommends
    individuals wear a well-fitting mask indoors in public, regardless of
    vaccination status (including in K-12 schools and other indoor
    community settings). At all COVID-19 community levels, people can wear
    a mask based on personal preference, informed by personal level of
    risk.

        People with symptoms, a positive test, or exposure to someone with
    COVID-19 should wear a mask. (See COVID-19 Community Levels at https://
    www.cdc.gov/coronavirus/2019-ncov/science/community-levels.html.)
    Experimental and epidemiologic data support community masking to reduce
    the spread of SARS-CoV-2, including among adults and children 2 years
    and older. (See Science Brief: Community Use of Masks to Control the
    Spread of SARS-CoV-2 at https://www.cdc.gov/coronavirus/2019-ncov/
    science/science-briefs/masking-science-sars-cov2.html.) Mask use has
    been found to be safe and is not associated with clinically significant
    impacts on respiration or gas exchange under most circumstances, except
    for intense exercise. The limited available data indicate no clear
    evidence that masking impairs emotional or language development in
    children.

        Question. If you believe the masking of young children is
    justified, please provide specific medical or scientific studies to
    support this position.

        Answer:
         1.  Jehn M., McCullough J.M., Dale A.P., Gue M., Eller B., Cullen
    T., Scott S.E. Association between K-12 school mask policies and
    school-associated COVID-19 outbreaks--Maricopa and Pima Counties,
    Arizona, July-August 2021. MMWR Morb Mortal Wkly Rep. 2021;
    70(39);1372-1373.
         2.  Budzyn S.E., Panaggio M.J., Parks S.E., Papazian M., Magid J.,
    Eng M., Barrios L.C. Pediatric COVID-19 cases in counties with and
    without school mask requirements--United States, July 1-September 4,
    2021. MMWR Morb Mortal Wkly Rep. 2021; 70(39);1377-1378.
         3.  Donovan C.V., Rose C., Lewis K.N. et al. SARS-CoV-2 Incidence
    in K-12 School Districts with Mask-Required Versus Mask-Optional
    Policies--Arkansas, August-October 2021. MMWR Morb Mortal Wkly Rep.
    2022; 71 (March 8; available online as an early release at https://
    www.cdc.gov/mmwr/volumes/71/wr/
    mm7110e1.htm?s_cid=mm7110e1_e&ACSTrackingID=USCDC_
    921-DM77309&ACSTrackingLabel=MMWR%20Early%20Release%20-%20Vol.
    %2071%2C%20March%208%2C%202022&deliveryName=USCDC_921-DM77
    309.
         4.  Smith J., Culler A., Scanlon K. Impacts of blood gas
    concentration, heart rate, emotional state, and memory in school-age
    children with and without the use of facial coverings in school during
    the COVID-19 pandemic. FASEB J. 2021;35(Suppl 1) doi:10.1096/
    fasebj.2021.35.S1.04955.
         5.  Lubrano R., Bloise S., Testa A., et al. Assessment of
    respiratory function in infants and young children wearing face masks
    during the COVID-19 pandemic. JAMA Netw Open. 2021;4(3):e210414.
         6.  Dost B., Komurcu O., Bilgin S., Dokmeci H., Terzi O., Bar1s S.
    Investigating the effects of protective face masks on the respiratory
    parameters of children in the post-anesthesia care unit during the
    COVID-19 pandemic. J Perianesth Nurs. 2021; doi.org/10.1016/
    j.jopan.2021.02.004.
         7.  Ammann P., Ulyte A., Haile S.R., Puhan M.A., Kriemler S.,
    Radtke T. Perceptions towards mask use in school children during the
    SARS-CoV-2 pandemic: The Ciao Corona Study. medRxiv. 2021; doi.org/
    10.1101/2021.09.04.21262907
    external icon, https://www.medrxiv.org/content/10.1101/
    2021.09.04.2126290
    7v1.
         8.  Gori M., Schiatti L., Amadeo M.B. Masking emotions: Face masks
    impair how we read emotions. Front Psychol. 2021;12:669432.
         9.  Ruba A.L., Pollak S.D. Children's emotion inferences from
    masked faces: Implications for social interactions during COVID-19.
    PLoS One. 2020;15(12): e0243708.
        10.  Singh L., Tan A., Quinn P.C. Infants recognize words spoken
    through opaque masks but not through clear masks. Dev Sci.
    2021;24(6):e13117.
        11.  Sivaraman M., Virues-Ortega J., Roeyers H. Telehealth mask
    wearing training for children with autism during the COVID-19 pandemic.
    J Appl Behav Anal. 2021;54(1):70-86.
        12.  Halbur M., Kodak T., McKee M., et al. Tolerance of face
    coverings for children with autism spectrum disorder. J Appl Behav
    Anal. 2021;54(2):600-617.
        13.  Lillie M.A., Harman M.J., Hurd M., Smalley M.R. Increasing
    passive compliance to wearing a facemask in children with autism
    spectrum disorder. J Appl Behav Anal. 2021;54(2):582-599.
        14.  Schneider J., Sandoz V., Equey L., Williams-Smith J., Horsch
    A., Bickle Graz M. The role of face masks in the recognition of
    emotions by preschool children. JAMA Pediatr. 2021;e214556.

        Question. Do you believe the administration should revisit this
    policy?

        Answer. CDC will continue to evaluate emerging evidence on benefits
    and risks of masking for children and adults and will update
    recommendations if warranted. In addition, performance of COVID-19
    community levels will be reassessed as the pandemic continues to
    evolve.
                                   telehealth
        Question. Patients in Wyoming are using telehealth to help meet
    their health-care needs during the pandemic. Members of this committee
    support making sure telehealth becomes a permanent part of health-care
    delivery for those patients who want to utilize this service.

        Can you discuss the importance of telehealth in terms of the
    delivery of mental health services for young people?

        Answer. Telehealth has become an increasingly important tool in
    supporting mental health-care services for special populations such as
    youth. Throughout the pandemic, not only have telehealth services for
    mental health grown exponentially, helped in large part by a range of
    new regulatory action taken by States and HHS, but telehealth has also
    filled an urgent need to maintain access to behavioral health care for
    youth while social distancing was necessary. However, the benefits of
    telehealth for mental health services extend beyond the COVID-19
    pandemic. Telehealth for mental health services can help with the
    improvement of behavioral health for youth outcomes, and reduction of
    health-care costs. Telehealth benefits for youth and their families
    include improving access to health care by providing care closer to or
    in the home, reducing travel time, reducing time away from school and
    work, and easier access to mental health specialists. Telehealth
    benefits for providers include maintaining the behavioral health
    provider relationship with the patient and generally high provider
    satisfaction.

        Access to mental health care is challenging for children and
    families, particularly in rural areas.\87\ Children in rural areas also
    tend to experience higher rates of depression, anxiety, and behavioral
    problems (ages 3-17 years).\88\ It is important to promote virtual care
    services to maximize the ability of existing mental health providers
    and reach those in rural and remote areas without access to care. HRSA
    supports several programs that employ telehealth to: improve access to
    quality health care and specialty services for children with special
    health-care needs; strengthen the health workforce; and improve access
    to care and services.
    ---------------------------------------------------------------------------
        \87\ http://www.rupri.org/wp-content/uploads/Behavioral-Health-in-
    Rural-America-Challenges-and-Opportunities.pdf.
        \88\ https://mchb.hrsa.gov/sites/default/files/mchb/Data/NSCH/
    rural-urban-differences.pdf.

        Recognizing the important role of telehealth in ensuring access to
    care and services during the COVID-19 pandemic, HRSA awarded funding
    from the Coronavirus Aid, Relief, and Economic Security (CARES) Act in
    FY 2020 to increase telehealth access and infrastructure for providers
    and families to help prevent and respond to COVID-19. One of the awards
    had a focus on behavioral health services in pediatric care by
    providing telehealth-care access for infants, children, adolescents and
    young adults, including those with special health-care needs, and
    helping community-based pediatric practices, unaccustomed to
    telehealth, develop capacity to meet the needs of their practices,
    ---------------------------------------------------------------------------
    particularly in rural and underserved areas.

        In addition, HRSA's Pediatric Mental Health Care Access (PMHCA)
    Program supports behavioral health integration in pediatric primary
    care by supporting statewide or regional pediatric mental health care
    telehealth access programs that provide teleconsultation, training,
    technical assistance, and care coordination for pediatric primary care
    providers to diagnose, treat and refer children with behavioral health
    conditions.

        Question. Can you discuss policies Congress should consider that
    will allow more young people to take advantage of telehealth?

        Answer. Congress could incentivize States to provide Medicaid
    coverage for mental health services for youth provided via telehealth
    through and support training programs for behavioral health providers
    in the treatment of youth via telehealth as well as improving
    coordination with primary care providers using technology.

        The role of telehealth in ensuring access to care and services
    during the COVID-19 pandemic is crucial. Telehealth can be a cost-
    effective alternative to the traditional face-to-face way of providing
    care. It is important that States implement flexibilities related to
    Medicaid reimbursement for services provided via telehealth so that
    young people have easy access to telehealth services.\89\ To support
    broader access to telehealth, HRSA funded four awards from the
    Coronavirus Aid, Relief, and Economic Security (CARES) Act to increase
    health-care access and infrastructure for providers and families to
    prevent and respond to COVID-19, particularly for vulnerable maternal
    and child health populations, including young people. Through the
    support of CARES Act funds, the American Academy of Pediatrics (AAP)
    initiated numerous activities to support pediatric providers, including
    virtual office visits, Telehealth 101 trainings, Project ECHOs, and
    more to advance telehealth.
    ---------------------------------------------------------------------------
        \89\ https://www.medicaid.gov/medicaid/benefits/telemedicine/
    index.html.

        Congressional support of pediatric mental health care telehealth
    access programs continues to promote behavioral health integration into
    pediatric primary care as well as overall health-care access.
    Investments in programs that focus on retention and recruitment of
    pediatric providers and nurses and programs that utilize telehealth
    services have been and continue to be helpful and effective. Moreover,
    additional support for training on telehealth and telemedicine
    infrastructure could also improve access and utilization of telehealth
    ---------------------------------------------------------------------------
    for young people.

        Opportunities such as those provided for under the Pediatric Mental
    Health Care Access (PMHCA) new area expansion program support efforts
    of State or regional networks of pediatric mental health-care teams to
    provide teleconsultation, training, technical assistance, and care
    coordination support for pediatric primary care providers (PCPs) to
    diagnose, treat, and refer children with behavioral health conditions.

                                     1_____

                     Prepared Statement of Hon. Ron Wyden,
                           a U.S. Senator From Oregon
        On behalf of Senator Crapo and myself, it's our hope that this
    morning's hearing on the state of mental health for our youth serves as
    a wake-up call. Millions of young Americans are struggling under a
    mental health epidemic. Struggling in school. Struggling with addiction
    or isolation. Struggling to make it from one day to the next.

        Our country is in danger of losing much of a generation if mental
    health care is business as usual. For families across America, this is
    the issue that dominates their kitchens and living rooms. With the
    Children's Health Insurance Program and Medicaid--the largest payer of
    mental health care for our young--within this committee's jurisdiction,
    the Finance Committee must step up with solutions.

        I hear way too many heartbreaking stories from parents and young
    people at Oregon town meetings, at the grocery store, and at the
    schools I've visited all over the State. I'm certain that's the way it
    is for every member of the committee.

        Imagine being a parent scrambling desperately to find help for your
    kid who's in crisis--who may be a danger to themselves or somebody
    else. Too many parents are making call after call only to learn that
    there aren't any beds available, or that the wait list to see a
    psychiatrist could be weeks or months long. Or they're told that their
    insurance company won't pay for the care a psychiatrist says their
    child needs.

        The law requires equality between coverage for physical health and
    coverage for mental health. Too many families are put through
    bureaucratic torment when they try to use that coverage--coverage they
    pay for. Your kid is suffering, the insurance company takes thousands
    of dollars in premiums out of your pocket, and you get little more than
    jazz in your ear while you sit on hold.

        There is new urgency for Congress to step up the fight against this
    epidemic. Diagnosing an issue and getting the right care for young
    people was already too difficult before anyone had heard of COVID-19.
    The crisis is even larger today. Kids are feeling isolated, and
    depression is up. Suicide attempts are up. An estimated 140,000
    children have lost a parent or a caretaker to COVID-19, and that number
    will continue to rise.

        The bottom line is, every loving parent wants what's best for their
    child, so as a Nation, shouldn't we have that same level of concern for
    our young, that same level of commitment?

        We're fortunate to be joined this morning by Surgeon General Dr.
    Murthy, who has been a crusader for improving mental health care for
    our children. He's going to help us attack this challenge from all
    sides, including how to help families navigate a broken, complicated
    mental health-care system; how to respond to a young person in crisis
    without demonizing or criminalizing them; how to build on what's proven
    to work when it comes to health care for kids, specifically CHIP and
    Medicaid.

        I also want to address the road ahead for the Finance Committee.
    For several months, we've been working on a bipartisan basis to break
    down the big policy challenges in mental health care. With today's
    hearing, the Finance Committee is ramping up our legislative efforts as
    a group. Several of our members have graciously agreed to partner on
    specific policy challenges, one Democrat and one Republican. The goal
    is to produce a bipartisan bill this summer that brings all that work
    together.

        Senators Carper and Cassidy are going to focus on the subject of
    today's hearing, mental health care for America's children. Senators
    Stabenow and Daines will work together on building up the mental
    health-care workforce, which is far too limited to meet our needs
    today. Senators Cortez Masto and Cornyn will look at how to make mental
    health care more seamless, because too many people today are falling
    through the cracks of a fractured system. Senators Bennet and Burr will
    look at how to ensure that mental health care gets finally treated the
    same way as physical health care. Senators Cardin and Thune will team
    up on making it easier to get mental health care via telehealth.

        The north star for this effort is achieving what the committee
    talked about in a hearing last year: everybody in America must be able
    to get the mental health care they need when they need it. In the
    coming weeks, the full committee will stay busy with hearings featuring
    mental health experts and advocates, as well as families who can share
    with us their own experiences with mental health challenges.

        This morning's hearing will be the first of two that put a special
    focus on our youth. I'm looking forward to our discussion. Again, I
    want to thank Dr. Murthy for joining us, and I'll turn it over to
    Senator Crapo for his opening remarks.

                                     ______

     FACT SHEET: In One Year of the Biden-Harris Administration, the U.S.
                        Department of Education Has Helped Schools Safely
                        Reopen and Meet Students' Needs

    January 20, 2022

    On January 20, 2021, less than half of K-12 students were learning in
    person. Today, 1 year since the start of the Biden-Harris
    administration, nearly all students are back in school and learning in
    person with caring teachers and alongside their peers. Across the
    country, schools are putting in place new programs and supports to
    address the impact of the pandemic on students' learning and mental
    health. To achieve this goal, the U.S. Department of Education
    (Department) distributed unprecedented resources to states, districts,
    and K-12 schools, including funding, guidance, and technical assistance
    to help educators meet the needs of all students, especially those
    disproportionately impacted by the pandemic. The Department also
    distributed unprecedented resources to colleges and universities to
    help ensure students could access a high-quality education as well as
    the social, emotional, and mental health supports needed to earn their
    degrees and thrive. The Department also canceled $15 billion in loan
    debt for hundreds of thousands of students and borrowers, took action
    to advance equity in education, and made critical progress in creating
    educational environments free from discrimination or harm.

    The Department's key 2021 accomplishments include:

    Helped reopen over 95% of America's public schools for in-person
    learning full-time--up from 46% at the beginning of the Biden
    administration.

          Due to historic investments in K-12 schools through the American
    Rescue Plan and using the full force of the administration to get
    educators, staff, and students vaccinated throughout the year, 95% of
    public school elementary and middle schools were open, in-person full-
    time in early January 2022, compared to just 46% in January 2021.
          On top of these unprecedented investments, the Biden-Harris
    administration made available $10 billion in American Rescue Plan funds
    specifically for States and districts to implement testing programs
    starting in March 2021. Earlier this month, the administration also
    announced it is increasing the number of COVID-19 tests available for
    schools by 10 million per month to help schools safely remain open and
    implement screening testing and test-to-stay programs.

    Invested $122 billion in American Rescue Plan funds to help K-12
    schools safely reopen, stay open, and address lost instructional time
    and students' needs.

          The Department distributed unprecedented funding \1\ from the
    American Rescue Plan to help schools reopen safely and support
    students. As part of this work, the Department also developed guidance
    to help schools use these funds for their most pressing needs,
    including addressing students' mental health, learning needs, and
    addressing staffing shortages that are impacting schools. Schools
    across the country, from Vermont to Hawaii, are hosting vaccination
    clinics. Many districts, like DeKalb County, Georgia, have improved
    ventilation. Washington Local Schools, in Ohio, hosted its first summer
    camp, for students in grades K-3, which included a focus on academics.
    Arkansas created the Arkansas Teaching Corps. New York City is hiring
    hundreds of school social workers. And Gaston County Schools, in North
    Carolina, used ARP ESSER funds to double nursing staff and secure a
    nurse for each of their 54 school locations, so that nurses no longer
    have to split their time between two buildings.
    ---------------------------------------------------------------------------
        \1\ https://www.ed.gov/news/press-releases/us-department-education-
    announces-distribution-all-american-rescue-plan-esser-funds-and-
    approval-all-52-state-education-agency-plans.

    Invested $40 billion in American Rescue Plan funds to over 5,000
    ---------------------------------------------------------------------------
    institutions of higher education.

          The Department distributed emergency grants \2\ to over 5,000
    colleges and universities to provide emergency financial aid to
    millions of students and ensure learning continued during the pandemic.
    Half of the funding awarded went directly to students in the form of
    financial aid to help them remain enrolled during the pandemic. As part
    of the American Rescue Plan, the Department also released over $3
    billion in funding to Historically Black Colleges and Universities,
    Tribally Controlled Colleges and Universities, and Minority Serving
    Institutions to support students at historic and under-resourced
    institutions. A recent survey \3\ of college presidents conducted by
    the American Council of Education found that a majority strongly agreed
    that Higher Education Emergency Relief Funds enabled their institution
    to keep students enrolled who were at risk of dropping out due to
    pandemic-related factors.
    ---------------------------------------------------------------------------
        \2\ https://www.ed.gov/news/press-releases/us-department-education-
    makes-available-36-billion-american-rescue-plan-funds-support-students-
    and-institutions?utm_content=&utm_medium
    =email&utm_name=&utm_source=govdelivery&utm_term=.
        \3\ https://www.acenet.edu/Research-Insights/Pages/Senior-Leaders/
    Presidents-Survey-HEERF.aspx.

    Invested more than $3 billion in American Rescue Plan funds to support
    ---------------------------------------------------------------------------
    children with disabilities.

          The pandemic and its disruptions to in-person learning had a
    disproportionate impact on students with disabilities. This funding \4\
    within the American Rescue Plan is specifically aimed at helping more
    than 7.9 million infants, toddlers, and students served under the
    Individuals with Disabilities Education Act recover from the pandemic
    and succeed in the classroom.
    ---------------------------------------------------------------------------
        \4\ https://www.ed.gov/news/press-releases/us-department-education-
    releases-more-3-billion-american-rescue-plan-funds-support-children-
    disabilities?utm_content=&utm_medium=email&
    utm_name=&utm_source=govdelivery&utm_term=.

          Use of the funds include hiring additional special education
    personnel, upgrading technology in schools, procuring professional
    development for special educators and new educational materials for
    classrooms, supporting transportation for students with disabilities,
    ---------------------------------------------------------------------------
    and funding before and after-school programs.

    Released the Return to School Roadmap to help our schools return to in-
    person learning safely and successfully.

          The Department launched a nationwide campaign around returning
    to school in-person this fall and developed resources as part of the
    ``Return to School Roadmap'' \5\ that parents, educators, schools, and
    communities could use to build confidence and excitement around
    returning to school in-person. The Department launched a five-state bus
    tour--the Return to School Road Trip--to celebrate the return to school
    in fall 2021. And, the Department made available \6\ first-of-its-kind
    funding to keep school districts whole if they were penalized by their
    State for implementing proven mitigation strategies, like masking, to
    keep students and staff safe.
    ---------------------------------------------------------------------------
        \5\ https://www.ed.gov/news/press-releases/us-department-education-
    releases-%E2%80%9Cre
    turn-school-roadmap%E2%80%9D-support-students-schools-educators-and-
    communities-preparing-2021-2022-school-year.
        \6\ https://www.ed.gov/news/press-releases/us-department-education-
    announces-new-grant-program-provide-funding-school-districts-being-
    penalized-implementing-covid-safety-measures.

    Discharged $15 billion in Federal student loans to over 675,000
    ---------------------------------------------------------------------------
    borrowers.

          The Department has provided targeted relief to over 675,000
    borrowers through executive action, including providing $1.5 billion
    \7\ to borrowers who have been taken advantage of by their
    institutions, $7 billion for over 400,000 borrowers who have a total
    and permanent disability, $1.26 billion \8\ to over 100,000 borrowers
    who attended the now-defunct ITT Technical Institute, and close to $5
    billion to 70,000 borrowers through the revamped Public Service Loan
    Forgiveness program.
    ---------------------------------------------------------------------------
        \7\ https://www.ed.gov/news/press-releases/department-education-
    announces-approval-new-categories-borrower-defense-claims-totaling-500-
    million-loan-relief-18000-borrowers?amp;amp;amp
    ;amp.
        \8\ https://www.ed.gov/news/press-releases/extended-closed-school-
    discharge-will-provide-115k-borrowers-itt-technical-institute-more-11b-
    loan-forgiveness.

    Revamped the Public Service Loan Forgiveness program to restore its
    ---------------------------------------------------------------------------
    promise to our nation's public service workers.

          In October, the Department announced changes \9\ to the Public
    Service Loan Forgiveness program to allow borrowers to receive credit
    \10\ for past periods of repayment on loans that may not otherwise
    qualify for Public Service Loan Forgiveness. Prior to making changes to
    the Public Service Loan Forgiveness program, only 16,000 borrowers had
    ever received forgiveness through the program, in total. Today, this
    change has already helped more than 70,000 borrowers qualify for
    Federal student loan forgiveness, totaling close to $5 billion in
    relief. The Department also communicated with hundreds of thousands of
    public service workers to let them know the minimum number of payments
    they would gain credit for towards loan forgiveness under these
    temporary changes.
    ---------------------------------------------------------------------------
        \9\ https://www.ed.gov/news/press-releases/us-department-education-
    announces-transformation
    al-changes-public-service-loan-forgiveness-program-will-put-over-
    550000-public-service-workers-closer-loan-forgiveness.
        \10\ https://studentaid.gov/announcements-events/pslf-limited-
    waiver.

    ---------------------------------------------------------------------------
    Issued guidance for supporting students' mental health.

          As part of the Department's effort to help schools reopen safely
    and address the impacts of the COVID pandemic, the Department released
    comprehensive guidance on how schools and higher education institutions
    can address students' mental health needs, \11\ including through using
    American Rescue Plan funds. The Department encouraged districts and
    states to use American Rescue Plan funds to hire more mental health
    professionals, guidance counselors, and incorporate more social,
    emotional, and mental health resources into K-12 schools and
    institutions of higher education.
    ---------------------------------------------------------------------------
        \11\ https://www.ed.gov/news/press-releases/us-department-
    education-releases-new-resource-supporting-child-and-student-social-
    emotional-behavioral-and-mental-health-during-covid-19-era.

    Started a comprehensive review of title IX and held the first-ever
    national public hearing on the topic. Issued a notification to the
    public that the Department interprets title IX to cover sexual
    ---------------------------------------------------------------------------
    orientation and gender identity discrimination.

          The U.S. Department of Education's Office for Civil Rights
    issued a Notice of Interpretation \12\ explaining that it will fully
    enforce title IX to prohibit discrimination based on sexual orientation
    and gender identity. The Department also started a comprehensive review
    of title IX to implement President Biden's executive orders
    guaranteeing educational environments free from discrimination and on
    preventing and combating discrimination on the basis of gender identity
    or sexual orientation.
    ---------------------------------------------------------------------------
        \12\ https://www2.ed.gov/about/offices/list/ocr/docs/202106-
    titleix-noi.pdf.

    Awarded or released $6.7 billion in additional pandemic relief and
    ---------------------------------------------------------------------------
    other grant funds to Puerto Rico.

          In June, U.S. Secretary of Education Miguel Cardona announced
    that the Puerto Rico Department of Education \13\ now has full access
    to all Federal education pandemic relief funds earmarked for the
    Commonwealth and other education program grant dollars that were
    previously withheld.
    ---------------------------------------------------------------------------
        \13\ https://www.ed.gov/news/press-releases/education-department-
    provides-nearly-4-billion-pandemic-relief-aid-and-other-grants-puerto-
    rico-department-education-secretary-cardona-visits-commonwealth.

    In partnership with schools, districts, and State leaders, the
    Department has made great strides in supporting the reopening of our
    Nation's schools and colleges, and helping students and teachers return
    safely to in-person learning. As 2022 begins, the Department remains
    committed to delivering necessary supports to our schools, students,
    and teachers, while continuing to advance President Biden's vision of
    building our education system back better than before the COVID-19
    ---------------------------------------------------------------------------
    pandemic.

                                     ______

                                 Communications

                                  ----------

                     American Academy of Family Physicians

                     1133 Connecticut Ave., NW, Suite 1100

                           Washington, DC 20036-4305

                                 (800) 794-7481

                                 (202) 232-9033

    February 8, 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:

    On behalf of the American Academy of Family Physicians (AAFP), which
    represents more than 133,500 family physicians and medical students
    across the country, I write to share testimony in advance of the
    hearing ``Protecting Youth Mental Health: Part I--An Advisory and Call
    to Action'' on February 8, 2022.

    Access to comprehensive primary care is especially important for
    children and adolescents. Family physicians care for patients at all
    stages of life, from newborn care to geriatrics. Family physicians are
    the usual source of care for about 20 percent of U.S. children, and in
    rural and underserved areas this percentage is even higher.\1\
    Additionally, family physicians are critically important to addressing
    the mental health crisis because nearly 40 percent of all visits for
    depression, anxiety, or cases defined as ``any mental illness'' were
    with primary care physicians.\2\ Primary care physicians are also more
    likely to be the main source of physical and mental health care for
    patients with lower socioeconomic status and for those with co-
    morbidities.\3\
    ---------------------------------------------------------------------------
        \1\ Jetty, A., Romano, M.J., Jabbarpour, Y., Petterson, S., and
    Bazemore, A. (2021). ``A Cross-Sectional Study of Factors Associated
    With Pediatric Scope of Care in Family Medicine.'' The Journal of the
    American Board of Family Medicine, 34(1), 196-207. https://doi.org/
    10.3122/JABFM.2021.01.200300.
        \2\ Jetty, A., Petterson, S., Westfall, J.M., and Jabbarpour, Y.
    (2021). ``Assessing Primary Care Contributions to Behavioral Health: A
    Cross-sectional Study Using Medical Expenditure Panel Survey,'' https:/
    /Doi.Org/10.1177/21501327211023871.
        \3\ Jetty, A., Petterson, S., Westfall, J.M., and Jabbarpour, Y.
    (2021). ``Assessing Primary Care Contributions to Behavioral Health: A
    Cross-sectional Study Using Medical Expenditure Panel Survey,'' https:/
    /Doi.Org/10.1177/21501327211023871.

    The AAFP applauds the Surgeon General's recent advisory on Protecting
    Youth Mental Health (https://www.hhs.gov/sites/default/files/surgeon-
    general-youth-mental-health-advisory.pdf) and commitment to improving
    access to behavioral health services. This advisory includes
    recommendations for families, schools, communities, employers, health-
    care workers, and more, illustrating the need for coordinated efforts
    to stymie the increasing mental health concerns for young people.
    However, to achieve the recommendations outlined, Congress must take
    action to support primary care physicians and the behavioral health
    ---------------------------------------------------------------------------
    workforce.

    To begin, Medicaid is a critical component of the response to the
    children's mental health crisis because it provides health insurance to
    1 in 5 Americans and covers some of our most vulnerable populations.
    Specifically, in July 2021 nearly 40 million children were enrolled in
    Medicaid and CHIP.\4\ This includes low-income children, pregnant
    women, and families, children with special health-care needs, non-
    elderly adults with disabilities, and other adults. When Congress
    raised Medicaid primary care payment rates to Medicare levels in 2013
    and 2014, patient access improved.\5\ Improving access to primary care
    through improved payment will in turn improve screening, diagnosis, and
    treatment of mental health and behavioral health needs for the 40
    million children enrolled in Medicaid and CHIP. The Ensuring Access to
    Primary Care for Women and Children Act (https://www.aafp.org/dam/AAFP/
    documents/advocacy/payment/medicaid/LT-SenBrownMurray-Ensuring
    AccessPrimaryCareWomenChildrenAct-052721.pdf) would return Medicaid
    payments for primary care services to Medicare payment levels for two
    years and expand the number of clinicians eligible for this increase to
    ensure that all Medicaid enrollees have access to the primary and
    preventive care they need. The legislation also raises Medicaid payment
    rates to those of Medicare for the duration of any future public health
    emergency and 6 months thereafter. During this time of crisis and once
    things return to normal, it is critical that the Medicaid program be
    able to respond to take on any qualified new individuals and ensure
    physicians have the means to serve these new patients.
    ---------------------------------------------------------------------------
        \4\ CMS. July 2021 Medicaid and CHIP Enrollment Trends Snapshot.
    https://www.
    medicaid.gov/medicaid/national-medicaid-chip-program-information/
    downloads/july-2021-medicaid-chip-enrollment-trend-snapshot.pdf.
        \5\ Polsky, Daniel; Richards, Michael; Basseyn, Simon; Wissoker,
    Douglas; Kenney, Genevieve; Zukerman, Stephen; Rhodes, Karin:
    ``Appointment Availability After Increases in Medicaid Payments for
    Primary Care,'' https://pubmed.ncbi.nlm.nih.gov/25607243/.

    To further bolster behavioral health access for Medicaid beneficiaries,
    the AAFP strongly recommends Congress pass legislation to establish a
    Medicaid demonstration program providing infrastructure, technical
    assistance, and sustainable financing for expanding access to
    integrated mental health care for children in primary care, schools, or
    other critical settings, including through telehealth. Such program
    should be designed to ensure long-term and sustainable access to
    integrated mental health care for children, with a special focus on
    improving access for traditionally marginalized populations.
    Integrating behavioral health in primary care requires significant
    upfront investment, which can be a barrier to implementation for
    physician practices. This demonstration program would provide practices
    with the support they need to integrate behavioral health into their
    ---------------------------------------------------------------------------
    practices, ultimately improving access to care for beneficiaries.

    Existing programs under Medicaid, like the early, periodic, screening,
    diagnostic, and treatment (EPSDT) benefit, have potential to improve
    access to early prevention and treatment for children and adolescents
    presenting with behavioral health concerns. However, state Medicaid
    programs implement EPSDT and medical necessity determinations
    differently, especially when contracting with Medicaid managed care
    plans. This variation has resulted in barriers to accessing mental
    health services treatment for children in some states. To this end, the
    AAFP recommends Congress direct CMS to review EPSDT implementation in
    states and release an informational bulletin clarifying coverage of
    EPSDT services to facilitate access to prevention, early intervention,
    and mental health services.

    Furthermore, accurate data collection is essential to understand areas
    most in need of behavioral health resources. The AAFP recognizes that
    integrated behavioral health services exist on a spectrum and can
    include consistent coordinate of referrals and exchange of information,
    colocation of services in the primary care setting, or full integration
    of treatment plans shared between primary care and behavioral health
    clinicians. The AAFP recommends Congress pass legislation directing the
    Director of the Agency for Healthcare Research and Quality (AHRQ) and
    the Assistant Secretary for Mental Health and Substance Use to create
    and implement a plan to improve measurement of the extent to which
    children and adults have access to integrated mental health care in
    primary care and the effectiveness of the care provided.

    The AAFP also recognizes the school nurses and counselors play an
    important role in ensuring children and adolescents can access care.
    However, current coordination between primary care physicians and
    school-based clinics is limited, and many family physicians do not
    receive all relevant information to ensure care continuity, especially
    during school breaks. School-based clinics often do not have
    information on the child's or family's insurance coverage, making it
    difficult to receive accurate and affordable referrals. The AAFP
    strongly recommends Congress make investments to improve care
    coordination between school-based health-care providers and primary
    care physicians.

    Thank you for the opportunity to respond to the committee's request for
    information. The AAFP is eager to support the committee in finding
    solutions to address the growing mental health crisis. For additional
    questions, please reach out to Erica Cischke, Director, Legislative and
    Regulatory Affairs at ecischke@aafp.org.

    Sincerely,

    Ada D. Stewart, M.D., FAAFP
    Board Chair, American Academy of Family Physicians

                                     ______

         American Academy of Pediatrics, American Academy of Child and
           Adolescent Psychiatry, and Children's Hospital Association
    The American Academy of Pediatrics (AAP), American Academy of Child and
    Adolescent Psychiatry (AACAP) and Children's Hospital Association
    (CHA), together representing more than 77,000 pediatric physicians,
    residents, and medical students and more than 220 children's hospitals,
    thanks the Senate Finance Committee for holding this hearing,
    ``Protecting Youth Mental Health: Part I--An Advisory and Call to
    Action,'' focused on this critical issue for children, families,
    pediatric health-care workforce and our entire nation.

    The challenges facing children's mental, emotional and behavioral
    health are so dire that our three associations, on behalf of the
    members we represent, declared 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. We call on this committee to join us in recognizing the
    magnitude of the situation and advance meaningful and transformational
    solutions to address it. 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.

    We also want to recognize the Surgeon General for raising the youth
    mental health crisis as a priority public health challenge. As his
    advisory notes, this is not a problem we will fix overnight, but
    starting now we can make a difference working together. We hope the
    advisory will encourage further, bold action by the administration such
    as a federal emergency declaration in children's mental health.

    The COVID-19 pandemic continues to take a serious toll on children's
    mental health as young people face ongoing social isolation,
    uncertainty, fear and grief. Even before the pandemic, mental health
    challenges facing children were of great concern, and COVID-19 has only
    exacerbated them. Despite sizable federal funds allocated to address
    mental health in multiple COVID-19 relief packages, pediatric providers
    report that they are unable to access such funds due to very broad
    funding goals spread across multiple populations and the lack of
    specific designated funding to improve mental health care for children
    in their own practices and other health-care settings. 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.

    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, on average, 11 years 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 for the better our children and
    our country as we avoid more serious and costly outcomes later--
    including suicidal ideation and death by suicide.
    ---------------------------------------------------------------------------
        \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.

    Although the trends in pediatric mental health noted above were
    worrying before the COVID-19 emergency, demand over the past 18 months
    for pediatric inpatient mental health services, partial
    hospitalization, step-down programs and other levels of crisis care has
    risen significantly. 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\ In the first three quarters of 2021, children's
    hospitals reported emergency room visits for self-injury and suicide
    attempts or ideation in children ages 5-18 at a 42% higher rate than
    during the same time period in 2019.\7\ 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\
    ---------------------------------------------------------------------------
        \6\ Centers for Disease Control and Prevention, Mental Health-
    Related Emergency Department Visits Among Children Aged <18 Years
    During the COVID-19 Pandemic--United States, January 1-October 17,
    2020, November 13, 2020, https://www.cdc.gov/mmwr/volumes/69/wr/
    mm6945a3.htm.
        \7\ Analysis of Children's Hospital Association PHIS database, n=38
    children's hospitals.
        \8\ Centers for Disease Control and Prevention, 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, June 18, 2021, https://www.cdc.gov/mmwr/volumes/
    70/wr/mm7024e1.htm.

    The challenges and limitations of the current mental health-care system
    are affecting all children, but the pandemic has exacerbated and
    highlighted existing disparities in mental health outcomes and access
    to high-quality mental health-care services for children of color. 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.
    ---------------------------------------------------------------------------
        \9\ Congressional Black Caucus, Ring the Alarm: The Crisis of Black
    Youth Suicide in America, December 17, 2019, https://youthtoday.org/
    2019/12/ring-the-alarm-the-crisis-of-black-youth-suicide-in-america/.

    The pandemic has struck at the well-being and stability of families. As
    reported in Pediatrics in October of 2021, over 140,000 children in the
    United States lost a primary or secondary caregiver, with youth of
    color disproportionately impacted. The emotional impact of losing a
    parent or caregiver, including trauma and grief, is often compounded
    with loss of material stability and economic hardship, and an increased
    risk of poor educational and long-term mental health consequences. We
    are already witnessing this in our pediatric practices, schools and
    communities where the number of young people with depression, anxiety,
    trauma, loneliness and suicidality are all increasing. We must identify
    strategies to meet these challenges through innovation and action,
    using state, local and national approaches to improve the access to and
    quality of care across the continuum of mental health promotion,
    prevention and treatment. We need to ensure these strategies are
    focused on children and youth and their unique needs, considering their
    ---------------------------------------------------------------------------
    social and community context and resources.

    We want to thank committee members for your support of the Health
    Resources and Services Administration's (HRSA) Pediatric Mental Health
    Care Access (PMHCA) Program (42 U.S.C. Sec. 254c-19). As of today, 45
    states, Washington, DC, tribal organizations and territories have
    received (https://mchb.hrsa.gov/training/projects.
    asp?program=34) a grant from HRSA to create or expand their programs.
    Integrating mental health with primary care has been shown to
    substantially expand access to subspecialist physicians, such as child
    and adolescent psychiatrists, while boosting a pediatric provider's
    knowledge of mental health care, improving health and functional
    outcomes, increasing satisfaction with care and achieving cost savings.
    Expanding the capacity of pediatric primary care providers to deliver
    behavioral health through mental and behavioral health consultation
    programs is one way to maximize a limited subspecialty workforce and to
    help ensure more children with emerging or diagnosed mental health
    disorders receive early interventions and continuous treatment.

    A recent RAND study found that 12.3% of children in states with
    programs such as the ones funded under this HRSA program had received
    behavioral health services, while only 9.5% of children in states
    without such programs received these services.\10\ The study's authors
    concluded that federal investments to substantially expand child
    psychiatric telephone consultation programs could significantly
    increase the number of children receiving mental health services. This
    model is one, among others, that Medicaid can and should be paying for.
    ---------------------------------------------------------------------------
        \10\ RAND Corporation, Child Psychiatry Telephone Consultation
    Programs Help Increase Mental Health Services for Children, July 15,
    2019, https://www.rand.org/news/press/2019/07/15.html.

    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 that will result in improved access to mental health
    services for children, from promotion and prevention through needed
    ---------------------------------------------------------------------------
    treatments:

          Increase investments to support the recruitment, training,
    mentorship, retention and professional development of a diverse
    clinical and non-clinical pediatric workforce, including funding for
    minority fellowship programs for mental health physician specialists.
    Currently, there are dire shortages of minority mental health providers
    that have only gotten worse due to the pandemic. More dedicated support
    for a larger and more diverse pediatric workforce is critical to
    addressing children's mental health needs now and into 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.
          Address low Medicaid payment rates for pediatric mental health
    services, ways to better support coordination and integration of care
    and access to services in schools. 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. At the same time, there is a benefit to better
    coordination and integration of care for children with mental health
    needs that is not supported consistently under Medicaid. This
    coordination results in demonstratable improvements in the health and
    well-being of children and their families. Children need to access
    services where they are, including in schools. Better assistance and
    technical guidance for schools to be reimbursed for health services
    delivered to Medicaid eligible and enrolled students will help address
    issues more effectively. Close to 40 million children receive their
    health insurance coverage through Medicaid and would be positively
    affected by advancement of these policies.
          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. We can do a better job of
    implementing this benefit more consistently for children to ensure they
    receive care as early as possible and at every point along the
    continuum if needed.
          Dedicate support for the pediatric mental health system and
    infrastructure, which is currently woefully underfunded. Support should
    focus on building a strong community-based system to address children's
    mental health needs across a wide array of settings, such as
    pediatricians' offices, early childhood educational programs, schools,
    outpatient individual or family therapy, intensive outpatient services,
    inpatient care when warranted and through telehealth.
          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 coverage for audio-only services and
    lifting originating site restrictions and geographic limitations and
    encourage state Medicaid programs to continue telehealth coverage and
    payment.
          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.

    Our organizations and our pediatricians, child and adolescent
    psychiatrists and children's hospital members are ready and 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.

                                     ______

                   Center for Adoption Support and Education

                         3919 National Drive, Suite 200

                             Burtonsville, MD 20866

                        301-476-8525 (general inquiries)

                     866-217-8534 (schedule an appointment)

                            www.adoptionsupport.org

                         caseadopt@adoptionsupport.org

    February 8, 2022

    U.S. Senate
    Committee on Finance

    I appreciate this opportunity to submit written testimony for the
    hearing on Protecting Youth Mental Health: Part I--An Advisory and Call
    to Action held on February 8, 2022. My name is Debbie Riley, LCMFT, and
    I am the Chief Executive Officer of the Center for Adoption Support and
    Education (C.A.S.E.). Since 1998, the Center for Adoption Support and
    Education (C.A.S.E) has created awareness of the deep need for adoption
    competency in mental health services and has grown to become the
    national leader providing mental health and child welfare professionals
    with training and coaching to become adoption competent. Our programs
    help professionals gain the skills, insight, and experience necessary
    to serve the needs of the adoption and foster care communities. We have
    been at the forefront of efforts to identify foster and adopted
    children and families as a population most at risk for a mental health
    crisis and have sought to improve the competency of the workforce
    through specialized training. Our efforts stem from over a decade
    experience with specialized adoption-competent mental health services
    to over 7000 clinical clients and on average over 6800 sessions
    annually.

    With this experience, we are very aware of the children's mental health
    crisis that is occurring in our country. In December, the U.S. Surgeon
    General released an advisory on Protecting youth Mental Health that
    outlined steps to support the mental health needs of youth involved in
    the child welfare system. This followed pediatricians, child and
    adolescent psychiatrists and children's hospitals declaring a National
    State of Emergency in Children's Mental Health. COVID-19 brought a
    devastating impact on children that came into this pandemic with a
    history of trauma, loss and grief exacerbated by fear of the pandemic
    itself, more loss and the reality of isolation from peers, teachers,
    extended family and other significant supports in their lives. Our
    caseloads, like others, have exploded with youth and families in
    crisis. The Surgeon General's report and the emergency declaration must
    be a call to action for Congress to advance real, tangible solutions
    for populations most at risk--children in foster, adoptive and
    guardianship families.

    First, please know we strongly support efforts to provide additional
    resources to ensure a seamless transition to the Families First
    Prevention Services Act so that all children and families can maximize
    the law's full potential. However, being on the front lines of this
    work to create forever families, it is vital to recognize that no
    program can truly be delivered effectively without a competent
    workforce that understands the unique needs of foster and adopted
    children and families. At the time of passage of the Families First
    Act, we were assured that building an adoption-competent workforce
    would be a priority to ensure that professionals serving children and
    families in need were appropriately trained. Adoptive parents
    consistently report that their greatest post-adoption support need is
    mental health services provided by someone who understands adoption.\1\
    Some families reported seeking therapy from as many as ten different
    therapists before finding one who is adoption-competent, if they find
    such a therapist at all.\2\ Therefore, it is not surprising that
    studies indicate that most mental health professionals lack the
    training to meet the diverse, complex clinical needs of adoptive
    families.\3\ Without access to adoption-competent mental health
    services, the risk of failed adoptions increases exponentially.
    Children may enter state child welfare agencies through ``forced
    relinquishments,'' or parents may place their children in residential
    treatment facilities and/or wilderness programs--choices they make when
    they lack access to the appropriate resources.
    ---------------------------------------------------------------------------
        \1\ Atkinson and Gonet, 2007; Smith, 2014, Brodzinsky, 2013.
        \2\ Casey Center for Effective Child Welfare Practice, 2003.
        \3\ Sass and Henderson 2002, McDaniel and Jennings, 1997.

    We are frustrated that Families First has not prioritized improving the
    competency of the child welfare workforce. For programs to be covered
    under the Act, the Title IV-E Prevention Services Clearinghouse
    established by the Administration for Children and Families (ACF) must
    rate programs and services as promising, supported, and well-supported
    practices, including mental health. After a decades-long push to commit
    to the mental health needs of children and families adopted and in
    foster care, Families First was a leap forward to ensure the delivery
    of much-needed mental health services when children are most at risk.
    Yet, despite going through the steps required for coverage, the
    Training for Adoption Competency (TAC) has not had its application
    ---------------------------------------------------------------------------
    reviewed. It was submitted October 30, 2019--over 2 years ago.

    Prior to developing TAC, C.A.S.E. convened nationally recognized
    experts--including adoption practitioners, researchers, advocates,
    policy makers, and adoptive parents--to identify the core knowledge,
    skills, and values competencies that mental health practitioners need
    to serve members of the adoption kinship network. This National
    Advisory Board helped develop a definition of an adoption-competent
    mental health professional using an expert-consensus process (see
    below).

         Definition of an Adoption-Competent Mental Health Professional
    An adoption-competent mental health professional has:
         The requisite professional education and professional licensure.
         A family-based, strengths-based, and evidence-based approach to
         working with adoptive families and birth families.
         A developmental and systemic approach to understanding and working
         with adoptive and birth families.
         Knowledge, clinical skills and experience in treating individuals
         with a history of abuse, neglect and/or trauma; and
         Knowledge, skills and experience in working with adoptive families
         and birth families.

    An adoption-competent mental health professional understands the nature
     of adoption as a form of family formation and the different types of
     adoption; the clinical issues that are associated with separation and
     loss and attachment; the common developmental challenges in the
     experience of adoption; and the characteristics and skills that make
     adoptive families successful.

    An adoption-competent mental health professional is culturally competent
     with respect to the racial and cultural heritage of children and
     families.

    An adoption-competent mental health professional is skilled in using a
     range of therapies to effectively engage birth, kinship, and adoptive
     families toward the mutual goal of helping individuals to heal,
     empowering parents to assume parental entitlement and authority, and
     assisting adoptive families to strengthen or develop and practice
     parenting skills that support healthy family relationships.

    An adoption-competent mental health professional is skilled in
     advocating with other service systems on behalf of birth and adoptive
     families.

    C.A.S.E. received accreditation of its TAC curriculum from the
    Institute for Credentialing Excellence (ICE) for a five-year period
    through November 20, 2025--making TAC part of an elite group of
    certificate programs dedicated to public protection and excellence in
    practice. TAC is now an assessment-based certificate accreditation
    program and is the only accredited adoption competency training program
    in the country. It is now on the California Evidenced-Based
    Clearinghouse for Child Welfare (CEBC), a nationally recognized body
    that applies rigorous standards of review to identify effective
    programs. TAC was rated in the Topic Area of Child Welfare Workforce
    Development and Support Programs with a scientific rating of (3)
    Promising Research Evidence and with a Child Welfare Relevance rating
    of High. Of 17 programs in the Child Welfare Workforce Development and
    Support topic area, TAC is one of only two programs rated (3) Promising
    Research Evidence and no programs in the Topic Area are rated higher.

    TAC is an instructor led, post-master's curriculum that includes
    clinical case consultation, making it the premiere national program to
    train mental health practitioners in adoption-competent skills.
    Research shows that children with traumatic experiences of abuse,
    neglect, loss, and abandonment are at greater risk of presenting
    adjustment problems within their adoptive families. Access to adoption-
    competent mental health services is a critical factor in the well-being
    of these children and their adoptive families. C.A.S.E. created TAC to
    strengthen adoption competency in mental health communities across the
    United States and have grown their TAC network to over 17 national
    training partners, including universities and child welfare agencies.
    Over 2,200 clinicians across the country have completed the 72-hour
    curriculum to date. An outcomes evaluation conducted in 2020 with
    funding from the Annie E. Casey Foundation with 159 families served by
    TAC-trained clinicians compared to comparably experienced but not TAC-
    trained clinicians, also showed that TAC produces more effective
    clinical practice for adoptive families. The families served by TAC-
    trained therapists experienced greater satisfaction with treatment,
    stronger therapeutic alliance, and greater family engagement over a
    higher number of sessions.

    Congress should direct the Title IV-E Prevention Services Clearinghouse
    to prioritize mental health: The Clearinghouse established by the
    Administration for Children and Families (ACF) must rate programs and
    services as promising, supported, and well-supported practices.
    Training for Adoption Competency should be a priority to ensure that
    the workforce delivering these programs are competent and have the
    knowledge needed to appropriately serve foster and adoptive families.

    Second, The National Adoption Competency Mental Health Training
    Initiative should be the Standard of Care for the workforce serving
    foster, adoptive, and kinship families. The National Adoption
    Competency Mental Health Training Initiative (NTI), a cooperative
    agreement between the Children's Bureau, Office of Administration for
    Children and Families and C.A.S.E., developed two state-of-the-art,
    standardized, web-based trainings to build the capacity of child
    welfare and mental health professionals in all states, tribes, and
    territories to effectively support children, youth, and their foster,
    adoptive, and guardianship families. The trainings were piloted in
    eight states and with one tribe, with final versions of the trainings
    now available for free nationally. During the pilot evaluation over
    6,000 child welfare workers enrolled in the 20-hour training with an
    astounding 72 percent completion rate and 2,900 mental health
    professionals with a 68 percent completion rate. Outcomes from the
    child welfare pilot evaluation indicate high ratings of participant
    satisfaction with the materials and trainings. 85 to 90 percent of
    supervisors agreed that this training is applicable to their work.
    Child Welfare workers improved 28 percent on average from pre-test to
    post-test; supervisors improved 23 percent on average from pre- to
    post-test. Completion of NTI training indicated a high level of change
    in the workforce understanding of separation and loss which is a
    critical foundational piece of learning in the child welfare system.
    Pretest scores on the loss and grief module for child welfare staff
    were the lowest and showed the highest gain from pre to post-test. On
    the mental health side, the modules on attachment and understanding the
    impact of race and diversity had the lowest pre-test scores and the
    highest gains from pre to post-test. Imagine the problems that arise
    from child welfare workers not able to support children in their
    healing from loss and then referring them to therapists that do not
    know how to promote attachment or understand the implications of
    transracial/transcultural adoption. This exemplifies the clinical
    implications when we are solely reliant on providers being trained in a
    specific EBP without having the ``core'' foundational knowledge that is
    necessary in addressing the mental health needs of the children they
    are serving. Even for the trauma module where such a focus has been
    nationally, as well as the utilization of EBP in trauma treatment, we
    saw a gain of 15-20 percent between pre- and post-test scores.

    Since its pilot, more than 17,000 professionals have enrolled in NTI
    Trainings and C.A.S.E. has a commitment from 26 state child welfare or
    mental health service systems across the country to integrate NTI into
    their training plans. The goal is for NTI Trainings to be the
    ``standard'' trainings throughout child welfare systems nationally.
    NTI's aligned trainings assure a skilled, competent workforce as
    required by the FFPSA and provide the skills, strategies, and tools
    professionals need to:

          Support children to heal from trauma and loss.
          Provide parents with skills to parent more effectively.
          Collaborate effectively with child welfare and mental health
    professionals.
          Improve outcomes for permanency, child well-being, and family
    well-being and stability.

    The Senate version of the legislation reauthorizing CAPTA includes a
    new provision within Adoption Opportunities that supports the mission
    of the National Adoption Competency Mental Health Training Initiative.
    It states ``adoption competency training that supports the mental
    health needs of adoptive families to promote permanency, including the
    evaluation and updating of adoption competency training curricula for
    child welfare and mental health professionals.'' We strongly support
    this new authority to ensure the curriculums developed for child
    welfare caseworkers and mental health professionals are standardized
    across states and represent best practices and up-to-date knowledge
    essential for professionals serving foster youth to have the core
    competencies needed to achieve permanency.

    Congress should pass legislation as part of CAPTA reauthorization that
    explicitly authorizes the Adoption Opportunities program to focus
    efforts on adoption competency training that supports the mental health
    needs of adoptive families to promote permanency. This includes the
    evaluation and updating of adoption competency training curricula for
    child welfare and mental health professionals. We support the language
    included in the Managers Amendment to S. 1927 CAPTA Reauthorization Act
    of 2021.

    Additionally, adoptive families often report that outpatient services--
    and in some cases, inpatient services--are not appropriate for children
    with foster care and adoption histories. An untrained therapist, for
    example, may use behavior modification techniques that do not address
    the underlying trauma and attachment challenges that a child is
    experiencing and can exacerbate a child's mental health problems. We
    see this situation as a direct service provider routinely. Adoptive and
    foster families often come to us after seeing multiple therapists who
    are not adoption competent. This makes our job more difficult as we
    address both the core issues of the underlying trauma and the impact of
    behavior modification, as well as other techniques utilized by earlier
    therapists that further exacerbated to the underlying problems.

    Adoptive parents consistently report that their greatest post-adoption
    support need is mental health services provided by someone who knows
    adoption. The lack of post-adoption mental health services in general,
    as well as the lack of access to adoption-competent mental health
    services, are significant barriers to recruiting adoptive families for
    children from the foster care system. In a national survey of 485
    individuals conducted by C.A.S.E., only 25 percent of adoptive families
    reported that the mental health professional they saw was adoption
    competent. Most respondents did not know whether assistance in
    accessing or paying for mental health services was available in their
    state, and only about 25 percent could confirm the availability of such
    assistance. Further, only 19 percent reported insurance subsidies
    adequate to address their children's mental health needs. Many
    respondents reported that the number of Medicaid mental health
    providers is quite limited and the majority of those who are available
    are not adoption competent. A great majority (81 percent) reported that
    if they had a choice, they would choose a therapist who has earned a
    certificate as an adoption-competent therapist.

    It is an unfortunate reality that children and youth in foster care--
    when they are able to receive mental health services--typically receive
    it from the least qualified professionals due to the low reimbursement
    rates typical of Medicaid programs. Mental health professionals often
    begin their careers in publicly funded community mental health centers
    that accept Medicaid--where most children in foster care and children
    who are adopted from foster care are seen. There are significant costs
    associated with the limited access to quality adoption-competent mental
    health care--both financially and emotionally. Studies suggest that
    lack of appropriate mental health services contribute to higher rates
    of adoption disruption and dissolution for families adopting from
    foster care, as well as interactions with the juvenile justice
    system.\4\
    ---------------------------------------------------------------------------
        \4\ See http://cascw.umn.edu/wp-content/uploads/2014/04/
    AdoptionDissolutionReport.pdf.

    We urge consideration of a pilot or demonstration project in a
    specified number of states/counties to enroll a target number of
    adoption-competent clinicians (defined as successful graduates of
    nationally recognized adoption-competent post graduate training
    programs that include a clinical case consultation component) as EPSDT
    clinical providers. Using random assignment of children, CMMI could
    evaluate the mental health outcomes for children in foster care with
    adoption goals who are served by these adoption-competent clinicians
    through EPSDT and those who are not. In certain states, C.A.S.E. has
    built a workforce of adoption-competent clinicians that could form the
    ---------------------------------------------------------------------------
    basis for this type of demonstration.

    We also urge the use of identified valid and reliable clinical
    screening and testing tools for designated conditions present in
    children in foster care, including those with adoption goals (such as
    attachment disorders, PTSD, developmental trauma) in conjunction with
    adoption-competent clinical interventions by adoption-competent
    clinicians. The primary focus would be on (1) children in foster care
    being prepared for adoption; and (2) children adopted from foster care
    receiving adoption assistance and Medicaid coverage.

    C.A.S.E. supports work to promote trauma-informed approaches to
    behavioral health. We recognize that for foster and adopted children
    and families, there are evidence-based approaches specific to this
    population that are also trauma-informed, including TAC. As
    policymakers seek to increase the number of trauma-specific services
    and trainings, we strongly urge the inclusion of trainings that will
    build the adoption competency of its programs and workforce.

    The impact of limited quality mental health services for children and
    youth in foster care--whether their permanency plan is reunification
    with parents, guardianships with relatives, or adoption--extends
    broadly. Studies confirm that the lack of quality mental health
    services impacts the outcomes for young people that are dually involved
    in the foster care and juvenile justice systems. The Brookings
    Institute Center on Children and Families reported:

            Although children in long-term foster care represent only a
            small fraction of the total child population of the United
            States, they represent a much bigger portion of the young
            people who go on to create serious disciplinary problems in
            schools, drop out of high school, become unemployed and
            homeless, bear children as unmarried teenagers, abuse drugs and
            alcohol, and commit crimes. A recent study of a Midwest sample
            of young adults aged twenty-three or twenty- four who had aged
            out of foster care found that they had extremely high rates of
            arrest and incarceration. Eighty-one percent of the long-term
            foster care males had been arrested at some point, and 59
            percent had been convicted of at least one crime. This compares
            with 17 percent of all young men in the U.S. who had been
            arrested, and 10 percent who had been convicted of a crime.
            Likewise, 57 percent of the long-term foster care females had
            been arrested and 28 percent had been convicted of a crime. The
            comparative figures for all female young adults in the U.S. are
            4 percent and 2 percent, respectively.

            Former foster youth are over-represented among inmates of state
            and federal prisons. In 2004 there were almost 190,000 inmates
            of state and federal prisons in the U.S. who had a history of
            foster care during their childhood or adolescence. These foster
            care alumni represented nearly 15 percent of the inmates of
            state prisons and almost 8 percent of the inmates of federal
            prisons. The cost of incarcerating former foster youth was
            approximately $5.1 billion per year.\5\
    ---------------------------------------------------------------------------
        \5\ Zill, N. (2011). Adoption from foster care: Aiding children
    while saving money. Retrieved September 10, 2013, from http://
    www.brookings.edu//media/research/files/reports/2011/5/
    adoption%20foster%20care%20zill/05_adoption_foster_care_zill.pdf.

    A study in Los Angeles County found that a quarter of youth formerly in
    foster care and two-thirds of dually involved youth have a jail stay in
    early adulthood. The average cumulative cost of jail stays over 4 years
    ranged from $18,430 for a youth formerly in care to $33,946 for a
    dually involved youth. The study also found that dually involved youth
    were more likely than youth in care with no juvenile justice
    involvement to experience serious challenges, including mental health
    problems, more than double the rates of those who were in foster care
    only. Washington State found that about one-third of the youth in the
    state's juvenile justice system either were or had been in the foster
    ---------------------------------------------------------------------------
    care system.

    Specific to foster care, the Government Accountability Office (GAO)
    issued a report in December 2012 on Children's Mental Health: Concerns
    Remain About Appropriate Services for Children in Medicaid and Foster
    Care. They reported that an annual average of 6.2 percent of
    noninstitutionalized children in Medicaid nationwide and 4.8 percent of
    privately insured children took one or more psychotropic medications.
    They also reported that 18 percent of foster children were taking
    psychotropic medications at the time they were surveyed, and 30 percent
    of foster children who may have needed mental health services did not
    receive them in the previous 12 months. The GAO's letter to Members of
    Congress stated, ``Children in foster care, most of whom are eligible
    for Medicaid, are an especially vulnerable population because may
    suffer from generally required to cover services to screen children for
    mental health problems and to provide treatment for any identified
    conditions, we previously reported that it can be difficult for
    physicians to find mental health specialists to whom they can refer
    children in Medicaid.''

    We believe that this report underscores an inherent and fundamental
    challenge in our Medicaid system around access to adoption-competent
    mental health services.

    We urge Congress to consider developing a pilot or demonstration
    project in a certain number of states/counties in which selected
    children in foster care with an adoption goal (experimental group) are
    assigned a treatment team consisting of a psychiatrist and an adoption-
    competent clinician who coordinate clinical care for the child. CMMI
    would then assess the impact on the usage levels of psychotropic
    medications as compared to children in foster care who do not have this
    treatment team (comparison group).

    As you know, children and youth in foster care and adopted from foster
    care face several challenges with the Medicaid system:

          Many foster, adoptive, and kinship families do not know what
    resources exist to help them identify and access quality mental health
    services in their states.
          When they access affordable mental health services, foster,
    adoptive, and kinship families have no assurance that these services
    are adoption competent. They generally are given little or no choice in
    providers.
          There is currently no process for identifying clinicians with
    special adoption-competent expertise, such as through a national
    accreditation/certification or central registry of clinicians who have
    obtained adoption competency training.
          Medicaid clinical services are an ``optional'' not mandatory
    Medicaid service, meaning that States can choose to cover (or not) the
    services of psychologists, clinical social workers, outpatient mental
    health services, and substance abuse clinical services. As states are
    facing budget shortfalls, there is concern that states may opt to
    eliminate any optional services that they are currently covering.
          EPSDT is unevenly implemented across states, resulting in wide
    variances in terms of coverage of mental health services for children,
    particularly with respect to the delivery of treatment services
    following diagnosis and assessment. As one example, in California,
    access to EPSDT mental health services is inequitable for eligible
    youth across the state. Despite the alarming prevalence of treatable
    mental health problems among youth in foster care, only 60 percent of
    California children who enter foster care receive the medically
    necessary mental health services to which they are entitled. Treatment
    rates range from 6 percent in some counties to 30 percent in others,
    and from 7 percent to 19 percent among the state's largest counties.\6\
    ---------------------------------------------------------------------------
        \6\ Alliance for Children's Rights. (2012). Safeguard children's
    rights: Require adequate funding and accountability for EPSDT
    realignment. Retrieved September 10, 2013, from http://
    www.youthlaw.org/fileadmin/ncyl/youthlaw/publications/yln/2012/02/
    EPSDT-Reallign-RevV
    21-FINAL_1_.pdf.
    ---------------------------------------------------------------------------
          The least experienced providers are providing services to the
    most complicated children with diverse clinical needs due to the low
    reimbursement rates.

    One study by the National Institute of Mental Health found that nearly
    half (47.9 percent) of youth in foster care were determined to have
    clinically significant emotional or behavioral problems. Researchers at
    Casey Family Programs estimate that between one-half and three-fourths
    of children entering foster care exhibit behavioral or social
    competency problems that warrant mental health services.\7\ These
    children often find permanent families through adoption (ranging
    between 51,000 and 57,000 children each year). According to some
    reports, the percentage of adopted children in residential treatment
    centers is reported to be between 30 and 40 percent and is even higher
    in centers specializing in attachment disorder treatment and
    developmental trauma treatment. Adoptive families are 2 to 5 times more
    likely to utilize outpatient mental health services, and 4 to 7 times
    more likely to seek care for their children in residential treatment
    centers.\8\
    ---------------------------------------------------------------------------
        \7\ Landsverk, J.A., Burns, B.J., Stambaugh, L.F. and Rolls Reutz,
    J.A. (2006). ``Mental health care for children and adolescents in
    foster care: Review of research literature.'' Casey Family Programs. 9-
    30.
        \8\ Smith, S.L. (2014, March). Keeping the promise: The case for
    adoption support and preservation. Donaldson Adoption Institute.
    Retrieved February 24, 2016, from http://adoptioninstitute.
    org/publications/keeping-the-promise-the-case-for-adoption-support-and-
    preservation/.

    In a most recent report, clinical program directors from 59 residential
    treatment facilities responded to an online survey addressing the
    representation of adopted youth currently being served by their
    organization, the extent to which adoption issues are incorporated into
    clinical intake and treatment processes, and the training needs of
    clinical staff related to adoption. Results indicated that adopted
    youth are disproportionately represented in these programs. Although
    constituting slightly more than 2 percent of the U.S. child population,
    25-30 percent of youth currently enrolled in these programs were
    adopted. The report concluded that to meet the needs of adopted youth
    in care, clinical and administrative staff of residential treatment
    programs need to become adoption clinically competent.\9\
    ---------------------------------------------------------------------------
        \9\ See http://dx.doi.org/10.1080/0886571X.2016.1175993.

    We recommend that higher reimbursement rates through Medicaid and
    private insurance be provided for mental health providers who complete
    the 72-hour accreditation program through Training for Adoption
    Competency. This would create an incentive for clinicians who work with
    the child welfare/adoption community to be adoption-competent and would
    create an incentive for highly trained, adoption-
    ---------------------------------------------------------------------------
    competent clinicians to accept Medicaid rates.

    In general, C.A.S.E. recommends a stronger research focus on the impact
    of integrated care models on achieving positive mental health outcomes
    for children in foster care and children and youth adopted from the
    foster care system. Studies indicate that continuous mental health
    treatment is beneficial for children with histories of maltreatment and
    foster care.\10\ Medicaid managed care organizations (MCO's) with
    adequate networks of adoption-competent mental health professionals,
    could demonstrate more positive outcomes for foster youth. Therefore,
    we suggest reforms that will enhance the positive outcomes for children
    and youth in foster care and those adopted from foster care, the
    majority of whom are Medicaid eligible.
    ---------------------------------------------------------------------------
        \10\ Child Welfare Information Gateway. (2012). Mental health.
    Retrieved September 10, 2013, from https://www.childwelfare.gov/
    systemwide/mentalhealth/.

    I look forward to working with Congress on improving access to, and
    quality of, the mental health services provided to children in foster
    care and those in adoptive families. Innovative strategies to improve
    the lives of our most vulnerable children should not be delayed.
    C.A.S.E. has already begun the process of developing the adoption-
    competent workforce through its existing TAC program and the continuing
    cooperative agreement with ACF on the National Adoption Competency
    Mental Health Training Initiative as well as direct services in
    Maryland, Virginia, and Washington, D.C. Now is the time to take action
    to ensure the continued building of an adoption-competent workforce and
    formalized network of those providers who can be connected to foster
    and adoptive families. The good news is that we have existing
    innovative training programs ready to bolster the competency of the
    child welfare and mental health workforce nationally. Together we can
    connect this underrepresented population to providers trained to meet
    ---------------------------------------------------------------------------
    their needs.

    I appreciate the opportunity to provide this testimony.

    Sincerely,

    Debbie Riley LCMFT, CEO
    Center for Adoption Support and Education
                  Child and Adolescent Mental Health Coalition

    February 8, 2022

    U.S. Senate
    Committee on Finance

    On behalf of our organizations, which are members of the Child and
    Adolescent Mental Health Coalition,\1\ we commend the Senate Finance
    Committee for holding a hearing on youth mental health. We seek to
    underscore the importance of addressing mental health in children
    across the continuum of mental health care, from promotion and
    prevention to early identification, intervention and treatment, to
    children and youth in crisis. This statement follows comments our
    coalition previously shared with the committee.\2\
    ---------------------------------------------------------------------------
        \1\ CAMH is a coalition of organizations dedicated to promoting the
    mental health and well-being of infants, children, adolescents, and
    young adults. Our organizations reflect a diversity of viewpoints and
    expertise, ranging from clinical providers to school-based services to
    suicide prevention organizations and others. As a coalition, we seek to
    advance a robust mental health safety net, inclusive of programs,
    supportive payment models, and infrastructure, that provide the full
    continuum of mental health care, in a manner that facilitates easy and
    prompt access to services. Our coalition has prepared a set of core
    principles (https://downloads.aap.org/DOFA/
    CAMH%20Principles%202021%20Final%2005-04-21.pdf). Our full coalition
    consists of over 30 organizations; entities specifically endorsing this
    statement are specified at the conclusion of this statement.
        \2\ https://downloads.aap.org/DOFA/
    CAMH%20Comments%20on%20Senate%20Finance%20RF
    I%20Final.pdf.

    The pandemic has exacerbated the already existing child and adolescent
    mental health crisis. The inequities that result from structural racism
    have contributed to the disproportionate impacts on children from
    communities of color. Rates of childhood mental health concerns and
    suicide rose steadily between 2010 and 2020, and by 2018 suicide was
    the second leading cause of death for youth ages 10-24. The pandemic
    has intensified this crisis: across the country we have witnessed
    dramatic increases in Emergency Department visits for all mental health
    ---------------------------------------------------------------------------
    emergencies, including suspected suicide attempts.

    The challenges facing children's mental, emotional, and behavioral
    health are so dire that the American Academy of Pediatrics, the
    American Academy of Child and Adolescent Psychiatry, and the Children's
    Hospital Association declared a national emergency \3\ in child and
    adolescent mental health last fall. We thank and appreciate the Surgeon
    General for raising the youth mental health crisis as a priority public
    health challenge. As his advisory notes, this is not a problem we will
    fix overnight, but starting now, we can make a difference working
    together. We hope the advisory will encourage further, bold action by
    the administration such as a federal emergency declaration in
    children's mental health.
    ---------------------------------------------------------------------------
        \3\ 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/.

    The pandemic has struck at the safety and stability of families. More
    than 140,000 children in the United States lost a primary or secondary
    caregiver, with youth of color disproportionately impacted. The
    emotional impact of losing a caregiver, including trauma and grief, is
    often compounded with loss of material stability and economic hardship,
    ---------------------------------------------------------------------------
    and with poor educational and long-term mental health consequences.

    The experiences and needs of children and adolescents are different
    from those of adults, and the system must be designed to address their
    needs across the continuum of care, improving access to and quality of
    care from mental health promotion and prevention to early
    identification, intervention and treatment to children and youth in
    crisis. We offer the following policy solutions that, if enacted, will
    help to increase access to quality pediatric mental health care:

          Workforce: To address the dire shortage of practitioners
    specializing in mental health care for infants, children, adolescents
    and young adults, the Committee should increase investments to support
    and strengthen the development of a diverse clinical and non-clinical
    pediatric workforce. To reduce the barrier that low payment rates
    presents for workforce development, the Committee should find ways to
    increase payment rates to primary care and behavioral health providers
    for mental and behavioral health care. Dedicated support for a larger
    and more diverse pediatric workforce is critical to addressing
    children's mental health needs now and into 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.

          Integration with Primary Care: Research supports the integration
    of mental health and primary care for infants, children, adolescents
    and youth. The Committee should work to develop sustainable funding
    models that allow for the integration of mental health practitioners
    and services into pediatric primary care practice, rather than these
    initiatives relying on patchwork funding. These models should allow
    providers to bill for time spent coordinating care.

          Care Coordination: Family navigators and family support
    providers are key partners in helping families navigate the difficult
    landscape of behavioral health care. The Committee should provide
    funding for care coordinators or navigators who help families navigate
    the mental health system.

          Early Access to Services: Children who may lack a diagnosis
    still have important mental health needs that require intervention, but
    pediatric providers and behavioral health providers often need to
    specify an ICD-10 diagnostic code to bill and be paid for their time.
    The Committee should find ways to allow providers to bill non-specific
    codes when a child does not have a diagnosable condition but has mental
    health needs that require care.

          EPSDT Access: As state Medicaid programs, as well as Medicaid
    Managed Care Plans, implement Early and Periodic Screening, Diagnostic
    and Treatment Benefit (EPSDT) and medical necessity determinations,
    differently, Congress can take action to direct CMS to review how EPSDT
    is implemented in states to support access to prevention and early
    intervention services, as well as developmentally appropriate mental
    health and substance use disorder services across a continuum of care.
    In addition, to address the real and perceived barriers to payment for
    mental health care for children by Medicaid, CMS should provide
    guidance to states on Medicaid payment for evidence-based mental health
    services for children including those that promote integrated care.

          Crisis Response: There has been an alarming increase in the
    number of children and adolescents in behavioral health crisis, with
    emergency departments seeing increases in suicidal ideation and self-
    harm. A 24/7 crisis response system must be accessible to meet the
    needs of children and families, schools and providers. The system must
    be equitable, accessible, trauma-informed and culturally appropriate,
    with staff that are trained in child development and family-centered
    approaches. The system should be able to connect families with the
    appropriate next level of care to meet their needs.

          School-based Services: Co-location of mental health services in
    schools allows children and adolescents to access the care they need
    with less disruption. The Committee should work to identify and reduce
    barriers to payment for services in schools and the ability of schools
    to recruit and retain mental health providers on-site. Better
    assistance and technical guidance for schools to be reimbursed for
    health services delivered to Medicaid eligible and enrolled students
    would expand access to services in that setting.

    American Academy of Pediatrics

    American Association of Child and Adolescent Psychiatry

    American Psychological Association

    Association of Children's Residential and Community Services (ACRC)

    Association of Maternal and Child Health Programs

    Bazelon Center for Mental Health Law

    Children's Hospital Association

    Eating Disorders Coalition for Research, Policy & Action

    National Association for Children's Behavioral Health

    National Association of Pediatric Nurse Practitioners

    Nemours Children's Health

    REDC Consortium

    School-Based Health Alliance

    Society for Adolescent Health and Medicine

    The National Alliance to Advance Adolescent Health

    Youth Villages

                                     ______

                          Children and Family Futures

                      25371 Commercentre Drive, Suite 250

                             Lake Forest, CA 92630

                              Phone: 714-505-3525

                            Toll-Free: 866-493-2758

                       Website: https://www.cffutures.org

                           Email: info@cffutures.org

    Children and Family Futures (CFF) is pleased to submit a written
    statement for the record in response to the Senate Finance Committee's
    hearing held on February 8, 2022, entitled ``Protecting Youth Mental
    Health: Part I--An Advisory and Call to Action.'' Our organization has
    been working at the intersection of child welfare and substance use
    treatment for over 25 years, in partnership with state and county
    agencies, tribes, the courts, private providers, and decision makers.
    We appreciate the Committee's longstanding bipartisan commitment to
    addressing the needs of families in the child welfare system who are
    affected by substance use disorders (SUDs) and look forward to working
    with you to identify approaches that meet the urgency and severity of
    the current mental health, overdose, and SUD crisis in the United
    States.

    There are approximately 8.7 million children (12.3 percent) under the
    age of 18 who are living with a parent with a substance use
    disorder.\1\ This equates to about three children in every classroom.
    Children growing up with parents with SUDs are at higher risk for poor
    developmental outcomes \2\, \3\, \4\,
    \5\, \6\ experiencing trauma \7\, \8\ and
    developing their own substance use problem later in
    life.\9\, \10\, \11\ Troubling data have recently
    been published on the number of youths who are affected by parental
    SUDs who are at risk for suicide. A 2019 published study found that
    adolescents of parents who misused prescription opioids were at twice
    the risk of a suicide attempt, compared to adolescents of parents who
    did not misuse prescription opioids.\12\

    There is also cause for great concern regarding adolescents who
    themselves use opioids or have an opioid use disorder, as they are also
    at high-risk for suicide. In the 2019 U.S. Youth Risk Behavior Survey,
    33 percent of adolescents who reported use of a prescription opioid had
    attempted suicide, compared to 6 percent of adolescents attempting
    suicide who reported no use of a prescription opioid.\13\ This has far-
    reaching effects on our health care, social services, and educational
    systems to support these young people and ensure their health, safety,
    and education. These effects are even more astounding when long-term
    impacts of parental SUDs (e.g., increased risk for poor developmental
    outcomes and the child/youth developing their own substance use
    disorder) are considered.

    Substance use is the number one reason associated with children who are
    separated from their parents and placed into foster care, and
    unaddressed mental health challenges are often the root cause of
    parental substance use. When parents cannot access timely mental health
    and SUD treatment services, it puts the entire family at risk. Rather
    than relying on our already-overburdened child welfare system to step
    in and remove more children from their families, it is our
    responsibility as a nation to expand mental health and SUD treatment
    options for parents, children and families--which will change the
    trajectory for children and youth and, in turn, future generations of
    Americans.

     Recommendations for Changing the Trajectory for Children and Youth Who
                        Are Affected by Substance Use Disorders

    As the Committee considers policy changes to address the current mental
    health crisis among children and adolescents, we urge you to take a
    family-centered, intergenerational approach to the delivery of services
    and supports to families affected by SUDs. Family-centered approaches
    recognize that parental substance use is a chronic disease and affects
    each member of the family, and that the most effective services are
    those that recognize the needs of parents, their children, the other
    members of the family network, and the family's overall functioning.

    The recommendations below echo many of the recommendations we shared
    with Chairman Wyden and Ranking Member Crapo on November 1, 2021 in
    response to the September 21, 2021 request for comments on
    Congressional action to improve timely access to quality mental health
    and SUD treatment services. These recommendations are tailored to meet
    the unique needs of infants, children and adolescents and their
    families who are affected by SUDs. These include efforts to strengthen
    the workforce and increase integration, coordination, and access to
    care.

     1. Strengthening the Workforce: The Power of Peer Recovery Specialists

    It is a well-known fact that parents affected by SUDs need assistance
    to navigate the child welfare, court, and treatment systems; in fact,
    the fear of having their children removed can be a motivator but also a
    significant barrier to parents seeking and accessing treatment. Peer
    recovery specialists are an essential treatment support for families
    with SUDs by helping families navigate confusing and often adversarial
    public systems. These individuals, which are called different names in
    different systems (peer recovery specialists, peer advocates, peer
    navigators, etc.), can more easily gain trust and buy-in from families
    than those who work for county or state agencies.

     Congress can help to expand the effectiveness of peer recovery
                        specialists for families affected by parental
                        substance use and child welfare by:

          Dedicating federal funding to expand access to peer recovery
    supports for all families affected by substance use and child welfare
    involvement; and

          Requiring child welfare and substance use treatment systems to
    align their qualifications for peer specialists to ensure they have in-
    depth knowledge of both systems, regardless of where they work, and can
    access and coordinate services for the entire family network--child,
    parent, and extended family.

     2. Increasing Integration, Coordination, and Access to Care:
                        Prevention of Child Welfare Involvement

    By the time families come to the attention of the child welfare system,
    they have often made multiple attempts to access and complete treatment
    but have not been able to access services and supports for their
    children. Many substance use treatment systems are focused on improving
    individual outcomes and do not have mechanisms to help families access
    the full range of services and supports needed for safety and stability
    such as early childhood development, childcare, early intervention
    services, housing, employment, and economic assistance.

     To prevent child welfare involvement, Congress can explore ways to
                        support treatment systems so they can take the
                        following steps to help families access the full
                        array of coordinated services for their families:

          In their data systems, tracking children of parents who
    participate in treatment and creating pathways for accessing services;

          Ensuring states and counties have maximum flexibility to braid
    funding streams on behalf of children and their parents that go beyond
    SUD treatment;

          Ensuring that treatment providers can connect families to
    prevention services across systems and do not have to resort to filing
    a report of abuse or neglect with the child welfare system to access
    such services; and

          Wherever possible, ensuring treatment providers have the
    resources and the competencies to allow children and parents to stay
    together in whatever type of treatment program is appropriate--
    community-based, out-patient, or residential.

     3. Increasing Integration, Coordination and Access to Care: A Public
                        Health Approach to Substance Use During Pregnancy

    A primary barrier to parental access to substance use treatment and
    mental health services is the number of states with child protection
    laws that equate prenatal substance exposure with child abuse and
    neglect. Although identifying children with prenatal substance exposure
    can connect families to services designed to keep them intact, some
    states have policies that stipulate that a prenatally exposed child is
    sufficient evidence to substantiate child maltreatment and remove the
    child from the home. These policies can prevent parents from accessing
    treatment and also disproportionately affect families of color.\14\

     Congress can promote a public health approach over a family punishment
                        approach to prenatal substance exposure by:

          Ensuring that states have access to funding to coordinate
    services and supports for pregnant people and their infants with
    prenatal substance exposure outside of the child protective services
    system. This approach is currently embedded in S. 1927, the CAPTA
    Reauthorization Act of 2022;

          Ensuring that states take a prevention approach by creating
    incentives for states to move away from equating substance use and
    mental health conditions during pregnancy with an automatic
    determination of child abuse or neglect. This would go a long way
    toward reducing the number of infants placed in out of home care; and

          Expanding the Regional Partnership Grants (RPGs) through
    reauthorization of Title IV-B. RPGs allow jurisdictions to implement
    cross systems collaboration across multiple child and family serving
    systems to ensure a more coordinated approach to supporting families
    with SUDs. An evaluation of RPGs found that this collaboration leads to
    timelier reunification and improved treatment and recovery outcomes.
    RPGs have been authorized since 2007, and it is time to take the
    lessons from these collaborations to a larger scale in state systems.

     4. Increasing Integration, Coordination and Access to Care:
                        Improvements to the Family First Prevention
                        Services Act

    The Family First Prevention Services Act (Family First) authorized in
    2018 takes important steps to prevent removal of children from their
    parents by allowing states to provide substance use treatment and
    mental health services to the whole family for children who are
    candidates for foster care. Two areas of the law need further
    improvement to enhance the potential to prevent family separation.
    These include:

    Evidence-based requirements: The requirements for evidence-based
    programs that can be funded through Family First are stringent, and in
    the three years since enactment, only a handful of programs to improve
    outcomes for families who are affected by substance use have been
    identified: four well-supported, two supported, and three promising
    programs. About half of these programs improve SUD outcomes for
    adolescents and half for parents. Child welfare agencies need a wider
    array of programs to choose from, both for implementation of Family
    First, as well as for prevention and intervention services to prevent
    child welfare involvement and family separation in the first place.

    Family-based residential treatment programs--Only a minority of the
    Title IV-E prevention plans that states have submitted to the
    Department of Health and Human Services (HHS) include using prevention
    dollars on family-based residential treatment programs. States are also
    not fully using the Title IV-E authority to use foster care maintenance
    funds to support children placed with a parent in a family-based
    residential treatment program. State officials point to two barriers to
    these programs that need to be addressed before they can reach their
    maximum potential: first, the requirement that children be in the
    custody of the state in order to be placed with their parents in
    family-based residential treatment; and second, far greater demand for
    family-based residential treatment than supply.

     Congress can maximize the potential of the Family First Prevention
                        Services Act to prevent family separation by:

          Aligning requirements for what constitutes an evidence-based
    program with the National Institute for Drug Abuse (NIDA) and the
    Substance Abuse Mental Health Services Administration (SAMHSA)
    evidence-based programs and practices;

          Ensuring that child welfare agencies can leverage family-based
    residential treatment programs without having to take legal custody of
    the child (e.g., family in-home prevention programming while the child
    is placed at the residential facility); and

          Ensuring that child welfare agencies and their treatment
    partners have access to infrastructure dollars to expand facilities
    that can accommodate parents and their children.

    We appreciate the Committee's leadership on these important issues and
    look forward to continuing to work with you to ensure that children,
    young people, and their parents can access the services and supports
    they need to remain together, improve treatment and recovery outcomes,
    and improve child well-being. Please don't hesitate to contact me at
    nkyoung@cffutures.org if you are interested in more information on any
    of the above ideas.

    Sincerely,

    Nancy K. Young, Ph.D., M.S.W.
    Executive Director

                                   Citations

    \1\ Lipari, R.N. and Van Horn, S.L. Children living with parents who
        have a substance use disorder. The CBHSQ Report: August 24, 2017.
        Center for Behavioral Health Statistics and Quality, Substance
        Abuse and Mental Health Services Administration, Rockville, MD.
        Accessed May 4, 2020 from https://www.samhsa.
        gov/?data/sites/default/files/?report_3223/??ShortReport-3223.html.

    \2\ Akin, B.A., Brook, J., and Lloyd, M.H. (2015). Co-occurrence of
        parental substance abuse and child serious emotional disturbance:
        Understanding multiple pathways to improve child and family
        outcomes. Child Welfare, 94(4), 71-96.

    \3\ Bailey, J.A., Hill, K.G., Guttmannova, K., Oesterle, S., Hawkins,
        J.D., Catalano, R.F., and McMahon, R.J. (2013). The association
        between parent early adult drug use disorder and later observed
        parenting practices and child behavior problems: Testing alternate
        models. Developmental Psychology, 49(5), 887-899. doi:10.1037/
        a0029235.

    \4\ Burlew, A.K., Johnson, C., Smith, S., Sanders, A., Hall, R.,
        Lampkin, B., and Schwaderer, M. (2012). Parenting and problem
        behaviors in children of substance abusing parents. Child and
        Adolescent Mental Health, 18(4), 231-239.

    \5\ Chasnoff, I.J., Telford, E., Wells, A.M., and King, L. (2015).
        Mental health disorders among children within child welfare who
        have prenatal substance exposure: Rural vs. Urban populations.
        Child Welfare, 94(4), 53-70. Retrieved from https://
        www.ncbi.nlm.nih.gov/pubmed/26827476.

    \6\ Conners, N.A., Bradley, R.H., Mansell, L.W., Liu, J.Y., Roberts,
        T.J., Bergdorf, K., and Herrell, J.M. (2004). Children of mothers
        with serious substance abuse problems: An accumulation of risks.
        American Journal of Drug and Alcohol Abuse, 30(1), 85-100.
        doi:10.1081/ada-120029867.

    \7\ Dube S.R., Felitti V.J., Dong M., Chapman D.P., Giles W.H., and
        Anda R.F. (2002). Childhood abuse, neglect and household
        dysfunction and the risk of illicit drug use: The Adverse Childhood
        Experience Study. Pediatrics, 111(3), 564-572. Sprang, G., Staton-
        Tindall, M., and Clark, J. (2008). Trauma exposure and the drug
        endangered child. Journal of Traumatic Stress, 21(3), 333-339.

    \8\ Sprang, G., Staton-Tindall, M., and Clark, J. (2008). Trauma
        exposure and the drug endangered child. Journal of Traumatic
        Stress, 21(3), 333-339.

    \9\ Arria, M.A., Mericle, A.A., Meyers, K. and Winters, C.K. (2012).
        Parental substance use impairment, parenting and substance use
        disorder risk. Journal of Substance Abuse Treatment, 43(1), 114-
        122. doi: 10.1016/j.jsat.?2011.10.001.

    \10\ Solis, J.M., Shadur, J.M., Burns, A.R., and Hussong, A.M. (2012).
        Understanding the diverse needs of children whose parents abuse
        substances. Current Drug Abuse Reviews, 5(2), 135-147. doi:10.2174/
        ?187447371120502013.5

    \11\ Svingen, L., Dykstra, R., Simpson, J., Jaffe, A.E., Bevins, R.A.,
        Carlo, G., DiLillo, D., and Grant, K.M. (2016). Associations
        between family history of substance use, childhood trauma, and age
        of first drug use in persons with methamphetamine dependence.
        Journal of Addiction Medicine, 10(4), 269 273. doi: 10.1097/ADM.
        0000000000000233.

    \12\ Brent, D.A., Hur, K., and Gibbons, R.D. (2019). Association
        Between Parental Medical Claims for Opioid Prescriptions and Risk
        of Suicide Attempt by Their Children. JAMA Psychiatry,
        2019;76(9):941-947. doi:10.1001/jamapsychiatry.2019.
        0940.

    \13\ Wilkins, N.J., Clayton, H., Jones, C.M., and Brown, M. (2020).
        Current Prescription Opioid Misuse and Suicide Risk Behaviors Among
        High School Students. Pediatrics, 147(3). Accessed March 22, 2021
        from https://pediatrics.?aappublica
        tions.??org/??content/early/2021/02/25/peds.2020-030601.

    \14\ Ingoldsby, E., Richards, T., Usher, K., Wang, K., Morehouse, E.,
        Masters, L., and Kopiec, K. (2021). Prenatal alcohol and other drug
        exposures in child welfare study: Final report. Children's Bureau,
        Administration for Children and Families, U.S. Department of Health
        and Human Services. Accessed February 21, 2021 from https://
        www.acf.hhs.gov/sites/default/files/documents/cb/paode-in-cw-final-
        report.pdf.

                                     ______

                                 Fountain House

                                425 W. 47th St.

                               New York, NY 10036

    February 21, 2022

    U.S. Senate
    Committee on Finance
    Dirksen Senate Office Bldg.
    Washington, DC 20510-6200

    Dear Chair Wyden and Ranking Member Crapo,

    Thank you for this opportunity to submit this comment to you and other
    members of the Committee regarding the urgent and unmet needs of the
    community living with serious mental illness, which currently numbers
    14 million in the U.S., many of whom are youth and young adults.
    Fountain House is pleased to engage with you on policy issues
    enumerated below that will benefit the unique community we serve. We
    believe that directing funding to clubhouses that provide evidence-
    based psychosocial rehabilitation, through programs such as the
    Community Mental Health Services Block Grant and other funding
    mechanisms, would prove effective at supporting the rights and recovery
    of those living with serious mental illness and substance use disorders
    and reduce Medicaid costs.

    About Fountain House

    Fountain House is a national mental health nonprofit fighting to
    improve health, increase opportunity, and end social and economic
    isolation for people living with serious mental illness. The majority
    of Fountain House members are BIPOC who are disproportionately affected
    by racism and systemic/structural barriers. Fountain House leads a
    national network of regional affiliates in San Antonio, TX, Phoenix,
    AZ, Sarasota, FL, Seattle, WA, Bellevue, WA, Everett, WA, Concord, CA,
    Ann Arbor, MI, Cleveland, OH, Queens, NY, Jamaica, NY, Staten Island,
    NY, New York, NY, and Bronx, NY and draws on more than 200 community-
    based social rehabilitative programs inspired by Fountain House and
    known as clubhouses--to reflect an insistence on belonging and
    acceptance--in nearly 40 states and with more than 60,000 clubhouse
    members nationwide. We are building a national movement for the dignity
    and rights of the 14 million people living with serious mental illness
    in our country while also providing necessary support and resources to
    the individuals we serve.

    Millions of Americans living with serious mental illness (SMI) are
    denied access to care and support in the community because mental
    health support systems in the United States were not built to address
    the wide-ranging needs of people with SMI, especially people who cannot
    afford care. These individuals then end up cycling through our nation's
    streets, shelters, emergency rooms, and jails, at great expense to
    local, state, and federal budgets. In addition, we know that people
    with SMI face social and economic isolation \1\ that has profound
    mental and physical health consequences.\2\ For far too long our
    punitive, ineffective, and costly approaches have taken away their
    capacity and humanity. Fountain House takes a public health approach to
    serious mental illness. We address both the health and social needs of
    our members through an integrated model that connects our physical
    clubhouse--where members are engaged in an innovative, proven
    therapeutic community called social practice designed to support them
    to take steps in reclaiming their agency and dignity--with holistic
    access to clinical support, housing, care management, education, and
    more. Since the onset of the COVID-19 pandemic, we have also built a
    virtual version of our clubhouse to provide connection and expand our
    reach to others who can benefit. We are pleased to report that
    preliminary data suggests this helps to better engage both younger
    adults and a more demographically diverse cross-section of people
    living with SMI.
    ---------------------------------------------------------------------------
        \1\ Fortuna, K.L., Ferron, J., Pratt, S.I., Muralidharan, A.,
    Aschbrenner, K.A., Williams, A.M., . . . and Salzer, M. (2019). Unmet
    needs of people with serious mental illness: Perspectives from
    certified peer specialists. Psychiatric Quarterly, 90(3), 579-586.
        \2\ Holt-Lunstad, J., Smith, T.B., Baker, M., Harris, T., and
    Stephenson, D. (2015). Loneliness and social isolation as risk factors
    for mortality: A meta-analytic review. Perspectives on psychological
    science, 10(2), 227-237.

    Simply put: Fountain House's approach works. Our members are
    hospitalized and experience crises at rates significantly lower than
    others living with serious mental illness, resulting in 21% lower
    Medicaid costs for the highest-risk population. Of the 40% of our
    members experiencing homelessness or unstable housing when they arrive
    at Fountain House, 99% are housed within a year. Of the 24% of Fountain
    House members with a history of incarceration and justice involvement,
    rates of recidivism are less than 5%. Our members complete their
    education, find paid work, and achieve health and wellness goals at
    significantly higher rates than people living with serious mental
    illness who don't have access to our programs. Our country has growing
    and intersecting crises of homelessness, police involvement,
    incarceration, and rising mental health needs, which require programs
    ---------------------------------------------------------------------------
    like Fountain House to be accessible and available to all.

    As this Committee recognized during its February 8, 2022 hearing,
    millions of young Americans are struggling under a mental health
    epidemic amounting to a national crisis, which will require both
    coverage of and access to physical and mental health care to solve. As
    this Committee works to produce a bipartisan bill this summer that can
    serve as a step forward in solving this nation's mental health crisis,
    we urge you to recognize that there are 14 million people in the United
    States living with serious mental illness (SMI). Traditional care
    delivery models fail to address many of the underlying needs of people
    with SMI, and these failures result in unnecessary morbidity,
    mortality, health-care costs, and other social service costs to
    society. We encourage states to use new Medicaid and behavioral health
    funding to support comprehensive models of psychosocial rehabilitation
    that break down social isolation and improve quality of life. Congress
    and the federal government should support these aims so that trained
    behavioral health staff can serve as social practitioners and offer the
    following services to the populations they serve: transitional
    employment; health and wellness programming; culinary food service and
    medically managed meals; housing assistance; care management; and
    supported education.

     Based on the needs of our community, we support the following proposed
                        Appropriations Report Language:

    The Committee directs the Center for Medicare and Medicaid Services
    (CMS) to provide a report the Committee within 180 days of enactment
    that addresses how CMS will encourage the following:

          How the Center for Medicare and Medicaid Innovation intends to
    develop new payment models that supplant fee-for-service models with
    more global-oriented payment models that reward value associated with
    breaking down social isolation for people living with SMI;
          How the Center for Clinical Standards of Quality will develop,
    specify, test, and integrate into payment models patient-reported
    outcome measures that address social isolation and loneliness; and
          How the Center for Medicaid and CHIP Services will encourage
    state Medicaid agencies to contract with payers that offer
    comprehensive psychosocial rehabilitation services, as described above.

    The Committee directs an additional $40 million to be allocated to the
    Patient-
    Centered Outcomes Research Institute (PCORI) to specifically support a
    funding announcement related to social drivers of health for people
    living with serious mental illness.

    In addition, the Committee directs the Substance Abuse and Mental
    Health Services Administration (SAMHSA) to provide a report to the
    Committee within 180 days of enactment that addresses how SAMHSA will
    clarify expectations that rehabilitation services should
    comprehensively address rehabilitation, including psychosocial
    rehabilitation as described above.

    Strengthening the Workforce

    As Senator Crapo recognized during this Committee's February 8, 2022
    hearing, strengthening the mental and behavioral health workforce will
    prove vital, especially in the face of widespread stress, fatigue, and
    burnout of providers and workers in the mental health field. And, as
    the Senate HELP Committee heard during its February 1, 2022 hearing to
    examine mental health and substance use disorders focusing on
    responding to the growing crisis, serious workforce gaps in the mental
    health community have been left unaddressed by broader efforts to
    strengthen the U.S. workforce. Fountain House encourages Congress to
    broaden its thinking as it considers policy and structural changes
    aimed at strengthening the workforce of mental health providers.

    Senator Cortez Masto's line of questioning regarding peer support
    services during this Committee's February 8, 2022 hearing recognized
    the vital role that peers play in recovery for people with SMI. The
    role of peers is incredibly important to social practice that works to
    address the requirements of our members and other individuals with
    mental health needs. Fostering a community of people with similar lived
    experiences is critical for promoting health equity. As SAMSHA reports,
    research shows that peer support provides important recovery benefits.
    Creating and resourcing additional pathways for peers and other mental
    health paraprofessionals to enter the field would play a critical role
    in addressing staffing gaps nationwide, contribute to innovation and
    more well-evidenced models of care, and create new employment
    opportunities for people from lower-resourced backgrounds to enter the
    helping profession and serve people with SMI. After entering the field,
    we recommend that there be clear pathways for peers to remain and grow
    in the mental health workforce to serve people with SMI. One way of
    ensuring continuity and robust availability of peer supports is to
    create standardized training programs for peers, which can contain
    advancement opportunities in and of themselves in addition to promoting
    a general understanding of the opportunities in the field.

    We urge Congress to consider the ways in which health-care payments
    limit growth of the mental health workforce, especially those who serve
    people with SMI. Psychosocial rehabilitation through the group setting
    model requires consistent management and leadership by providers.
    However, because most payment is derived through 1:1 billable services,
    management of community supports is not currently eligible for
    reimbursement by payers under traditional fee-for-service payment
    models.

    We also encourage you to consider policy that ensures that all
    workforce members are practicing at the top of their licenses. The
    pandemic has exacerbated an already serious mental health provider
    shortage in the U.S., which cannot be remedied quickly by relying on
    highly trained clinicians to fill in the gaps (it would take many years
    of education and training). The most feasible solution is to deploy
    people with lived experience from the community to provide critical
    support as an adjunct to more serious clinical expertise so we are
    maximizing what each person in the provider system can do.

    Combined, these impediments mean that the fee-for-service payment
    models, current scope of practice limitations, and licensing
    regulations restrict growth of this community support model that has
    proven highly effective.

    Increasing Integration, Coordination and Access to Care

    Fountain House has endorsed the bipartisan Behavioral Health Crisis
    Services Expansion Act (S. 1902) and we strongly recommend that the
    Committee consider the provisions of this bill. S. 1902 would address
    many of the issues enumerated in your communication to behavioral
    health stakeholders including expanding the availability of services
    such as 24/7 national hotlines, mobile crisis services, behavioral
    health urgent care facilities, crisis stabilization beds, and short-
    term crisis residential options. The bill also calls for data
    collection and evaluation of the current provision of services and
    programs offered, and it would help communities build up their
    behavioral health crisis response systems. These policies are critical
    to ensuring that people who require behavioral health care can access
    it in a safe and timely manner.

    Crisis intervention models need to focus on what factors drive crises
    (e.g., mental health, social challenges), enlist a wide range of people
    (various mental health professionals, peers, etc.), and focus training
    on de-escalation. Research shows that a public health approach to
    mental health crises works, and that law enforcement is rarely
    required.

    Most data systems do a poor job of addressing critical aspects of
    behavioral health, integrating social needs into patient records, and
    following the patient across settings.

    Psychosocial rehabilitation, such as the services that social
    practitioners provide in clubhouses, is a valuable, evidence-based
    element of the care continuum. It often serves as a critical bridge
    between high-acuity care and long-term health and productivity for
    people living with SMI. Research has shown that participating in the
    clubhouse model facilitates positive recovery trajectories by promoting
    a sense of unity and belongingness for members. Randomized controlled
    trials have indicated that members experience a significantly improved
    quality of life due to their involvement in the model.\3\,
    \4\ The competitive employment aspect of the model specifically has
    also been linked to improved global quality of life, with the greatest
    positive influence being on members' levels of self-esteem.\5\ Overall,
    aspects of the clubhouse model believed to account for these
    improvements include the focus on autonomy and personhood instead of
    patient-hood. Clubhouses have further been proven to reduce severe
    psychiatric symptoms, improve self-esteem,\6\ and decrease internalized
    stigma, promoting greater recovery experiences.\7\ Randomized
    controlled trials of clubhouse programs have shown reduced
    hospitalizations for clubhouse members.\8\ Additionally, membership in
    clubhouses shows lower drop-in rates and fewer hospitalizations,\9\ and
    clubhouse costs are substantially lower than partial hospitalization,
    thus clubhouse membership reduces overall cost of health care.\10\
    ---------------------------------------------------------------------------
        \3\ Chen, Y., Yau, E., Lam, C., Deng, H., Weng, Y., Liu, T., and
    Mo, X. (2019). A 6-month randomized controlled pilot study on the
    effects of the clubhouse model of psychosocial rehabilitation with
    Chinese individuals with schizophrenia. Administration and Policy in
    Mental Health and Mental Health Services Research, https://doi.org/
    10.1007/s10488-019-00976-5.
        \4\ McKay, C., Nugent, K.L., Johnsen, M., Eaton, W.W., and Lidz,
    C.W. (2018). A Systematic Review of Evidence for the Clubhouse Model of
    Psychosocial Rehabilitation. Administration and Policy in Mental Health
    and Mental Health Services Research; New York, 45(1), 28-47, http://
    dx.doi.org.proxy.lib.wayne.edu/10.1007/s10488-016-0760-3.
        \5\ Gold, P.B., Macias, C., and Rodican, C.F. (2016). Does
    competitive work improve quality of life for adults with severe mental
    illness? Evidence from a randomized trial of supported employment. The
    Journal of Behavioral Health Services and Research, 43(2), 155-171,
    https://doi.org/10.1007/s11414-014-9392-0.
        \6\ Tsang, A.W.K., Ng, R.M.K., and Yip, K.C. (2010). A 6-month
    prospective case-controlled study of the effects of the clubhouse
    rehabilitation model on Chinese patients with chronic schizophrenia.
    East Asian Archives of Psychiatry, 20, 23-30.
        \7\ Pernice, F.M., Biegel, D.E., Kim, J.-Y., and Conrad-Garrisi, D.
    (2017). The mediating role of mattering to others in recovery and
    stigma. Psychiatric Rehabilitation Journal, 40(4), 395-404, https://
    doi.org/10.1037/prj0000269.
        \8\ Solis-Romon, C., and Knickman, J. (2016). Project to evaluate
    the impact of Fountain House programs on Medicaid utilization and
    expenditures. Health Evaluation and Analytics Lab: New York University.
        \9\ Di Masso, J., Avi-Itzhak, T., and Obler, D.R. (2001). The
    clubhouse model: An outcome study on attendance, work attainment and
    status, and hospitalization recidivism. Work: Journal of Prevention,
    Assessment and Rehabilitation, 17(1), 23-30.
        \10\ Solis-Romon, C., and Knickman, J. (2016). Project to evaluate
    the impact of Fountain House programs on Medicaid utilization and
    expenditures. Health Evaluation and Analytics Lab: New York University.

    We urge the Committee to focus on the outcomes that matter the most to
    people living with mental illness. It is critical that our system moves
    beyond almost exclusive reliance on administrative data to measure
    provider performance. Utilizing this data does not capture the
    complexity of treating serious mental health diagnoses which requires
    markedly different treatment approaches than diagnoses such as heart
    disease, diabetes, or other chronic physical ailments. Yet success is
    measured with a system that does not adequately distinguish between
    behavioral and physical health. To address this issue, we recommend
    that the Committee consider policies that would integrate patient-
    reported measures into performance assessments especially as they
    relate to social isolation/connection/loneliness; function and quality
    of life; and self-efficacy, agency, empowerment, and engagement.

    Ensuring parity between behavioral and physical health care

    As alluded to above, lack of payer parity between behavioral and
    physical health care continues to challenge the delivery of care to
    individuals who require mental health care. Statutory advancements in
    parity have not been supported well enough by regulatory and legal
    infrastructure in a manner that truly actualizes parity in the real
    world. Unfortunately, payers frequently fail to apply evidence-based
    standards to benefit determinations, causing enormous financial
    hardship for patients and people who have family members living with
    mental illness or resulting in many people having to forego needed care
    due to expense of self-paying for it.

    The 2019 ERISA Wit v. United Behavior Health ruling demonstrates the
    need for a more comprehensive approach to making mental health parity a
    reality. We urge the Committee to consider the precedent set by this
    ruling as you work to ensure real and lasting parity for individuals
    who require mental health treatment.

    There is dramatic supply deficiency in terms of access to effective
    behavioral health programs at many levels of the system. Despite
    regulatory changes in the last decade, individuals who are covered by
    private health plans still face many hurdles when trying to identify an
    appropriate mental health provider. From workforce shortages to
    reimbursement challenges to payer coverage shortfalls, patients are
    often left without a viable path to getting the care they need.

    Federal coverage programs also fall short. Medicare is not subject to
    mental health parity requirements and imposes additional limitations on
    mental health benefits. The Medicare 190 hospital days lifetime
    limitation does not serve patients seeking behavioral health care well
    and is easily exceeded for these chronic conditions; according to NAMI,
    no other health condition is subject to a similar cap. In addition to
    denying care to people who have eclipsed the coverage limit, we are
    also concerned that this limitation may deter individuals from seeking
    care if they believe that they will exceed their lifetime coverage
    limit too early when, in fact, it's critical that individuals
    experiencing a severe mental health episode seek care as soon as
    possible. We urge the Committee to consider the provisions of the
    recently introduced, bipartisan Medicare Mental Health Inpatient Equity
    Act, which would permanently repeal the Medicare 190-day lifetime limit
    for inpatient psychiatric care. Medicaid also imposes arbitrary limits
    on treatment for mental health. The program excludes coverage for
    ``institutions for mental disease'' (IMDs). This exclusion, which has
    been in place for the duration of the existence of the Medicaid
    program, is a direct affront to Congress's work towards achieving
    mental health parity. We urge the Committee to work towards policy to
    eliminate this discriminatory limitation on access to care.

    Furthering the Use of Telehealth

    The COVID-19 pandemic has made clear the need for telehealth services
    for treatment of many conditions, including mental health diagnoses.
    While the flexibility afforded has resulted in easier access to care,
    we urge the Committee to consider fully the needs of the community we
    represent when considering policy that would further expand telehealth.
    More research is required to determine what support is best provided
    via in-person treatment. We want to ensure that individuals who prefer
    to access in-person treatment are not unduly forced into virtual
    treatment via a reimbursement structure that overly incentivizes this
    method of care delivery.

    As previously mentioned, it is critical that people suffering from SMI
    feel part of a community, whether that community exists in person or
    virtually. We urge the Committee to consider policies that would enable
    coverage for virtual community-based psychosocial rehabilitation.

    Conclusion

    Equitable access and quality care begin by engaging representative
    people with lived experience in all aspects of research, policymaking,
    and program design. In addition to the recommendations we have made
    above, we strongly encourage the Committee to ensure that individuals
    from the community you are attempting to serve with this effort are
    engaged in a meaningful way. Defining the best approaches to
    integrating, coordinating and accessing mental health care requires a
    thoughtful framework that lays out a national quality strategy for
    mental health. It is clear that the Committee appreciates this dynamic,
    and we thank you for this opportunity to respond to this Committee's
    discussion draft. If you have any questions or would like more
    information, please contact Jennifer Wang, Senior Director of National
    Policy and Advocacy at jennifer.wang@fountainhouse.org.

    Sincerely,

    Mary Crowley
    Interim President and Chief Executive Officer
    Fountain House

                                     ______

                               The Jed Foundation

                           530 7th Avenue, Suite 801

                               New York, NY 10018

                             info@jedfoundation.org

                                  212-647-7544

                           https://jedfoundation.org/

    February 8, 2022

    The Honorable Ron Wyden
    Chair
    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: Protecting Youth Mental Health: Part I--An Advisory and Call to
    Action

    Dear Chair Wyden and Ranking Member Crapo:

    Thank you for this opportunity to submit this statement for the record.
    The Jed Foundation (JED) is nation's leading non-profit dedicated to
    protecting emotional health and preventing suicide for our nation's
    teens and young adults. In our work, our practitioners see firsthand
    the mental health crisis facing our youth, which, while existing well
    before the current COVID-19 Pandemic, has been greatly exacerbated by
    the Pandemic and will have impacts that extend well after the Pandemic
    is over. That is why we feel the Federal government should be taking an
    active role in not only addressing the immediate crisis, but in laying
    a comprehensive and sustainable youth mental health infrastructure.

    We are grateful for your leadership and Congress's support to date, but
    there is still much to be done. We, as a Nation, can work to positively
    address mental health challenges now, or see them manifest in much more
    destructive forms well into the future. JED believes strongly in the
    importance of a comprehensive system of mental health support and
    suicide prevention planning for all teens and young adults,
    particularly in the communities of high schools and college campuses.
    Congress can play a critical role in ensuring that these environments
    have the necessary expertise, resources, and strategic planning in
    place through advancing several existing pieces of legislation.

    To that end, we believe that all schools and colleges should be
    encouraged to implement the federal Suicide Prevention Resource
    Center's developed, and scientifically shown to be effective,
    Comprehensive Approach to Suicide Prevention.\1\
    ---------------------------------------------------------------------------
        \1\ https://www.sprc.org/effective-prevention/comprehensive-
    approach.

    Along with additional funding and other support to schools to help with
    implementation of comprehensive approaches and suicide prevention, a
    national policy strategy around mental health should include the
    ---------------------------------------------------------------------------
    passage and implementation of the:

        1.  Enhancing Mental Health and Suicide Prevention Through Campus
    Planning Act (H.R. 5407--Representative Susan Wild), which would
    authorize the U.S. Department of Education to coordinate with the
    Health and Human Services Secretary to encourage institutions of higher
    education to implement comprehensive mental health and suicide
    prevention plans. Note that Sen. Richard Blumenthal is working on a
    similar bill.

        2.  Youth Mental Health and Suicide Prevention Act (H.R. 1803--Rep.
    Tony Cardenas), which would authorize the Secretary of Health and Human
    Services to establish a grant program to promote comprehensive mental
    health and suicide prevention efforts in high schools. Note that
    Senator Jacky Rosen and Senator Lisa Murkowski are set to introduce a
    Senate companion bill very soon.

    We hope these recommendations from JED will be helpful, and we look
    forward to continuing to work with Congress on the legislation
    mentioned above and other impactful policies that will strengthen and
    create comprehensive and sustainable systems to support positive mental
    health and suicide prevention for teens and young adults.

    If we can be of any further assistance on this or any other related
    matter, please feel free to reach out to our director of government
    affairs and advocacy, Manuela McDonough, at manuela@jedfoundation.org.

    Sincerely,

    John MacPhee, CEO

                                     ______

                               Journey to Success
    The Journey to Success campaign promotes federal policies that lead to
    better and more equitable outcomes for youth and young adults who
    experience foster care. We applaud the Senate Finance Committee for
    focusing on youth mental health--a hugely important issue for children
    and youth who have experienced the child welfare system. We look
    forward to working with you in the weeks and months to come, as well as
    to connecting you directly with young people who have experienced
    foster care and can speak directly to the importance of timely, high-
    quality mental health services in order to heal from trauma and adverse
    childhood experiences.

    Our policy framework is based on extensive review of relevant research
    and the perspectives of young people with lived expertise in the foster
    care. These youth and young adults have spoken extensively about their
    need for healing, health, and well-being, and have described the ways
    it is not being met under current policy. What follows is a summary of
    the key needs identified through the research and through personal
    insights from young people, as well as policy recommendations for the
    Committee's consideration.

     Mental Health and Healing: What Young People From Foster Care Need

    Children and youth in foster care often face significant difficulties
    due to health and mental health issues rooted in their history of
    childhood trauma, as well as in foster care itself. According to the
    American Academy of Pediatrics, the vast majority of children and
    adolescents who enter foster care have one or more serious physical or
    mental health issues stemming from a history of childhood trauma.
    Entering foster care and being removed from one's family is also
    emotionally traumatizing.

    Once in foster care, young people often do not receive care that is
    adequate, consistent, age-appropriate, or effective. Due to funding or
    coverage limitations, they may not have access to peer support services
    and other treatments that may be effective for their healing. Also,
    while the vast majority of children, youth, and young adults in foster
    care are eligible for Medicaid, many states do not cover all Medicaid-
    eligible services, and federal matching funding levels for Medicaid are
    also insufficient in many states, leaving providers without incentives
    to participate in Medicaid or to gain experience with specific
    populations receiving Medicaid, such as youth in foster care.
    Psychotropic medications are also often overused in lieu of more
    appropriate and effective treatment.

    As a result of these shortcomings, many youth from foster care enter
    adulthood without having the opportunity to heal and address issues
    that are likely to impact their future. This is a significant missed
    opportunity, because adolescence and young adulthood is a time when
    interventions can be highly effective in helping young people heal from
    past trauma. We must prioritize these young people's mental health and
    healing so that they can build resilience, achieve well-being, and
    ultimately thrive as youth and young adults.

     Policy Recommendations to Help Youth and Young Adults From Foster Care
                        Heal

    We urge you to consider the following proposals, which are intended to
    allow youth in foster care to heal, avoid further harm, and build
    resilience throughout their adolescence and young adulthood:

        1.  Strengthen current law specifically relating to the planning
    and coordination among child welfare, health, and mental health
    agencies to improve the availability, quality of, and access to, mental
    health treatment. The Health Oversight and Coordination Plans, a
    requirement of Title IV-B of the Social Security Act, have fallen short
    of providing the timely access and coordination of services that are
    critical to meeting the complex mental health needs of youth in foster
    care. Congress can expand the scope of these plans to more specifically
    account for the trauma histories of young people in foster care and
    better address their mental health needs in the following ways:
                    a.  Rename these plans to ``Health and Mental Health
                    Oversight and Coordination Plans'' and specify
                    coordination with Medicaid and behavioral health
                    agencies in the development and implementation of these
                    plans.
                    b.  Improve the array of (and access to) mental health
                    services that are available to meet the complex needs
                    of children and youth in foster care by specifying that
                    the plans coordinate clinical and non-clinical services
                    that help build and strengthen family, peer, and
                    community connections.
                    c.  Ensure that youth and young adults are involved in
                    the planning and continuous quality improvement of
                    these plans.
                    d.  Spur innovation of treatment specific to the needs
                    of youth in foster care through a new grant program,
                    modeled on the Regional Partnership Grant program
                    within Title IV-B, to support effective, varied mental
                    health treatments and supports in the community for
                    children, youth and young adults in foster care--making
                    them more likely to find approaches that meet their
                    needs so they will be able to heal and pursue their
                    goals.

        2.  Incentivize the provision of community-based mental health
    services for youth and young adults in foster care. We recommend
    increasing for three years the Federal Match Assistance Percentage
    (FMAP) to 100% for all mental health and supportive services provided
    under the Early and Periodic Screening, Diagnostic, and Treatment
    (EPSDT) program, and making all children and youth under the age of 21
    who are in or have experienced foster care eligible for EPSDT. This
    will encourage more providers to take Medicaid and to focus on
    providing high quality treatment and services for young people with
    experience in foster care.

        3.  Limit the use of psychotropic medications and increase
    oversight of their use. Requirements in the Health Oversight and
    Coordination Plan (Title IV-B) and the State Title IV-E Plan should be
    updated, and improved coordination and joint oversight with the Centers
    for Medicaid and Medicare Services should also be required. This will
    reduce the prescription of psychotropic medications and increase access
    to other treatments and interventions that help youth heal, address
    trauma; it will also ensure that youth are treated with medication only
    when appropriate and truly helpful to the young person.

        4.  Require Title IV-E agencies make a core set of supportive
    services available to all families caring for children and youth in
    foster care. Services could include peer support, 24-hour access to
    crisis planning and support, respite care, tailored in-service
    training, and access to mental and behavioral health supports.

    Thank you for your consideration of these recommendations, and for your
    leadership in prioritizing mental health for young people in America.
    As you continue your work on this important topic, we urge you to
    ensure that youth experiencing foster care receive the services and
    supports they need to thrive in their transition to adulthood and
    beyond.

                                     ______

                      National Alliance on Mental Illness

                        4301 Wilson Boulevard, Suite 300

                              Arlington, VA 22203

                                 (703) 524-7600

                         NAMI Helpline 1 (800) 950-NAMI

                              https://www.nami.org

    Chairman Wyden, Ranking Member Crapo, and distinguished members of the
    Committee, the National Alliance on Mental Illness (NAMI) would like to
    offer this Statement for the Record on your hearing, ``Protecting Youth
    Mental Health: Part I--An Advisory and Call to Action.'' NAMI is the
    nation's largest grassroots mental health organization dedicated to
    building better lives for the millions of Americans affected by mental
    illness. The communities we serve and advocate for are as diverse as
    our nation. NAMI is a voice for youth and adolescents, veterans and
    service members, individuals involved with the criminal justice system,
    those experiencing homelessness, family caregivers and all people who
    are impacted by mental illness. We are all connected by the shared hope
    of new and innovative treatments, improved health care coverage and
    support through recovery.

    Youth Mental Health: A Crisis

    Childhood and adolescence are critical periods for mental health, and
    there is strong research that links the mental, social, and emotional
    health of students to their academic achievement. Undiagnosed,
    untreated, or inadequately treated mental illnesses can significantly
    interfere with a student's ability to learn, grow, and develop.

    Yet, our nation's children and youth are experiencing soaring rates of
    anxiety, depression, trauma, loneliness, and suicidality. As U.S.
    Surgeon General Vivek Murthy identified in the 2021 U.S. Surgeon
    General's Advisory, ``Protecting Youth Mental Health,''\1\ our nation's
    youth are dealing with a devastating mental health crisis. Even prior
    to COVID-19, the need for more mental health care for youth and young
    adults was great, as we faced shortages of mental health professionals
    across the country. From 2007 to 2018, there was a 60% increase \2\ in
    the rate of suicide among 10- to 24-year-olds, making it the second
    leading cause of death for this age group.
    ---------------------------------------------------------------------------
        \1\ https://www.hhs.gov/sites/default/files/surgeon-general-youth-
    mental-health-advisory.pdf.
        \2\ https://www.cdc.gov/nchs/data/nvsr/nvsr69/nvsr-69-11-508.pdf.

    The COVID-19 pandemic has worsened the ongoing children's mental health
    crisis and increased the fragility of the mental health safety net
    system for children and adolescents. There is growing evidence that the
    mental health of children and youth is deteriorating in our current
    environment. More than half of adults (53%)\3\ with children in their
    household say they are concerned about the mental state of their
    children. Between April and October 2020, hospital emergency
    departments saw a sharp rise \4\ in the share of total visits that were
    from children with mental health-related emergencies. Additionally, at
    points during the pandemic, an astounding 25% of 18-24 years old
    surveyed \5\ reported experiencing suicidal ideation related to the
    pandemic in the past 30 days. These stressors are particularly evident
    for Latino, Black, Asian American & Pacific Islander, and American
    Indian & Alaskan Native youth who experience depression and suicidal
    ideation at higher rates.
    ---------------------------------------------------------------------------
        \3\ https://www.psychiatry.org/newsroom/news-releases/new-apa-poll-
    shows-sustained-anxiety-among-americans-more-than-half-of-parents-are-
    concerned-about-the-mental-well-being-of-their-children.
        \4\ https://www.cdc.gov/mmwr/volumes/69/wr/mm6945a3.htm.
        \5\ https://www.cdc.gov/mmwr/volumes/69/wr/
    mm6932a1.htm?s_cid=mm6932a1_w.

    Put bluntly, there is a national emergency in children's mental health.
    We greatly appreciate this Committee recognizing this urgent need and
    working to expand access to mental health care for our nation's youth
    and young adults.

    Prevention, Early Identification, and Early Intervention

    Roughly half \6\ of lifetime cases of mental illness begin by age 14
    and nearly three quarters begin by age 24. Early intervention is
    essential because the earlier people get help, the better the outcomes.
    Yet, too often, health care professionals, child-care workers, and
    teachers lack specialized knowledge to identify and treat the early
    signs of mental health conditions. Equally problematic, there are
    extensive barriers to accessing mental health care once a need has been
    identified--particularly in underserved communities. It is critical to
    focus on promoting greater awareness and early identification of mental
    health conditions in youth and young adults.
    ---------------------------------------------------------------------------
        \6\ https://pubmed.ncbi.nlm.nih.gov/15939837/.

    NAMI encourages the Committee to consider these opportunities to
    increase access to prevention, early identification and early
    ---------------------------------------------------------------------------
    intervention services within the Committee's jurisdiction:

          Allow states the option to provide Medicaid coverage to young
    adults experiencing early psychosis, supporting critical access to
    early treatment through Coordinated Specialty Care, an effective early
    treatment model that improves outcomes and saves lives.
          Incentivize screening for behavioral health symptoms at well-
    child visits and other early intervention services necessary to address
    needs early.
          Provide incentives to ensure more children can access services
    through Medicaid's Early and Periodic Screening, Diagnosis, and
    Treatment (EPSDT) benefit. EPSDT provides children with protections to
    ensure early identification and medically necessary treatment for those
    with or at risk of mental health conditions. Of all children eligible
    for an initial or periodic screening through EPSDT, less than 60
    percent \7\ received one, highlighting the need to encourage providers
    to complete the screenings.
    ---------------------------------------------------------------------------
        \7\ https://www.macpac.gov/subtopic/epsdt-in-medicaid/.
    ---------------------------------------------------------------------------

    School-Based Mental Health Services

    Mental health symptoms can affect success at school, yet too few
    students get the help they need to thrive. Since children spend much of
    their time in educational settings, schools offer a unique opportunity
    for early identification, prevention, and interventions that serve
    students where they already are. Schools also mitigate barriers to care
    such as lack of transportation, scheduling conflicts and stigma, as
    school-based mental health services can help students access needed
    services during the school day. Children and youth with more serious
    mental health needs can be referred to school-linked mental health
    services that connect youth and families to more intensive resources in
    the community.

    To support the increased need for comprehensive mental health services
    and the availability of school-based mental health professionals and
    partnerships in the community that support students' access to care, it
    is vital to provide robust federal investments. Such investments will
    help schools recruit and retain well-trained, highly qualified mental
    health professionals and bolster capacity to provide comprehensive
    mental, behavioral, and academic interventions and supports.

    NAMI encourages the Committee to consider these opportunities to
    increase access to school- based mental health care, within the
    Committee's jurisdiction:

          Increase the ability of Medicaid to support school-based mental
    health services, including providing updated CMS guidance to state
    Medicaid programs on how Medicaid can be utilized for this purpose.
          Provide incentives to school mental health programs to build
    strong partnerships with School-Based Health Centers, Federally
    Qualified Health Centers (FQHCs), Behavioral Health Organizations
    (BHOs), and community-based mental health providers to ensure timely
    access to needed care.
          Provide incentives to ensure school-based health providers are
    adequately trained to recognize the mental and behavioral health needs
    of students and to offer culturally sensitive and responsive evidence-
    based services.

    Child and Adolescent Mental Health Workforce

    There are severe shortages of mental health professionals across almost
    all specialties in this country. For youth and young adults, the
    shortage is dire. In 2020, SAMHSA estimated that 4.5 million additional
    behavioral health practitioners are needed to address the needs of
    children with serious emotional disturbances and adults with serious
    mental illness, including an additional 49,000 \8\ child and adolescent
    psychiatrists.
    ---------------------------------------------------------------------------
        \8\ https://annapoliscoalition.org/wp-content/uploads/2021/03/
    behavioral-health-workforce-report-SAMHSA-2.pdf.

    Expanding the child and adolescent mental and behavioral health
    workforce, as well as increasing cultural and linguistic competence
    among the workforce, is critical for addressing the enormous unmet
    mental health needs of children, adolescents, and young adults. NAMI
    encourages the Committee to take action to address mental health
    workforce issues and consider these opportunities within the
    ---------------------------------------------------------------------------
    Committee's jurisdiction:

          Increase the federal reimbursement rate for mental and
    behavioral health care services under Medicaid through the Medicaid
    Bump Act (S. 1727/H.R. 3450), which would enhance the ability to
    recruit and retain needed mental health providers.
          Recognize peer supports workers, mental health counselors and
    family therapists as integral mental health practitioners, increasing
    the supply of providers and addressing health disparities and barriers
    to access care through the Medicare Mental Health Access Improvement
    Act of 2021 (S. 828/H.R. 432) and the PEERS Act of 2021 (S. 2144/H.R.
    2767).
          Create incentives to ensure that the workforce is diverse and
    culturally competent to best meet the diverse needs of children with
    mental health conditions.

    Insurance Coverage and Access to Care

    Medicaid and the Children's Health Insurance Program (CHIP), which now
    cover more than 37 million children, are vital sources of insurance
    coverage for mental health and substance use disorder services.
    However, beginning in 2017,\9\ the child uninsurance rate began to
    climb.
    ---------------------------------------------------------------------------
        \9\ https://ccf.georgetown.edu/2020/10/08/childrens-uninsured-rate-
    rises-by-largest-annual-jump-in-more-than-a-decade-2/.

    Even for people with insurance, timely access to qualified mental and
    behavioral health providers is often limited because cost-sharing
    requirements are too high, in-network provider capacity is low, access
    to out-of-network providers is prohibited, and essential mental and
    behavioral health services are often not covered. We encourage the
    Committee to ensure that all children and youth have comprehensive and
    affordable coverage for mental health care by considering these
    ---------------------------------------------------------------------------
    opportunities:

          Require that state Medicaid programs cover a more robust set of
    mental health benefits. Currently, many benefits that are critically
    important for people with mental health conditions are optional,
    including targeted case management, rehabilitation services, therapies,
    medication management, clinic services, licensed clinical social work
    services, peer supports, and stays in institutions of mental disease
    (IMDs) for children up to age 21.
          Ensure nationwide Medicaid expansion to address that certain
    low-income older adolescents in the 12 states that have not expanded
    Medicaid are ineligible for coverage.
          Ensure all pregnant women, children and youth enrolled in
    Medicaid and CHIP can maintain coverage for 12 months to reduce the
    risk that they will experience gaps in coverage or lose coverage
    altogether through provisions included in H.R. 5376, the Build Back
    Better Act.
          Make CHIP permanent through H.R. 1791, the Children's Health
    Insurance Program Permanency Act or the CHIPP Act, so that this
    critical program doesn't require periodic reauthorization by Congress
    and children's access to coverage isn't at risk.
          Make permanent the Medicaid Express Lane Eligibility option,
    which allows states to take various steps to streamline enrollment and
    eligibility renewals for children in Medicaid and CHIP, through
    provisions included in H.R. 5376, the Build Back Better Act.
          Provide Medicaid coverage of health care services for people 30
    days prior to leaving jail or prison, which could help connect justice-
    involved youth and young adults to the care they will need in the
    community and reduce their risk of returning to jail or prison due to
    unmet health care needs, through the H.R. 955/S. 285, the Medicaid
    Reentry Act.
          Extend mental health parity protections to Medicaid fee-for-
    service.
          Ensure that children in foster care who have been diagnosed as
    having serious emotional disturbance (SED) and need specialized
    services delivered in facilities known as qualified residential
    treatment programs can access those services through S. 2689, the
    Ensuring Medicaid Continuity for Children in Foster Care Act of 2021.

    Conclusion

    Now more than ever, families and children from infancy through
    adulthood need access to mental health screening, diagnostics, and a
    full array of evidence-based therapeutic services to appropriately
    address their mental and behavioral health needs. NAMI would like to
    express our gratitude to the Chairman, Ranking Member and the Committee
    for your commitment to addressing the mental health needs of our
    nation's youth. If you would like to discuss any issue addressed in
    this statement, please contact Hannah Wesolowski, Chief Advocacy
    Officer at hwesolowski@nami.org.

                                     ______

             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 8th and 15th.

    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,\1\ 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.
    ---------------------------------------------------------------------------
        \1\ https://www.congress.gov/bill/117th-congress/house-bill/
    2611?q=%7B%22search%22%3A%5
    B%22hr+2611%22%2C%22hr%22%2C%222611%22%5D%7D&s=1&r=2.

    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 \2\ and ECSII \3\ 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.
    ---------------------------------------------------------------------------
        \2\ https://www.aacap.org/aacap/Member_Resources/
    Practice_Information/CASII.aspx.
        \3\ https://www.aacap.org/aacap/Member_Resources/
    Practice_Information/ECSII.aspx.

    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, postpartum, 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
    pat.johnston@nacbh.org

                                     ______

                  National Association of School Psychologists

                       4340 East West Highway, Suite 402

                               Bethesda, MD 20814

                              Phone: 301-657-0270

                               FAX: 301-657-0275

                          https://www.nasponline.org/

    February 7, 2022

    Honorable Ron Wyden                 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,

    On behalf of the more than 25,000 members of the National Association
    of School Psychologists (NASP), I submit this statement for the record
    for the U.S. Senate Finance Committee hearing ``Protecting Youth Mental
    Health: Part 1--An Advisory and Call to Action.'' We share your goal of
    creating a comprehensive mental and behavioral health system that
    serves all people. NASP represents school psychologists who work with
    students, families, educators, administrators, and communities to
    ensure all of our students have the supports they need to be
    successful. School psychologists provide direct and indirect
    interventions to support student social-emotional learning, mental and
    behavioral health, and academic success.

    As you know, we were experiencing a mental health crisis before COVID-
    19 laid bare existing inequities and exacerbated difficulties in
    children and youth receiving necessary care. This is in large part due
    to the critical role that schools play in our mental and behavioral
    health care system. Approximately 1 in 5 students will experience a
    mental health disorder over the course of their school trajectory, yet
    only 20% of those students who need care will receive it. Of those who
    do get the care they need, the vast majority of children and youth
    receive those services in school.

    NASP recently surveyed our members, and more than half of survey
    respondents reported significant increases in the number of students
    presenting with social-
    emotional or mental and behavioral health challenges. In addition, the
    reported behaviors are much more severe than in the past. The scope of
    the problem is so significant that the American Academy of Pediatrics,
    the American Academy of Child & Adolescent Psychiatry, and the
    Children's Hospital Association recently declared a national emergency
    for children's mental health. This declaration was shortly 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. These advisories underscore the need for immediate action from
    Congress to build capacity in our mental healthcare system.

    Improving access to and the quality of mental health care for children
    and youth is predicated on addressing the critical workforce shortages
    of school-employed mental health professionals. While every school has
    access to the services of a school psychologist in some capacity, our
    field is experiencing a critical shortage, both in the number of
    practitioners and in the availability of graduate education programs
    and faculty needed to train the workforce necessary to keep up with the
    growing student population. In order to provide necessary comprehensive
    services, NASP recommends a ratio of one school psychologist per 500
    students. Current data estimates a national ratio of about 1:1200;
    however, great variability exists among states, with some states
    approaching a ratio of 1:5000. It is estimated that we need an
    additional 63,000 school psychologists to meet our recommended ratio
    and ensure access to comprehensive school psychological services.
    Shortages in school psychology significantly undermine the availability
    of high-quality services to students, families, and schools,
    particularly in rural, underserved, and other hard to staff school
    districts. This is particularly devastating for communities in which
    the school psychologist, counselor, or social worker is the only mental
    and behavioral health provider readily available. Staffing shortages
    also undermine effective school community partnerships, as outlined in
    this brief NASP co-authored with the National Center for School Mental
    Health.*
    ---------------------------------------------------------------------------
        * https://www.nasponline.org/x57108.xml.

    Successful implementation of the Surgeon General's recommendations will
    require interagency collaboration at the Federal level and coordination
    among government and non-governmental organizations at the state and
    local level. NASP is pleased to be collaborating with the Department of
    Health and Human Services and the Department of Education and we look
    forward to continued collaboration with Congress. The following
    recommendations do not represent the full slate of policy solutions
    needed to address this issue. Rather, the recommendations below are
    specific to areas within the jurisdiction of the Senate Finance
    Committee. We would be more than happy to discuss other policy
    solutions that we believe Congress must advance.

    Necessary Updates to School-Based Medicaid

    Schools have always played an important role in meeting the health care
    needs of their students, but there has never been a more important time
    to ensure school districts have the knowledge and tools to access
    Medicaid funding. Medicaid is the third largest federal funding stream
    for school districts, providing much-needed funding to support school
    health services, including mental and behavioral health. Despite this,
    the CMS school-based Medicaid claiming guides have not been updated
    since 1997 and 2003, respectively. Updating these guidance documents
    will allow CMS to finally incorporate the 2014 free care policy
    reversal, which expands eligibility for school-based Medicaid programs,
    build on the demonstrated efficacy of telehealth services, address some
    of the administrative challenges some schools face in receiving
    Medicaid reimbursement. According to a recent report from the AASA, the
    School Administrators' Association, two-thirds of districts report
    using Medicaid reimbursement to support the work of school mental
    health professionals (e.g., school psychologists and school social
    workers,) who provide comprehensive mental health services available to
    students. Medicaid funds also help implement, scale up, and sustain
    effective school community partnerships, which are a necessary
    component of a comprehensive system of school-based care.

    We are pleased that the Department of Health and Human Services and the
    Department of Education are currently considering what administrative
    changes are necessary. NASP, in collaboration with several other
    education and school health organizations recommend that new guidance
    or technical assistance related to school-based Medicaid:

          Address the administrative and documentation challenges
    associated with school-based Medicaid, particularly those faced by
    small and rural school districts, and support states' efforts to
    include school psychologists and other school-based providers who are
    credentialed by state education agencies in becoming Medicaid-eligible
    providers;
          Highlight best practices and state examples for how Medicaid has
    increased the availability of school-based mental and behavioral health
    services, including expanding and streamlining the types of
    reimbursable providers and services; improving care coordination and
    partnerships with community-based mental and behavioral health
    services; and opportunities to allow for reimbursement of more early-
    intervention and prevention services, as well as building trauma-
    informed schools and preventing and treating substance use disorders;
          Address the use of telehealth services. This type of treatment
    modality is not a substitute for ensuring fully staffed schools, nor is
    it appropriate for everyone. However, in communities experiencing
    significant personnel shortages, telehealth services should be a viable
    option to connect students to care;
          Support improvements to the early and periodic screening,
    diagnostic, and treatment (EPSDT) requirements to ensure consistent
    application across states.

    We encourage the Senate Finance committee to hold the Department of
    Health and Human Services to their commitment to update these resources
    and address the current barriers that prevent districts from accessing
    this critical federal funding stream to support student mental health.

    We also recommend increasing the federal reimbursement rate for mental
    health and substance use disorder care under Medicaid through passage
    of the Medicaid Bump Act (S. 1727/H.R. 3450). As the Committee knows,
    Medicaid is the nation's largest insurer of mental health and substance
    use treatment for both adults and children. However, many beneficiaries
    remain on long wait lists for mental and behavioral health services or
    languish for long periods of time in emergency rooms awaiting
    treatment. The Medicaid Bump Act would incentivize states to expand
    their Medicaid coverage of mental health and substance use treatment
    services by providing a corresponding raise in the Federal Assistance
    Percentage (FMAP) matching rate to 90 percent for behavioral health
    services. Significantly, increasing Medicaid reimbursement rates also
    would flow to the mental health and substance use treatment workforce,
    greatly enhancing the behavioral health system's ability to recruit and
    retain needed providers.

    Finally, we ask that you work swiftly with your colleagues on the
    Senate Appropriations Committee to pass a FY 2022 budget that includes
    robust increases for programs that increase access to comprehensive
    mental and behavioral health services for all students. We need
    Congress to act quickly to provide increased resources to already
    authorized Substance Abuse and Mental Health Services Administration
    (SAMHSA) and Department of Education programs that provide mental
    health services for young people, including the maximum level of
    funding for two grant programs within Safe Schools National Activities.
    The Mental Health Services Professional Demonstration Grants program
    and School-Based Mental Health Services Grants program together address
    the critical shortage of school-based mental health professionals in
    two distinct and essential ways: by increasing the available workforce,
    and by helping school districts support increased positions to improve
    access to services. The youth mental health crisis cannot be fully
    addressed without building a high-quality workforce capable of meeting
    the increasing needs of our students, educators, and communities.

    Thank you for your leadership and commitment to improving our mental
    and behavioral health care system. We look forward to working with you
    on this critical issue. If you have any questions or would like to
    follow up, please contact Dr. Kelly Vaillancourt Strobach, NASP
    Director of Policy and Advocacy at kvaillancourt@
    naspweb.org.

    Sincerely,

    Kathleen Minke, PhD, NCSP
    Executive Director

                                     ______

                          National Health Law Program

                         1444 I Street, NW, Suite 1105

                              Washington, DC 20005

                                 (202) 289-7661

                             https://healthlaw.org/

    U.S. Senate
    Committee on Finance

    On behalf of the National Health Law Program (NHeLP), we submit this
    statement for the record for the U.S. Senate Finance Committee hearing
    entitled ``Youth Mental Health: Part I--An Advisory and Call to
    Action.''

    NHeLP is a public interest law firm working to protect and advance the
    health rights of low income and underserved individuals. Founded in
    1969, NHeLP advocates, litigates, and educates at the federal and state
    levels. Consistent with its mission, NHeLP works to ensure that all
    people in the United States have access to affordable, quality health
    care, including comprehensive behavioral health services.

    As this committee is well-aware, an unacceptable number of children in
    the United States struggle with unmet mental health needs, and the
    pandemic has only exacerbated crucial gaps in services and supports. We
    are gravely concerned by the growth in the proportion of pediatric
    emergency department visits for mental health conditions during the
    pandemic.\1\ Since the start of the COVID-19 pandemic, the proportion
    of pediatric emergency department visits for mental health conditions
    compared to visits for all other reasons has grown.\2\ The American
    Academy of Pediatrics, Children's Hospital Association, and the
    American Academy of Child and Adolescent Psychiatry have declared a
    ``national emergency in child and adolescent mental health,'' noting
    this increase in emergency department visits and increasing ``rates of
    depression, anxiety, trauma, loneliness, and suicidality.''\3\

    We appreciate the Senate Finance Committee's commitment to examining
    ways to improve behavioral health and reduce gaps in care, and we
    commend the committee for inviting the Surgeon General to address these
    critical needs. Below, we offer policy options in three areas where
    additional legislation, oversight, or guidance would further the Senate
    Finance Committee's priority of improving behavioral health care for
    young people and children: (1) improving access to intensive community-
    based services for children and youth enrolled in Medicaid; (2)
    enhancing oversight and enforcement of parity for mental health and
    substance use disorder services; and (3) improving Medicaid coverage
    for youth involved in the juvenile justice and foster care systems. We
    provided additional details on the recommendations below in our
    response to the Senate Finance Committee's request for information,
    submitted November 12, 2021.

          I. Intensive Community-Based Services for Children and Youth

    The good news is that with the right approach, youth with even the most
    significant mental health needs can and do thrive in family
    settings.\4\ However, to do so, youth must have access to appropriate
    services and supports. At a bare minimum, any robust community-based
    system of care for children and adolescents with significant behavioral
    health needs must include: (1) intensive care coordination; (2) mobile
    response and stabilization services; (3) in-home services; and (4)
    therapeutic foster care.\5\ These are the essential building blocks to
    any functioning community-based system for children and adolescents
    with significant behavioral health needs.\6\ Such evidence-based
    interventions ``can prevent the unnecessary use of emergency
    departments and other restrictive settings, such as inpatient and
    residential treatment facilities, that remove children and adolescents
    from their homes, schools, and communities.''\7\

    Under the Early and Periodic Screening, Diagnostic and Treatment
    (EPSDT) benefit, state Medicaid agencies are required to provide
    enrollees under age 21 with access to periodic and preventive
    screenings, as well as services that are necessary to ``correct or
    ameliorate'' medical conditions, including behavioral health
    conditions.\8\ Thus, states must cover medically necessary behavioral
    health services for enrollees under age 21, regardless of whether the
    services are included in the state's plan.

    Because state Medicaid programs must cover children's behavioral health
    services, including the intensive services described above, it is
    unnecessary and counterproductive for Congress to mandate or
    incentivize children's behavioral health services that states are
    already required to provide pursuant to the EPSDT benefit.

    However, compliance with EPSDT is still a serious issue, and
    enforcement of states' requirement to provide behavioral health
    treatment often requires years of litigation to vindicate the rights of
    Medicaid enrollees.\9\ Thus, we recommend that the Senate Finance
    Committee evaluate the need for increased guidance and technical
    assistance, and oversight of states' implementation of the EPSDT
    mandate. For example, recently MACPAC recommended that HHS should
    direct CMS and SAMHSA to issue joint guidance regarding states'
    obligation to provide these community-based services. We agree that
    updates to guidance to reflect current best practices may be helpful.

                              II. Enhancing Parity

    Congress enacted federal mental health parity laws to end long-standing
    discriminatory practices that allowed insurance plans to restrict
    access to mental health and substance use disorder treatment. Parity
    laws require plans to cover these services on par with other medical
    surgical services. Yet, more than two decades after Congress's first
    attempts to level the playing field and enact behavioral health parity,
    serious gaps remain. In order to eliminate current holes in the system,
    Congress should: (a) improve enforcement mechanisms for current parity
    protections; (b) extend behavioral health parity to Medicare and
    Medicaid fee-for-service programs; and (c) require the agencies
    responsible for enforcing parity to establish a centralized,
    accessible, public-facing complaint process and create easy-to-
    understand educational materials about parity for the general public.

                     A. Improving Compliance and Disclosure

    Despite strong efforts by Congress and the federal agencies, parity
    noncompliance remains a significant problem that prevents millions of
    people in the United States from accessing necessary behavioral health
    services. Enforcing behavioral health parity is a significant challenge
    for multiple reasons. First, the current system of parity compliance
    relies almost entirely on consumer complaints, placing the burden on an
    individual seeking behavioral health services to first be able to
    identify that their denial, increased costs, or additional
    administrative burdens are a parity violation, and then to walk through
    a convoluted web of paperwork, appeals, and agency enforcement
    mechanisms.

    Additionally, analysis of parity complaints is complex, requiring
    evaluation of both quantitative treatment limits (QTLs) (e.g., limits
    on the number of visits to a provider or the length of a specified
    treatment) and non-quantitative treatment limits (NQTLs) (e.g., medical
    necessity criteria used to deny treatments or prescription drug
    formulary designs).\10\ While a fair amount of progress has been made
    identifying and correcting QTLs, addressing NQTLs has been more
    challenging.\11\ In part, this is because enforcement of NQTLs requires
    disclosure of a broad range of detailed information by the plan itself.
    Not only is it difficult, if not impossible, for individuals to access
    this information, but even once they have it, the level of analysis
    required to determine whether a plan has violated parity rules is
    difficult and requires a high level of technical expertise. Over the
    past six years, Congress has taken several steps to improve enforcement
    of NQTLs. The 21st Century Cures Act included several provisions
    designed to increase transparency.\12\ In December of 2020, the
    Consolidated Appropriations Act (CAA) amended the Mental Health Parity
    and Addictions Equity Act (MHPAEA) to require plans to perform and
    document a comparative analysis of NQTLs applied to mental health and
    substance use disorder benefits versus those applied to medical-
    surgical benefits. Plans must be prepared to disclose this analysis,
    upon request, to the applicable enforcement agency.\13\ Additionally,
    there have been recent legislative proposals to allow the Department of
    Labor to levy civil monetary penalties for violations of federal parity
    protections.\14\

    While we support these efforts, we believe that there is more Congress
    can do to help ensure robust parity enforcement. The CAA takes one-step
    toward improving plan transparency and disclosure requirements, yet it
    relies exclusively on the plans themselves to perform a comparative
    analysis of NQTLs and to disclose all the information necessary to
    support this analysis. We have little faith in health plans'
    willingness to perform a comprehensive analysis of NQTLs and even less
    confidence that plans will disclose the type of information truly
    necessary to perform this comparison or that they will disclose the
    information at a level that allows parity violations to be identified.
    The 2022 Annual Report to Congress noted that none of the comparative
    analysis reviewed contained sufficient information comply with the
    requirements of parity.\15\ This lack of disclosure, even at a minimal
    level, occurs in practice even when plans are required to do so by law.
    For example, a case recently decided by First Circuit Court of Appeals
    involves a family who requested documents under the regulatory mandate
    that preceded CAA, but were unable to obtain the documents they needed
    from the plan, even with legal assistance.\16\ Congress must work with
    the enforcement agencies to ensure that, whenever it is required by
    law, plans fully disclose, upon request, all documents and information
    necessary to ensure parity compliance without necessitating affirmative
    litigation against the plan to do so.

    Thus, in addition to the requirements imposed by the CAA, the Senate
    Finance Committee should explore ways to build upon these enforcement
    efforts. We are aware that additional guidance is forthcoming, but
    there is also a role for Congress. The recent tri-agency report to
    Congress suggested amending MHPEAEA to ensure that MH/SUD benefits are
    defined in an ``objective and uniform manner, pursuant to external
    benchmarks that are based in nationally recognized standards.''\17\
    While we support this proposal, we also note it is important that any
    standards applied must keep in mind the non-discrimination provisions
    that protect the right of individuals with disabilities to not be
    segregated from society by receiving services in restrictive settings
    that can be provided through community-based services and not
    congregate settings. All too often, the ``nationally recognized
    standards'' rely on standards of care that incorporate an institutional
    bias. Instead, the standards must incorporate the types of intensive
    community supports outlined in this testimony above (e.g., services
    such as intensive care coordination; mobile response and stabilization
    services; in-home services; and therapeutic foster care).

    Another option would be to create neutral independent auditing
    entities, potentially housed within the parity enforcement agencies,
    that have the authority to investigate plans compliance with parity
    regulations. These entities would proactively examine plans for
    compliance and could also respond to complaints. We discussed this
    option in further depth in our comments to the committee, submitted
    November 2021.

          B. Extending Parity to Medicare and Fee-For-Service Medicaid

    Medicaid is the largest payer of mental health services in the United
    States and plays a vital role in ensuring access to behavioral health
    services for Medicaid's more than 80 million of low-income
    enrollees.\18\ Medicare covers nearly 62 million older adults and
    people with disabilities, including young adults and transition age
    youth with disabilities, and provides an important link to behavioral
    health coverage.\19\ Yet, current federal parity protections apply only
    to Medicaid Managed Care Organizations (MCOs), Medicaid Alternative
    Benefit Plans (ABPs) and the Children's Health Insurance Program
    (CHIP), but not to fee-for-service Medicaid or Medicare.

    To strengthen behavioral health coverage in Medicare and Medicaid,
    Congress should extend the federal parity protections to all Medicare
    plans and Medicaid fee-for-service plans. However, as discussed above,
    extending federal parity protections alone is not enough. To ensure
    that parity provides meaningful protections for Medicare, Medicaid, and
    CHIP recipients, Congress must work to ensure that there is strong
    oversight and enforcement of these provisions in both public and
    private health plans. Congress should explicitly affirm that parity
    protections can be privately enforced by Medicare, Medicaid and CHIP
    beneficiaries and continue to mandate strong disclosure and
    transparency requirements for all health plans.

               C. Improving Public Facing Materials and Supports

    Behavioral health care and insurance systems can be difficult to
    navigate. Knowing what behavioral health services are covered and then
    finding care often requires multiple phone calls, sifting through
    complex insurance paperwork, provider directories and drug formularies.
    Most beneficiaries are not familiar with the specifics of federal
    parity protections. Even if they were, the current federal parity
    enforcement scheme is complex and multi-faceted with enforcement
    authority spread between states and multiple federal agencies. Further,
    our parity enforcement system remains largely complaint driven, with
    the onus placed on individuals to file appropriate appeals and
    complaints, and there is no clear way to file a complaint for Medicaid.
    Navigating this patchwork system of enforcement is confusing and
    overwhelming.

    Therefore, Congress should mandate that the agencies responsible for
    enforcing parity should coordinate to create a centralized, easily
    accessible, public complaint process. Further enforcement agencies
    should coordinate to produce easy-to-understand educational materials
    for the general public. These materials should include clear examples
    of what parity violations look like and should be part of an ongoing
    outreach campaign to provide up-to-date support, information, and
    resources on behavioral health parity.

           III. Improving Coverage of Youth in the Juvenile Justice
                            and Foster Care Systems

    The behavioral health needs of justice-involved and child-welfare
    involved children and youth are significantly higher than their non-
    system-involved peers, yet their needs are far too often not met.
    Research suggests that 70 percent of youth in the juvenile justice
    system experience mental illness and 80 percent of children in foster
    care have significant mental health issues; in contrast between 18 and
    22 percent of youth in the general population experience mental health
    issues.\20\ There are several concrete steps Congress could take now to
    improve coverage of these populations, thus improving access to care.

    First, the 2018 SUPPORT Act prohibits states from terminating youths'
    Medicaid eligibility upon incarceration, and instead requires states to
    suspend eligibility for the period of incarceration and then to lift
    that suspension upon release.\21\ This allows for youth leaving the
    juvenile justice system to more quickly and seamlessly receive
    behavioral health care they need upon release, including counseling,
    case management, substance use disorder treatment, and other supports.
    In addition, the SUPPORT Act requires states to conduct a
    redetermination of eligibility before youth are released from custody
    without requiring them to submit a new application. Finally, the law
    mandates that states process applications from eligible youth who apply
    for Medicaid prior to their release.

    We are concerned, however, that the promises of the SUPPORT Act have
    not been fully realized. As a bipartisan group of Senators and
    Representatives identified last year, the full implementation of these
    provisions has been delayed in states across the country.\22\ It
    appears that CMS has yet to confirm that all state Medicaid programs
    have enacted these provisions in order to better serve these young
    people. Thus, we recommend that the Senate Finance Committee
    investigate the status of implementation of Section 1001 of the SUPPORT
    ACT, and remove any barriers to implementation of the requirement to
    suspend, not terminate, Medicaid eligibility for youth in the juvenile
    justice system.

    Second, Congress could remedy gaps in coverage for youth who age out of
    the foster care system. While virtually all youth in foster care are
    covered by Medicaid, once a young person ages out of foster care, they
    may experience gaps in coverage. Currently, in order to be eligible for
    Medicaid under the former foster youth pathway, a young person must be
    (1) under age 26, (2) have been in foster care upon reaching age 18 (or
    any age up to 21 if the state extends foster care to that age), and (3)
    have been enrolled in Medicaid while in foster care. Thus, youth who
    move from one state to another to pursue education or employment may
    lose their eligibility.

    Section 1002 of the SUPPORT Act included a partial remedy this problem
    by requiring every state to offer Medicaid coverage to any former
    foster youth up to age 26, including youth who were in foster care in a
    different state. Unfortunately, Section 1002 only applies to youth who
    turn 18 on or after January 1, 2023. Thus, children currently as young
    as 17 who are in the foster care system still risk losing their
    coverage if they move states after they age out of Medicaid. The Dosha
    Joi Immediate Coverage for Foster Youth Act would make Section 1002
    effective immediately, ensuring Medicaid eligibility for all former
    foster youth in the country, even if they turned 18 before 2023,
    regardless of where they currently live.\23\ An additional bill, the
    Expanded Coverage for Former Foster Youth Act would remove even more
    barriers to Medicaid eligibility for former foster youth.\24\
    Currently, youth must have been enrolled in Medicaid while in the
    foster care system and have been in foster care when they ``aged out''
    at 18, or a later age up to 21 if a state has decided to extend foster
    care accordingly. The Expanded Coverage for Former Foster Youth Act
    would broaden eligibility to young people who (1) may not have been
    enrolled in Medicaid while in the foster care system; (2) left foster
    care prior to age 18 because they were placed in legal guardianship
    with a kinship caregiver; or (3) were emancipated from foster care
    prior to age 18.\25\ We urge the Senate Finance Committee to move
    forward and pass both the Dosha Joi Immediate Coverage for Foster Youth
    Act and the Expanded Coverage for Former Foster Youth Act

    We appreciate the Senate Finance Committee's commitment to engaging in
    bipartisan reform to improve access to timely, quality behavioral
    health care. Thank you for your consideration of our comments. If you
    have questions about these comments, please contact Jennifer Lav
    (lav@healthlaw.org).

    Sincerely,

    Jennifer Lav
    Senior Attorney

    End Notes

    \1\ CDC, Morbidity and Mortality Weekly Report, Mental Health-Related
    Emergency Department Visits Among Children Aged <18 Years During the
    COVID-19 Pandemic--United States, January 1-Ocobter 17, 2020 (November
    13, 2020), https://www.cdc.gov/mmwr/volumes/69/wr/
    mm6945a3.htm?s_cid=mm6945a3_w.

    \2\ CDC, Morbidity and Mortality Weekly Report, Mental Health-Related
    Emergency Department Visits Among Children Aged <18 Years During the
    COVID-19 Pandemic--United States, January 1-October 17, 2020 (November
    13, 2020) (``whereas the overall number of children's mental health-
    related ED visits decreased, the proportion of all ED visits for
    children's mental health-related concerns increased, reaching levels
    substantially higher beginning in late-March to October 2020 than those
    during the same period during 2019.''), https://www.cdc.gov/mmwr/
    volumes/69/wr/mm6945a3.htm?s_cid=mm6945a3_w.

    \3\ American Academy of Pediatrics, A declaration from the American
    Academy of Pediatrics, American Academy of Child and Adolescent
    Psychiatry and Children's Hospital Association (October 19, 2021),
    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/.

    \4\ ``Family setting'' is used here to refer to non-group home-based
    settings. A family could be biological parent(s), a foster parent, a
    grandparent or other relative, or adoptive family. See generally Annie
    E. Casey Found., Every Kid Needs a Family (2015), http://www.aecf.org/
    m/resourcedoc/aecf-EveryKidNeedsAFamily-2015.pdf. In 1999, the Surgeon
    General released a seminal report finding that there is convincing
    evidence to support the use of in-home services for this population.
    See SAMHSA and National Institute of Mental Health, Mental Health: A
    Report of the Surgeon General 168 (1999), https://
    www.surgeongeneral.gov/library/reports/index.html. See SAMHSA, The
    Comprehensive Community Mental Health Services for Children with
    Serious Emotional Disturbances Program, Report to Congress (2015),
    https://www.samhsa.gov/sites/default/files/programs_campaigns/nitt-ta/
    2015-report-to-congress.pdf. See also Joint CMS and SAMHSA
    Informational Bulletin, Coverage of Behavioral Health Services for
    Children, Youth, and Young Adults with Significant Mental Health
    Conditions 5 (May 7, 2013), https://www.
    medicaid.gov/federal-policy-guidance/downloads/cib-05-07-2013.pdf. See
    Oswaldo Urdapilleta et al., National Evaluation of the Medicaid
    Demonstration Waiver Home- and Community-Based Alternatives to
    Psychiatric Residential Treatment Facilities, Final Evaluation Report
    (May 30, 2012, Amended April 2, 2013), https://www.medicaid.gov/
    medicaid-chip-program-information/by-topics/delivery-systems/downloads/
    cba-evaluation-final.pdf.

    \5\ As DOJ explained in its findings letter regarding its investigation
    of West Virginia Children's Mental Health System,

         A sufficient array of in-home and community-based services
    incorporates several discrete clinical interventions, including, at a
    minimum:

            Intensive care coordination, e.g., Wraparound with fidelity to
    the National Wraparound Initiative standards;
            In-home and community-based direct services of sufficient
    frequency, intensity, comprehensiveness, and duration to address the
    youth and family's needs . . .
            Responsive and individualized crisis response and
    stabilization services available 24 hours a day, 7 days a week,
    including immediate access to back-up crisis stabilization when
    actually needed so a youth can spend the majority of his/her time
    living in a more integrated community setting; and
            Therapeutic Foster Care, which . . . is an intensive,
    individualized mental health service provided in a family setting,
    using specially trained and intensively supervised foster parents.

    Department of Justice, Findings Letter, Investigation of West Virginia
    Children's Mental Health System Pursuant to the Americans with
    Disabilities Act 22 (June 1, 2015), https://www.ada.gov/olmstead/
    documents/west_va_findings_ltr.pdf.

    \6\ Id.

    \7\ MACPAC, Report to Congress on Medicaid and CHIP, Access to
    Behavioral Health Services for Children and Adolescents Covered by
    Medicaid and CHIP 79 (June 2021), https://www.macpac.gov/wp-content/
    uploads/2021/06/June-2021-Report-to-Congress-on-Medicaid-and-CHIP.pdf.
    For more information on the evidence base for these services, see Kim
    Lewis and Jennifer Lav, National Health Law Program, Children's Mental
    Health Services: The Right to Community-Based Care, Appendix: Selected
    Students of Home-Bases Services for Children with Significant Mental
    Health Needs (August 2018), https://healthlaw.org/resource/childrens-
    mental-health-services-the-right-to-community-based-care/ and Jennifer
    Lav and Kim Lewis, National Health Law Program, Children's Behavioral
    Health Mobile Response and Stabilization Services (February 2021),
    https://healthlaw.org/resource/childrens-behavioral-health-mobile-
    response-and-stabilization-services/.

    \8\ 42 U.S.C. Sec. Sec. 1396a(a)(10)(A), 1396a(a)(43), 1396d(a)(4)(B);
    1396d(r).

    \9\ See e.g., Rosie D. v. Romney, 410 F. Supp. 2d 18, 25 (D. Mass.
    2006); Katie A. ex rel. Ludin v. Los Angeles County, 481 F.3d 1150,
    1158 (9th Cir. 2007); Settlement Agreement, T.R. v. Dreyfus, C09-1677-
    TSZ (W.D. Wash. December 19, 2013), https://www.disabilityrightswa.org/
    wp-content/uploads/2017/12/Settlement-Agree
    ment-and-Order-signed-8.30.2013_0.pdf; Department of Justice, Findings
    Letter, Investigation of West Virginia Children's Mental Health System
    Pursuant to the Americans with Disabilities Act (June 1, 2015), https:/
    /www.ada.gov/olmstead/documents/west_va_findings_ltr.pdf; Disability
    Rights North Carolina v. Brajer, 5:16-cv-854 (E.D.N.C. 2016), http://
    www.disabilityrightsnc.org/sites/default/files/L28-3-
    1%20Settlement%20Agreement.pdf; Alabama Joint Settlement Agreement,
    https://centerforpublicrep.org/wp-content/uploads/2018/01/
    Alabama_Joint-Settlement-Agreement.executed.pdf.

    \10\ CMS, The Mental Health Parity and Addictions Equity Act (MHPAEA),
    https://www.cms.gov/CCIIO/Programs-and-Initiatives/Other-Insurance-
    Protections/mhpa
    ea_factsheet.

    \11\ See, e.g., Steve Melek et al., Addiction and Mental Health v.
    Physical Health, Widening Disparities in Network Use and Provider
    Reimbursement, https://assets.milliman.com/ektron/
    Addiction_and_mental_health_vs_physical_health_Widen
    ing_disparities_in_network_use_and_provider_reimbursement.pdf (parity
    issues remain in NQTLs of network adequacy and provider reimbursement);
    Mental Health and Substance Use Disorder Parity Task Force, Final
    Report 12 (2016), https://www.hhs.gov/sites/default/files/mental-
    health-substance-use-disorder-parity-task-force-final-report.PDF.

    \12\ 21st Century Cures Act, Pub. L. 114-255 (2016). These provisions
    included a requirement for the Secretary of Health and Human Services
    to create a parity action plan, mandating that the Department of Labor
    issue a report on parity violations in Employee Retirement Income
    Security Act (ERISA) plans, and directing the Government Accountability
    Office to produce a report on parity compliance.

    \13\ Consolidated Appropriations Act of 2021, Pub. L. 116-260 Sec. 203
    (2020).

    \14\ Build Back Better Act, H.R. 5736, 117th Cong. (2021), https://
    www.congress.gov/bill/117th-congress/house-bill/5376/text.

    \15\ Departments of Labor, Health and Human Services, and Treasury,
    2022 MHPAEA Report to Congress (January 2022), https://www.dol.gov/
    sites/dolgov/files/EBSA/laws-and-regulations/laws/mental-health-parity/
    report-to-congress-2022-realizing-parity-reducing-stigma-and-raising-
    awareness.pdf.

    \16\ See N.R. v. Raytheon, No. 20-1639, 2022 WL 278537 (1st Cir.
    January 31, 2022).

    \17\ Supra note 15.

    \18\ Center for Medicare and Medicaid Services, Behavioral Health in
    the United States, https://www.medicaid.gov/medicaid/benefits/
    behavioral-health-services/index.html.

    \19\ Wyatt Kom, et al., Kaiser Family Foundation, A Snapshot of Sources
    of Coverage Among Medicare Beneficiaries in 2018 (March 23, 2021),
    https://www.kff.org/medicare/issue-brief/a-snapshot-of-sources-of-
    coverage-among-medicare-beneficiaries-in-2018/.

    \20\ Sarah Hammond, Mental Health Needs of Juvenile Offenders, National
    Conference of State Legislatures. (2007), https://www.ncsl.org/print/
    health/Mental_health_needsojuvenileoffendres.pdf; Mental Health and
    Foster Care, National Conference of State Legislatures (November 1,
    2019), https://www.ncsl.org/research/human-services/mental-health-and-
    foster-care.aspx.

    \21\ See Jennifer Lav, New Omnibus Opioid Law Contains Medicaid Fix for
    Justice-Involved Children and Youth, National Health Law Program
    (January 30, 2019), https://healthlaw.org/new-omnibus-opioid-law-
    contains-medicaid-fix-for-justice-involved-children-and-youth/.

    \22\ Senator Chris Murphy, Press Release: Murphy, Booker, Cardenas,
    Griffith Demand Answers on Delayed Implementation of Health Care
    Coverage for Youth in Juvenile Justice System (September 29, 2020),
    https://www.murphy.senate.gov/newsroom/press-releases/murphy-booker-
    crdenas-griffith-demand-answers-on-delayed-implementation-of-health-
    care-coverage-for-youth-in-juvenile-justice-system.

    \23\ Dosha Joi Immediate Coverage for Foster Youth Act, S. 712, 117th
    Cong. (2021), https://www.congress.gov/bill/117th-congress/senate-bill/
    712/.

    \24\ Expanded Coverage for Former Foster Youth Act, S. 709, 117th Cong.
    (2021), https://www.congress.gov/bill/117th-congress/senate-bill/709.

    \25\ Id.

                                     ______

               National Hospice and Palliative Care Organization

                                1731 King Street

                              Alexandria, VA 22314

                               Tel. 703-837-1500

                               Fax. 703-837-1233

                             https://www.nhpco.org/

    U.S. Senate
    Committee on Finance

    February 8, 2022

    The Honorable Ron Wyden             The Honorable Mike Crapo
    Chairman                            Ranking Member
    United States Senate                United States 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:

    Thank you for holding today's hearing entitled ``Protecting Youth
    Mental Health: An Advisory and Call to Action.''

    On behalf of the National Hospice and Palliative Care Organization
    (NHPCO), the nation's largest membership organization for hospice and
    palliative care professionals, we share your commitment to addressing
    the mental health crisis facing the America's young people.

    One often overlooked aspect of mental health is addressing grief. NHPCO
    and our hospice and palliative care members nationwide have more than
    40 years of experience in helping individuals, families, and
    communities process grief. As part of the Medicare hospice benefit,
    providers offer families of hospice patients 13 months of bereavement
    care after the death of a loved one. In times of need, hospice
    providers are often turned to as experts in bereavement care and extend
    this care to the wider community, free of charge.

    The COVID-19 pandemic has changed how people die, and how we grieve.
    Families have had limited ability to visit those that are most
    vulnerable, including those experiencing serious illness and the end of
    life. Time spent together has been cut short. Many patients have lost
    the opportunity to choose the hospice benefit due to the rapid
    progression of the illness, and some families have been unable to
    access mental health care in the wake of a loss.

    COVID-19 has brought new attention to critical mental health issues,
    including complicated and prolonged grief and the impact of bereavement
    on children. More than 175,000 American children have lost a parent or
    grandparent caregiver to COVID-19, and concentrated loss in underserved
    communities has unequally distributed the psychological cost of these
    losses. Some of the negative consequences of childhood grief are
    increased use of substance abuse, higher risk of depression and
    criminal behavior, lower employment rates and academic
    underachievement. This has underscored the need for a national
    conversation on grief, the expansion of grief literacy, and the
    extension of bereavement care in underserved vulnerable communities and
    across the country.

    We are grateful for your leadership as the nation battles a mental
    health crisis. Congress must play an active role in addressing this
    crisis; including legislation to combat grief with funding for targeted
    care and research. As Congress continues to address this long-term
    effect of the COVID-19 pandemic, we look forward to continuing to
    collaborate toward this common goal. Should you have any questions,
    please don't hesitate to reach out to our Chief Advocacy Officer,
    Hannah Yang Moore (hmoore@nhpco.org).

    Sincerely,

    Edo Banach, J.D.
    President and CEO

                                     ______

                          Partnership to End Addiction

                    711 Third Avenue, Fifth Floor, 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
    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 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.

    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

                                     ______

                           Rainbows for All Children

                           614 Dempster St., Suite C

                               Evanston, IL 60202

                             https://rainbows.org/

    The state of youth mental health is in crisis. There is a shortage of
    mental health professionals in the United States and financial barriers
    for families seeking mental health services for their children. This is
    especially prevalent in minority and vulnerable communities.
    Intervention is needed now in order to mitigate the potential for
    another public health emergency if we ignore the mental health needs of
    an entire generation of children.

    Approximately 68% of children living in the United States (or 51
    million children) will experience a life-altering event triggering
    profound grief before they turn 18, including death in the family,
    divorce, abandonment, military deployment of a loved one,
    incarceration, or diagnosis of a life-threatening illness. Children who
    experience trauma and grief are at an increased risk for learning,
    emotional, and behavioral issues; physical health problems; aggression;
    and substance and alcohol abuse. These statistics have not been updated
    to recognize the 140,000 children who have experienced a major loss due
    to the COVID-19 pandemic, and time will only tell how our children will
    respond to the shared trauma of the pandemic.

    There is an entire generation of children that are facing loss; loss of
    their loved ones, loss of crucial time in school, loss of routine and
    relationships, and a loss of their childhood due to the COVID-19
    pandemic. Rainbows for All Children helps children and youth
    successfully navigate grief and heal from loss or trauma, leading to
    improvements in development, problem-solving skills, behavior, anger
    management, school attendance and academic performance, depression and
    anxiety, emotional pain and suffering, communication, and destructive
    behavior such as involvement with gangs, alcohol, and substance abuse.

    Death isn't the only traumatizing loss caused by the pandemic. Pre-
    pandemic, 68% of children in the United States experience one or more
    traumatic event, also known as an Adverse Childhood Experience, at some
    point during their childhood. Some of these Adverse Childhood
    Experiences include being the victim of or witness to community or
    school violence, divorce or separation, sudden loss of a loved one,
    military family-related stressors, incarceration of a parent, living
    with a person who has a problem with alcohol or drugs, domestic
    violence, and psychological, physical, or sexual abuse.

          25% of children will experience the breakup of their parents'
    marriage and 25% of that group will also experience the breakup of a
    parent's second marriage.
          1 in 15 children will experience the death of a parent or
    sibling.
          1 in 10 children will experience a parent's diagnosis of a
    serious medical condition.
          8% will experience a parent or guardian being incarcerated, and
    half of these children will be under 10 years old.
          3% will experience at least one parent being deployed.

    These 51 million children will experience an Adverse Childhood
    Experience, and that is outside of the trauma of the COVID-19 pandemic
    that is impacting all children. Children often do not have the ability
    to cope with their feelings and experiences around a traumatic event or
    a loss. It can be difficult for children to process and understand what
    they have experienced. When children are exposed to Adverse Childhood
    Experiences, their neurodevelopment can be disrupted. As a result, the
    child's cognitive functioning or ability to cope with negative or
    disruptive emotions may be impaired. The child's reactions to Adverse
    Childhood Experiences can interfere with his or her daily life and
    ability to function and interact with others. Symptoms can include
    nightmares, depression, physical symptoms such as stomachaches and
    headaches, self-harm, insomnia, fatigue, appetite disturbances, abrupt
    changes in personality, poor emotional control, lack of motivation,
    substance abuse, truancy, academic problems, peer problems, anxiety,
    and more. Other children may hide their emotions, acting as though
    nothing has happened, but are still negatively impacted. Long-term
    effects can continue to surface for decades to come. Assuming children
    are naive, ``they don't know what's going on'' or that they are
    resilient is a neglect of a child's mental and emotional healing and
    development that may cause severe consequences.

    Adverse Childhood Experiences have negative, lasting effects on a
    child's health and well-being. We have yet to see how the ongoing
    COVID-19 pandemic will impact this generation of children. Research has
    shown that Adverse Childhood Experiences are strongly related to the
    development and prevalence of a wide range of behavioral and health
    problems throughout a person's life span, including substance abuse,
    mental health issues, depression, obesity, learning and behavioral
    issues, aggression, and more.

          Each Adverse Childhood Experience increased the likelihood of
    illicit drug use by 2- to 4-fold.\1\
    ---------------------------------------------------------------------------
        \1\ SAMHSA. ``Adverse Childhood Experiences,'' https://
    www.samhsa.gov/capt/practicing-effective-prevention/prevention-
    behavioral-health/adverse-childhood-experiences. Updated July 9, 2018.
    ---------------------------------------------------------------------------
          Four or more Adverse Childhood Experiences puts a child at a
    twelve-time greater risk of committing suicide as a young adult. In one
    study, individuals who reported 6 or more Adverse Childhood Experiences
    had 24.36 times increased odds of attempting suicide.\2\
    ---------------------------------------------------------------------------
        \2\ Ibid.
    ---------------------------------------------------------------------------
          Adverse Childhood Experiences may increase the risk for long-
    term physical health problems (e.g., diabetes, heart attack) in
    adults.\3\
    ---------------------------------------------------------------------------
        \3\ Ibid.
    ---------------------------------------------------------------------------
          Exposure to Adverse Childhood Experiences may increase the risk
    of experiencing depressive disorders well into adulthood.\4\
    ---------------------------------------------------------------------------
        \4\ Ibid.
    ---------------------------------------------------------------------------
          Individuals who experience Adverse Childhood Experiences and do
    not receive treatment have elevated risks of early death.\5\
    ---------------------------------------------------------------------------
        \5\ Velitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F.,
    Spitz, A. M., Edwards, V., . . . Marks, J. S. ``Relationship of
    childhood abuse and household dysfunction to many of the leading causes
    of death in adults: The adverse childhood experiences (ACE) study.''
    American Journal of Preventive Medicine, 14(4), 245-258. DOI: 10.1016/
    S0749-3797(98)00017-8.

    However, the negative effects of Adverse Childhood Experiences are
    preventable, and children can be taught coping skills to help them
    develop greater resiliency. Rainbows for All Children works to address
    Adverse Childhood Experiences as soon as possible after they occur to
    allow children to grow into flourishing and healthy adults. Rainbows
    creates a safe place for children to openly discuss their feelings with
    understanding and validation and provides the tools they need to
    process their experiences and their feelings. Children journey through
    ---------------------------------------------------------------------------
    a curriculum carefully designed support their emotional needs.

    Children going through adverse experiences have shown a significant
    improvement by participating in Rainbows programs, including
    improvements in the areas of anger and stress management, stress level,
    and overall happiness. Evaluation of our programs has revealed the
    following results:

          The number of children who agreed or strongly agreed they knew
    healthy ways to be less stressed nearly doubled (increased 91%).
          The number of children who agreed or strongly agreed they were
    stress free most or all of the time nearly doubled (increased 91%).
          The number of children who strongly agree they can go through
    hard times and still be okay increased 154%.
          82% of children agree or strongly agree helping others can help
    them too.
          The number of children who strongly agree they are happy most or
    all of the time nearly doubled (increased 95%).
          The number of children who strongly agree the divorce was not
    their fault increased by 68%.
          90% of children attend school regularly.
          87% of children believe they were listened to in their groups.

    Every day, we receive calls from families in communities across the
    U.S. looking for a Rainbows site for their grieving child in need,
    where no sites are active. We are working to garner funding to open
    Rainbows sites in schools in highly vulnerable communities, and to
    provide support and training to enhance currently existing Rainbows
    groups. In several communities, there are youth who need our programs,
    willing partnerships, and community volunteer facilitators. All that is
    needed is funding to launch these new sites and bring our programming
    to children and communities that would greatly benefit from our
    volunteer-led, peer-to-peer support model of care.

    A Note on Surgeon General Vivek Murthy's Recommendations

    Dr. Murthy gave four key recommendations in his statement to the
    committee:

          Ensuring that every child has access to high-quality,
    affordable, and culturally competent mental health care.
          Focusing on prevention by investing in school and community-
    based programs that have been shown to improve the mental health and
    emotional well-being of children at low cost and high benefit.
          Developing a better understanding of the impact that technology
    and social media has on mental health.
          Taking steps to guarantee that no child should feel ashamed of
    their hurt, confusion, or isolation, and no one should feel too ashamed
    to ask for help.

    Rainbows programming aligns with three of Dr. Murthy's four
    recommendations. Rainbows programming has been developed over the past
    38 years and we have a community of over 10,000 Rainbows-trained
    Facilitators with a repository of resources designed to guide youth in
    their grieving process. We have peer-support sites meeting in 38 states
    and 13 countries. Our programming is provided at no cost to
    participants and takes place in their own communities where they feel
    most understood--whether it be their school, community center, place of
    worship, or other location comfortable to our participants.

    Recent studies have shown that peer support for children with mental
    health conditions can result in:\6\
    ---------------------------------------------------------------------------
        \6\ SAMHSA. ``Peer Support Recovery,'' https://www.samhsa.gov/
    sites/default/files/programs_campaigns/brss_tacs/peers-supporting-
    recovery-mental-health-conditions-2017.pdf.

          Increased social functioning
          Increased empowerment and hope
          Increased quality of life and life satisfaction
          Reduced use of inpatient services
          Decreased costs to the mental health system
          Decreased hospitalization
          Decreased self-stigma
          Increased community engagement
          Increased engagement and activation in treatment

    The growth children see in peer support groups helps them to understand
    and cope with their grief and feel less isolated, as well as lessening
    the burden on an already burdened public health system. Finally, there
    are many benefits to group support that is not seen in individual
    settings, such as:\7\
    ---------------------------------------------------------------------------
        \7\ Mayo Clinic. ``Support groups: Make connections, get help,''
    https://www.mayoclinic.
    org/healthy-lifestyle/stress-management/in-depth/support-groups/art-
    20044655/. Updated August 29, 2020.

          Feeling less lonely, isolated or judged
          Reducing distress, depression, anxiety or fatigue
          Talking openly and honestly about your feelings
          Improving skills to cope with challenges
          Staying motivated to manage chronic conditions or stick to
    treatment plans
          Gaining a sense of empowerment, control or hope
          Improving understanding of a disease and your own experience
    with it
          Getting practical feedback about treatment options
          Learning about health, economic or social resources

    Conclusion

    Assuring the healthy development of all children is essential for
    societies seeking to achieve their full health and potential. Finding
    early remedies to shared trauma and loss is critical to the flourishing
    of our communities. Rainbows for All Children works to promote
    conditions that reduce or eliminate risky behavior and develop healthy
    children. At Rainbows for All Children, we know first-hand the
    important work we are doing, and it has been a joy to see children on
    their journey of restored health. Our founder once said that she,
    ``would never stop until every grieving child had a voice.'' We are
    committed to ensuring her mission lives on with the same compassion and
    commitment.

                                     ______

                                      REAP

                                 P.O. Box 86341

                               Portland, OR 97286

                               Phone 503-688-2784

                               Fax 1-888-473-2963

                              https://reapusa.org/

    U.S. Senate
    Committee on Finance

    REAP is a multi-cultural youth leadership non-profit organization
    focused on developing the next wave of leaders for the future now.
    Based in the state of Oregon, REAP serves culturally students across
    four counties, eight school districts in 24 schools.

    REAP values mental health initiatives and social emotional learning as
    a dimension of support in our service to students. REAP has worked to
    elevate student voice around this topic since the formation of the
    organization whether through Mental Health Summits or collaborating
    with various local and state organizations to develop groundbreaking
    research and training concerning suicide prevention.

    REAP is in support of the work Sen. Ron Wyden is doing to increase
    access to mental healthcare. REAP recently connected our students with
    the Sen. Wyden's Mental Health Listening Session on January 31st.
    Students spoke of their experience with the lack of access to mental
    health support. Many students reported not having enough access to
    counselors in their schools, preventing timely care for student needs.
    This need is disproportionate among racially and culturally diverse
    students.

    It is imminently vital to the lives of our youth that we strive to
    improve access to timely mental healthcare in effort to elevate the
    current and the next generation of leaders for a better future. REAP
    supports the bipartisan work that Sen. Ron Wyden and the U.S. Senate
    Committee on Finance to improve mental health systems in our country.

    Sincerely,

    Mark Jackson
    Executive Director

                                     ______

                    Statement Submitted by Ethan J.S.H. Reed
    Honorable Chairman Wyden, Ranking Member Crapo, and members of the
    Finance Committee, I share to express my support for today's hearing on
    tackling the mental health and substance use crisis we are currently
    facing across America. As an 18-year old youth activist, I had begun my
    civic engagement shortly after my community of Douglas County,
    Colorado, was ravaged by a school shooting at a STEM school in
    Highlands Ranch, Colorado, and one of my good friends happened to be in
    the classroom where it had begun. Fortunately, he had made it out alive
    to safety, however he had to witness a classmate of his get shot in the
    back while attempting to run outside of the school. To this day he
    still suffers from several mental health issues, including anxiety,
    PTSD, etc. I've unfortunately lost two friends to suicide as well--
    their names were Hannah and Olivia. Since these tragedies, it brought
    me to the realization of just how severe the mental health among young
    Americans truly is.

    I have had the privilege to serve my home state of Colorado by
    championing two mental health bills in the state legislature, and it is
    with great hope I further mental health legislation and its priorities
    in Congress. I am currently working with congressional leadership and
    other members of Congress on the priorities of mental health and
    substance use legislation, and so I applaud the efforts by this
    esteemed committee to begin hearings on tackling this crisis.

    I remain optimistic that by the end of this session of Congress, we
    will have passed several pieces of legislation, and a potentially
    landmark mental health package that will further provide benefits and
    support for mental health services for young Americans to continue to
    have adequate access for support. It is with good intentions that I
    will continue to work with Congress and this esteemed committee to get
    legislation prioritized for the millions of young Americans across this
    country suffering and struggling with mental health and substance use
    issues.

    One thing is made clear--the young people are NOT okay. We need
    reliable and adequate services and support from adults and our elected
    officials to provide us the benefits and funding that is so desperately
    needed right now. The COVID-19 pandemic has only exacerbated this
    crisis, and the youth are in dire need of help. I urge all American
    families and parents to check up on their children and youth, because I
    can guarantee that we need to be asked more about how we are feeling
    and whether we are okay or not.

    Thank you so much for giving me this privileged opportunity to share my
    shared experiences as a young American, and for my voice to be on this
    platform with the Finance Committee. Let's get to work on immediate
    mental health and substance use legislation.

                                     ______

                         Sandy Hook Promise Action Fund

                                 P.O. Box 3489

                               Newtown, CT 06470

                  Statement of Mark Barden, Co-Founder and CEO

    I would like to begin by thanking Chairman Wyden, Ranking Member Crapo,
    and the members of the Senate Finance Committee for holding this
    important hearing today. I am grateful for your commitment to
    addressing the United States' growing mental health crisis and
    specifically, the mental health needs of our nation's youth.

    My name is Mark Barden, and I am one of the co-founders of Sandy Hook
    Promise. On December 14, 2012, the youngest of my three children, my
    sweet little Daniel, was murdered in his first-grade classroom at Sandy
    Hook Elementary School. The pain my family has endured every day since
    Daniel was taken from us is impossible to fully convey to you.

    Following the shooting, I began working with other family members whose
    loved ones were killed that day to find a way to prevent other parents
    from experiencing the senseless, horrific death of their child due to
    gun violence. The result was Sandy Hook Promise, a national nonprofit
    organization dedicated to honoring all victims of violence by turning
    our tragedy into a moment of transformation. By empowering youth to
    ``know the signs'' and uniting all people who value the protection of
    children, we can take meaningful action in schools, homes, and
    communities to prevent violence and stop the tragic loss of life.

    Youth in this country are facing a mental health emergency. Since 2010,
    suicide has been the second-leading cause of death for young Americans
    aged 10-24.\1\ Mental Health America's 2021 State of Mental Health
    report showed that 77,470 youth, over one third of whom identify as
    LGBTQ+, are experiencing frequent suicidal ideation.\2\ Additionally,
    youth between the ages of 10 and 17 are now more likely than any other
    age group to score for moderate to severe symptoms of anxiety and
    depression.\3\
    ---------------------------------------------------------------------------
        \1\ Ten Leading Causes of Death and Injury Charts, Center for
    Disease Control and Prevention. Available at https://www.cdc.gov/
    injury/wisqars/LeadingCauses.html.
        \2\ Mental Health America. (2021). The State of Mental Health in
    America. MHA. Retrieved from https://mhanational.org/get-involved/
    download-2021-state-mental-health-america-report.
        \3\ Ibid (4).

    Certain communities have borne the brunt of this tragic escalation.
    Suicide rates among American Indian and Alaskan Native adolescents ages
    15-19 are 60% higher than the national average for all teenagers.\4\
    Suicide and suicidal behaviors for Black youth are also rising; Black
    boys ages 5-12 are twice as likely to die by suicide as compared to
    their white peers.\5\
    ---------------------------------------------------------------------------
        \4\ Ibid (4).
        \5\ Bridge, J., Horowitz, L., Fontanella, C., Sheftall, A.,
    Greenhouse, J., Kelleher, K., and Campo, J. (2018). Age-Related Racial
    Disparity in Suicide Rates Among U.S. Youths From 2001 Through 2015.
    JAMA Pediatrics, 172(7), 697. doi: 10.1001/jamapediatrics.2018.0399.

    The ongoing COVID-19 pandemic has only exacerbated these already
    alarming trends. Last fall, the American Academy of Pediatrics (AAP),
    the Children's Hospital Association (CHA), and the American Academy of
    Child and Adolescent Psychiatry (AACAP) declared a national emergency
    in child and adolescent mental health, specifically citing the toll of
    the pandemic.\6\ This was followed by a December 2021 U.S. Surgeon
    General advisory calling for a unified response to the mental health
    challenges facing young people.\7\
    ---------------------------------------------------------------------------
        \6\ AAP, AACAP, CHA declare national emergency in children's mental
    health (October 2021), https://publications.aap.org/aapnews/news/17718.
        \7\ U.S. Surgeon General Issues Advisory on Youth Mental Health
    Crisis Further Exposed by COVID-19 Pandemic, U.S. Department of Health
    and Human Services (December 2021), https://www.hhs.gov/about/news/
    2021/12/07/us-surgeon-general-issues-advisory-on-youth-mental-health-
    crisis-further-exposed-by-covid-19-pandemic.html.

    To address this crisis, it is crucial that all children and youth have
    access to mental health care and resources. When Sandy Hook Promise's
    15-year-old Youth Advisory Board (YAB) member Arriana Gross testified
    before the Energy and Commerce Committee in June 2020, she discussed
    having to travel almost 2 hours from her home and school in Covington,
    Georgia to receive mental health services. Too many young people
    ---------------------------------------------------------------------------
    currently have similar barriers to accessing mental health care.

    Schools can serve as one of the best mechanisms to offer mental health
    care for youth, particularly for those living in provider shortage
    areas and low-resourced communities. Current availability of school-
    based mental health professionals remains low, particularly in schools
    where many students come from low-income households.\8\ To expand
    access to school-based mental health services, we recommend allowing a
    payment model to fund mental health professionals to provide services
    in schools through Medicaid. By creating a funding model that allows
    local education agencies (LEAs) and schools to coordinate Medicaid
    payments for school mental health services, we can start to address the
    gap in access to youth mental health care.
    ---------------------------------------------------------------------------
        \8\ https://nces.ed.gov/programs/digest/d19/tables/
    dt19_233.69b.asp?current=yes.

    We also recommend guaranteeing reimbursements for pediatricians who
    conduct suicide-risk screenings through Medicaid. Screening for risk of
    suicidal behavior can be a crucial first step in preventing suicide
    among young people. In December 2021, the Health Resources & Services
    Administration (HRSA) accepted an update to the AAP's Bright Futures
    Periodicity Schedule, adding screening for suicide risk for youth aged
    12-21 to the current Depression Screening category.\9\ Many major
    health insurance companies reimburse providers for use of suicidal risk
    measures under CPT Code 96127 and, while many state Medicaid plans
    allow payment for adolescent health risk assessments, including
    depression screenings as a preventative service, it is important that
    we ensure that this extends to suicide-risk screenings.
    ---------------------------------------------------------------------------
        \9\ https://mchb.hrsa.gov/programs-impact/programs/bright-futures.

    We know that funding access to mental health care and resources has the
    power to save lives and help protect our children and youth. Thank you
    for your committee's commitment to making youth mental health a top
    priority and for the opportunity to submit testimony today on this
    ---------------------------------------------------------------------------
    critical issue.

                                     ______

                    Sports and Fitness Industry Association
    The Sports and Fitness Industry Association (SFIA) applauds the Senate
    Finance Committee for its leadership in bringing attention to the
    pandemic's egregious effects on mental health. The December 2021
    Surgeon General's report, Protecting Youth Mental Health, sounded the
    alarm in terms of what is happening in our schools and what families
    are experiencing at home.

    We agree with U.S. Surgeon General Vice Admiral Vivek H. Murthy's
    findings that Americans are not protecting their mental and physical
    health enough. Equally troubling, we also agree with the Centers for
    Disease Control and Prevention report recent January 2022 findings on
    the sedentary lifestyle that is becoming all too common throughout
    America. Together, the rise in obesity and diabetes rates, as well as
    adult substance abuse and adolescent depression, anxiety, and suicide
    provide a fatal combination that will have longstanding repercussions
    for our nation's health-care system.

    As the leading active lifestyle trade association in the U.S., we are
    responsible for tracking physical activity levels for Americans each
    year--data that is shared with the U.S. Department of Health and Human
    Services. Given the annual survey, we know firsthand how these rates
    have declined over time and their corresponding spike in behavioral
    health issues.

    This lens provides important insight into the vital role that sports
    and exercise play in mental, social, and physical development. It is
    why SFIA has been working steadfastly on solutions to help Americans
    recover and reconnect. Those two words are behind our daily mission
    touting the benefits of exercise for all age groups. No matter the
    challenge, physical fitness is a key ingredient to healthy body and
    mind. The Surgeon General's report highlights this aspect and
    specifically, the stress that children experience when sports are
    canceled and conversely, the stress levels that are mitigated when a
    child exercises.

    It comes as no surprise that we need policies to make exercise more
    accessible and affordable. This ranges from school and community-based
    programs to expanding the use of pre-tax medical accounts to encourage
    healthy lifestyles. For example, the U.S. Tax Code does not acknowledge
    exercise as a form of prevention despite overwhelming evidence on the
    health benefits of activity, yet endless medical treatments are
    deducted. It's time to hit reverse and allow families to use their own
    money for the sake of staying mentally and physically fit. These
    accounts continue to grow in popularity with over 96 million Americans
    having access to either a health savings account or flexible spending
    account.

    Legislation known as the Personal Health Investment Today (``PHIT'')
    Act embraces this approach. This bipartisan bill is led by Senators
    John Thune (R-SD) and Chris Murphy (D-CT), as well as Representatives
    Ron Kind (D-WI) and Mike Kelly (R-PA). The measure passed
    overwhelmingly in the House back in 2018 by a vote of 277 to 142. With
    over 4,000 industry stakeholders all in support, the PHIT Act serves as
    a multigenerational ``win-win'' designed to take on the pandemic's
    aftershocks.

    As the Senate Finance Committee strives to address this important
    issue, we encourage you to consider all available remedies including
    broader treatment of physical activity as preventative care. SFIA looks
    forward to working with the Committee and serving as a data resource.

    We respectfully submit the enclosed statement. If you have any
    questions or need additional information, please feel free to contact
    Tom Cove, SFIA President, at tcove@sfia.org, or visit our website at
    https://sfia.org/.

                                     ______

                           Texas Children's Hospital

                               6621 Fannin Street

                              Houston, Texas 77030

                                  832-824-1000

    February 7, 2022

    Hon. Ron Wyden
    Chair
    U.S. Senate
    Committee on Finance
    219 Dirksen Senate Office Building
    Washington, DC 20510

    Hon. Mike Crapo
    Ranking Member
    U.S. Senate
    Committee on Finance
    219 Dirksen Senate Office Building
    Washington, DC 20510

    On behalf of Texas Children's Hospital, we submit this letter for the
    record in connection with the Senate Finance Committee hearing,
    ``Protecting Youth Mental Health: Part I--An Advisory and Call to
    Action,'' which was held on February 8, 2022. Located in Houston,
    Texas, Texas Children's Hospital is a not-for-profit organization with
    a mission to create a healthier future for children and women
    throughout our global community by leading in patient care, education
    and research. We are proud to be consistently ranked among the top
    children's hospitals in the nation.

    According to the Child Mind Institute, an estimated 17.1 million
    children in the U.S. have or have had a psychiatric disorder, which is
    more than the number of children with cancer, diabetes and AIDS
    combined (2019). Pediatric emotional and behavioral health challenges
    were of growing concern pre-pandemic, but the impact of COVID-19 on the
    mental health of children has been catastrophic. A recent research
    study (Racine, et al., 2021) showed that the prevalence of anxiety and
    depression in children and adolescents doubled in the first year of the
    pandemic as compared to pre-pandemic estimates, with higher rates in
    data collected later in the pandemic--suggesting that as the pandemic
    continues, we may in fact see even more impact on pediatric mental
    health.

    We know that children thrive on structure, routine, and predictability
    and that children who live in homes where their primary caregivers
    experience stress--related to financial hardship, job loss, and
    uncertainty--are at higher risk for the development of emotional and
    behavioral disorders. The pandemic has impacted nearly every household
    in the United States in both of these areas. In addition, COVID-19
    restrictions removed children and families from their sources of
    support--school, friends, extended family members, places of worship,
    community centers, and youth programs at places like the YMCA and Boys
    & Girls Clubs. COVID-19 also has further magnified inequities that
    adolescents and children from disadvantaged backgrounds and
    impoverished communities face due to health disparities, social
    determinants of health, and lack of access to technology.

    We see the mental health crisis at Texas Children's Hospital at every
    single entry point into our system--the Emergency Centers, outpatient
    clinics, and even in our pediatrician practices. Children and
    adolescents present to our Emergency Centers with acute behavioral
    health needs including aggressive episodes, suicidal ideation, and
    suicide attempts. From 2019-2021, the number of patients coming to
    Texas Children's Hospital's Emergency Centers for behavioral health
    crises went from fewer than 100 patients a month to upwards of 400 a
    month.

    Oftentimes, these patients and their families arrive at Texas
    Children's Hospital because they do not know where else to turn. For
    example, each week we see adolescents with severe developmental
    disabilities such as Autism and related aggressive and/or self-
    injurious behavior. Most of the time, their parents have spent the
    child's entire life advocating, caring for, and protecting their
    vulnerable child--but with the pandemic, they find their child out of
    his or her specialized school programs, with in-home therapies reduced
    or eliminated, and themselves unable to access respite care in the
    community. However, under these conditions, a child's aggressive
    behavior has become too hard to manage at home. We need to find better
    ways to care for these children and support their parents and families.

    Appropriate discharge of behavioral health patients presenting to
    emergency centers has become very challenging. Often there are no beds
    at facilities equipped to provide the higher levels of care needed
    (such as psychiatric inpatient hospitalization or an intensive
    outpatient program), or no access to programs that can meet the
    patient's complex needs. As a result, children with acute mental health
    needs either remain in our Emergency Centers for extended periods of
    time or are admitted to our medical floors where, unfortunately, the
    staff are not trained or equipped to provide the best care for these
    children and adolescents. We have seen staff injured by behavioral
    health patients, as well as patients who find ways to self-harm or
    attempt to elope from the medical floors. The influx of behavioral
    health patients from 2019-2021 resulted in a 2,775% increase in the
    number of patient sitters needed for suicidal patients, and a 612%
    increase in the number of patient sitters needed for aggressive
    patients. At times, we have to shuttle patient sitters among our three
    campuses to keep staffing numbers in line with the number of behavioral
    health patients admitted. Not only are we seeing more behavioral health
    patients on our medical units, but they also are staying longer than
    other patient groups. This is especially true for our most vulnerable
    children in CPS custody and in foster care.

    Meanwhile, in outpatient care, we have seen nearly 22,000 referrals in
    our mental health specialty areas this fiscal year to-date. This
    significant demand has created wait-lists of six months to a year for
    many of our behavioral health services. Children simply are not getting
    the care they need. We surveyed families of our behavioral health
    patients to hear more about how they felt the system was addressing
    their needs. We received feedback that our patients preferred to stay
    in our care when possible, but a lack of inpatient resources has caused
    us to have to transfer these patients to other facilities, many of
    which are unprepared to care for children's complex medical needs. We
    also heard their frustration and fear for the health, safety and well-
    being of their children.

    As a result of what we have seen among our patients throughout the
    pandemic, Texas Children's Hospital created an internal Behavioral
    Health Task Force comprised of clinical and operational leaders to
    determine what steps we could take to meet the growing behavioral
    health needs of children who need our care, both immediately and over
    the long term. The behavioral health needs of our children will not go
    away in the next three to five years; in fact, we expect them to grow
    as the full effect of the pandemic is revealed, including longer-term
    mental health concerns, the impact of learning gaps that resulted from
    school closures, and grief and bereavement related to the over 900,000
    Americans who have died from the virus. Therefore, through the Task
    Force's work, we have developed short- and long-term strategies that
    could meet the behavioral health needs of children in Texas that
    include both program and workforce development.

    Our hope is to:

    In the next year, deploy a Short-Term Strategy to:

          Implement Behavioral Health Support Team;
          Implement Inpatient Psychiatric Unit;
          Implement Intensive Outpatient Program;
          Expand outpatient programs;
          Improve training for staff and providers; and
          Improve ``safe'' care locations throughout the system.

    Over the next three to five years, deploy a Long-Term Strategy
    inclusive of:

          Dedicated behavioral health urgent care;
          Dedicated behavioral health inpatient facility;
          Robust preventive care, family education and support; and
          Expanded behavioral health clinical research and education
    programs.

    But, we cannot do it alone. Texas has severe gaps along the entire
    continuum of care--from early intervention and detection through crisis
    intervention and stabilization--in terms of access, capacity and
    workforce. This entire continuum of care is vital to ensuring the long-
    term health and well-being of children, and we are just one piece of
    that continuum. Our Emergency Centers are where frantic parents arrive
    when their kids are in crisis. Our goal is to keep children out of
    crisis, living safely at home with their families, and not returning to
    our Emergency Centers. Simply put, we need community partnerships that
    do not currently exist. In a robust continuum of care, early
    identification and intervention would help reduce the number of kids in
    emergency departments and keep them living in their communities and
    with their families whenever possible. Current resources are unable to
    meet demand. To effectively address the broader impacts that we have
    experienced, we offer the following suggested solutions.

          Stronger Community Partnerships: We know children's hospitals
    will never be able to meet the immense behavioral health needs in our
    state. Through strong partnerships with community stakeholders and
    service providers, we can ensure that our children get the right mental
    health care, in the right place, at the right time. Some examples
    include:
              Expanding clinical collaboration between
    children's hospitals and the Texas Child Mental Health Care Consortium
    to partner on the development of strategies to increase access to
    evidence-based behavioral health services across the continuum of care;
              Employing community health workers or navigators
    to coordinate family access;
              Implementing pediatric primary care practice
    behavioral health integration;
              Conducting pediatric training for crisis
    response;
              Educating individuals providing daily care for
    children and adolescents in child welfare and juvenile justice settings
    regarding trauma informed care, identifying mental health concerns, and
    finding the right resources for
    evidence-based mental health care for those in need;
              Establishing mental and behavioral health urgent
    care; and
              Implementing community-based initiatives, such as
    school-based partnerships and initiatives to decompress emergency
    departments, including partial hospitalization and intensive outpatient
    programs.

          Address Behavioral Health Workforce Limitations: There is a
    national shortage of pediatric mental health professionals. Through
    support for workforce development that includes more specialists,
    increasing education in mental health assessment and interventions for
    general pediatric practitioners, and training peer support specialists,
    community health workers, and non-clinical professionals and
    paraprofessionals in early detection of mental health concerns, we can
    improve the long-term picture for pediatric mental health in Texas. We
    recommend achieving this by:
              Increasing funding to support training the next
    generations of pediatric mental and behavioral health-care providers
    (child and adolescent psychiatry, developmental and behavioral
    pediatrics, psychology internship and fellowship programs);
              Improving models of reimbursement that allow for
    billing of mental health services provided by advanced learners under
    supervision (e.g., for psychology interns and fellows);
              Requiring parity for mental health treatment for
    all insurance carriers;
              Revisiting reimbursement for mental health
    services to reduce the number of ``cash only'' mental health providers
    in the community; and
              Advocating to change ACGME residency training
    requirements to reflect ``real world'' pediatric practice that includes
    less acute medical care and additional training in developmental and
    behavioral health for emerging pediatricians, internal medicine, and
    family practice physicians.

          Increase Access to Behavioral Health Care for Families:
    Expanding access to high quality, evidence-based care across the
    spectrum of mental health needs, from prevention and early intervention
    to acute and crisis care is critically important. We want to ensure
    that parents, caretakers, and family members can be engaged in
    collaborative decision-making and treatment planning to address their
    children's mental health concerns by:
              Increasing school-based mental health-care
    programs;
              Creating models of community-based support for
    parents of children with mental health concerns to address parenting
    and parental mental health and substance abuse issues;
              Expanding access to mental health services for
    women and families in the postpartum period, particularly those with
    critically ill newborns;
              Improving high speed Internet infrastructure to
    increase access to telehealth and other virtual services; and
              Continuing support for services rendered via
    telehealth and, where needed, telephone-only services, including those
    rendered when the patient is at home or at school.

    We commend the committee for holding this important hearing on
    behavioral health and urge Congress to use these recommendations to
    take meaningful action to protect the well-being and mental health of
    all children across the country.

    If you have any questions please contact Johnna Carlson, Texas
    Children's Assistant Vice President of Government Relations, at
    jlcarls1@texaschildrens.org or Emily Felder, Shareholder, Brownstein
    Hyatt Farber Schreck, at efelder@bhfs.com.

    Sincerely,

    Karin L. Price, Ph.D.
    Chief of Psychology

                                     ______

                   UCLA Center for the Developing Adolescent

                        760 Westwood Plaza, Semel B7-435

                             Los Angeles, CA 90095

    U.S. Senate
    Committee on Finance

    As developmental scientists and Co-Executive Directors of the Center
    for the Developing Adolescent,\1\ professors of psychiatry and
    psychology, and scientists at the Jane and Terry Semel Institute for
    Neuroscience and Human Behavior, all at UCLA, we have spent years
    studying adolescent development and well-being. We appreciate the
    Senate Finance Committee's commitment to addressing the youth mental
    health crisis and working toward policy solutions focused on
    prevention. As the Committee hearing made clear, the issue of youth
    mental health is real and serious, and predates the pandemic, with
    increases in loneliness, depression, and anxiety beginning at least a
    decade ago. The pandemic has been a strong reminder that as a society,
    we need to prioritize the well-being of our young people and give this
    issue the attention it deserves. We are pleased to submit a statement
    for the record as the Committee continues it's work on this issue.
    ---------------------------------------------------------------------------
        \1\ https://developingadolescent.semel.ucla.edu/.

    The adolescent years--from about 10 to around 25--are a period of
    remarkable learning and adaptation.\2\ At the beginning of puberty, our
    brains are changing rapidly in response to our experiences, forming and
    strengthening connections between neurons (brain cells) faster than
    they ever will again. These changes make us especially sensitive to the
    world around us. As we engage with that world, our relationships and
    experiences in turn provide feedback that further shapes our developing
    brain.
    ---------------------------------------------------------------------------
        \2\ https://www.researchgate.net/profile/Ronald-Dahl/publication/
    230698133_Understanding_
    adolescence_as_a_period_of_social-
    affective_engagement_and_goal_flexibility/links/00463524c73
    9f89085000000/Understanding-adolescence-as-a-period-of-social-
    affective-engagement-and-goal-flexibility.pdf.

    The learning potential of this time of life creates enormous
    opportunity, opening a pivotal window to impact not only mental health,
    but life trajectories. With the right kinds of opportunities and
    support, we can leverage \3\ the remarkable adaptivity of these years
    to support positive learning and discovery and even mitigate the
    effects of earlier adversity.
    ---------------------------------------------------------------------------
        \3\ https://www.nature.com/articles/nature25770.

    Research on adolescent social and cognitive development tells us the
    kinds of opportunities and support that adolescents need to promote not
    only their mental health but their broader capacity to thrive. These
    include safe and satisfying ways to explore the world and test out new
    ideas and experiences, real-world scenarios in which to build and hone
    problem-solving and decision-making skills, avenues to develop a sense
    of meaning and purpose by helping and supporting families and
    communities,\4\ access to social interactions that support a positive
    sense of identity, and warmth and support from parents and other caring
    adults.
    ---------------------------------------------------------------------------
        \4\ https://journals.sagepub.com/doi/10.1177/1745691618805437.

    As Surgeon General Dr. Vivek Murthy shared in his Advisory and
    reiterated in his February 8 testimony, the COVID pandemic has created
    barriers to many of the opportunities that young people need for
    positive development. The pandemic has also exacerbated long-standing
    social inequities, disproportionately imposing these developmental
    barriers on youth of color and those from low-income families. It is
    not surprising that Dr. Murthy and the advisory flags these youth as
    ---------------------------------------------------------------------------
    being at higher risk of mental health challenges during the pandemic.

    In his December 2021 Advisory, Dr. Murthy called for ``policy,
    institutional, and individual changes in how we view and prioritize
    mental health.'' As the Committee's work on youth mental health moves
    forward, we see an opportunity to not only address youth well-being at
    the crisis level, but to set a higher goal of helping youth to flourish
    by prioritizing adolescence itself. As you consider policy solutions
    and work to establish the interventions and supports all youth need to
    protect their mental health, we urge you to ensure that your
    recommendations regarding funding, programs, and policies are grounded
    firmly in what science tells us is crucial to establishing the
    foundations for life-long health and well-being for all adolescents,
    including:

          Exploration and Healthy Risk Taking--During adolescence, we are
    uniquely motivated toward new and intense experiences. This increased
    motivation to explore and pursue novel experiences is fundamental to
    learning during this window of development. Inequities in our society
    often limit opportunities for healthy risk taking and amplify negative
    consequences of mistakes for young people from traditionally
    marginalized groups. We urge the Committee to prioritize investments in
    programs that provide safe opportunities for positive exploration and
    risk taking.
          Contribution--Opportunities to provide ideas, resources, and
    help that impact their social worlds support adolescents to build
    autonomy, identity, and intimacy, while providing real benefits to
    society. All adolescents need opportunities to make meaningful
    contributions to their families, peers, schools, and wider communities
    and to have those contributions recognized. As the Committee's work
    moves forward, we encourage you to center this principle in both policy
    and practice, including ensuring that young people are at the table to
    share their lived experiences and ideas for solutions as part of the
    Committee's work.
          Emotional regulation and decision making skills--Adolescence is
    a time when we are developing the skills to manage our emotions,
    control our behavior, and make good decisions. We must support young
    people in the development of these skills by providing opportunities to
    learn and observe coping skills, see examples of healthy emotional
    expression, have avenues to make real-world decisions, and receive
    support to learn from mistakes.
          Identity--During adolescence, we're figuring out who we are,
    what we value, and who we want to be. This makes it a period of time
    when racism and other forms of discrimination can have a strong impact
    on a young person's sense of self. We urge the Committee to prioritize
    efforts proven to support a positive sense of identity, including
    addressing racial disparities in discipline and access to messages and
    spaces that affirm a healthy racial-ethnic identity.
          Connections--Supportive relationships with parents and other
    caring adults are still extremely important in adolescence, even as
    peer relationships become a more central focus. Policies and programs
    that support the whole family are essential to the well-being of all
    adolescents, particularly those facing adverse experiences. We urge the
    Committee to prioritize investments in research-
    informed programs that support parents of adolescents, including within
    youth-serving systems such as the child welfare and youth justice
    systems.

    Thank you for your commitment to addressing the youth mental health
    crisis and working toward policy solutions focused on prevention. As
    your work moves forward we hope you will consider funding, programs,
    and policies that are grounded firmly in what science tells us is
    crucial to ensuring that our youth can thrive in ways that ensure a
    bright future for us all. Please don't hesitate to contact us (agalvan
    @ucla.edu and afuligni@g.ucla.edu) should you like to discuss the
    research on adolescent development and well-being or our
    recommendations.

    Adriana Galvan, Ph.D., and Andrew J. Fuligni, Ph.D.

                                     ______

          University Hospitals Rainbow Babies and Children's Hospital

                                11100 Euclid Ave

                               Mailstop MPV 6003

                              Cleveland, OH 44106

    In follow-up to the February 8, 2022 hearing, ``Protecting Youth Mental
    Health: Part I--An Advisory and Call to Action,'' Rainbow Babies and
    Children's Hospital strongly endorses the positions taken by the
    American Academy of Pediatrics (AAP), the American Academy of Child and
    Adolescent Psychiatry (AACAP) and the Children's Hospital Association
    (CHA) in their statement for the record.

    Since the fall of 2021, the above member organizations have declared a
    national emergency in child and adolescent mental health. The
    situation, already dire prior to the Pandemic \1\ has only worsened
    with increased social isolation, fear and grief amongst our children
    and adolescents. Twenty percent of children and adolescents experience
    a mental health disorder in a given year.\2\ For children needing
    treatment, it takes on average 11 years after the first symptoms appear
    before getting that treatment.\3\ There is also alarming signal of
    inequity in mental health outcomes and access to high-quality mental
    health care services for children of color. 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 improve the mental health of our children and our country
    as we avoid more serious and costly outcomes later--including suicidal
    ideation and death by suicide.
    ---------------------------------------------------------------------------
        \1\ Daniel G. Whitney and Mark D. Peterson, ``U.S. 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.
        \2\ Centers for Disease Control and Prevention (CDC), ``Key
    Findings: Children's Mental Health Report,'' March 22, 2021.
        \3\ National Alliance on Mental Illness, ``Mental Health
    Screening,'' accessed on November 10, 2021.

    Rainbow Babies and Children's Hospital is appreciative of the Senate
    Finance Committee's recognition of the children's mental health
    emergency and focus on the unique needs of this population. As the
    Committee works on legislative solutions, we echo the AAP, AACAP and
    CHA conclusions that the following policy priorities are critical to
    ---------------------------------------------------------------------------
    improve access to mental health services for children:

          Increased investments to support the recruitment, training,
    mentorship, retention and professional development of a diverse
    clinical and non-clinical pediatric workforce, including funding for
    minority fellowship programs for mental health physician specialists.
    We currently face dire shortages in mental health providers with an
    even more significant dearth of minority providers. We need to
    encourage more people to enter these fields.
          Address low Medicaid payment rates for pediatric mental health
    services, ways to better support coordination and integration of care
    and access to school-based services. These low rates result in lower
    provider engagement and participation in the Medicaid program as well
    as contribute to the mental health worker shortage with consequent
    limitations in access to services.
          Direct CMS to review how Early and Periodic Screening,
    Diagnostic and Treatment (EPSDT) is implemented in the states to
    improve access to early intervention services, developmentally
    appropriate mental health services and to provide guidance to states on
    Medicaid payment for evidence-based mental health services that promote
    integrated care. As noted earlier, delays in identification and
    treatment of mental health issues is a substantial problem. The EPSDT
    benefit is tailored to children's unique needs and ensures that
    children receive care as early as possible.
          Dedicate support for the pediatric mental health system and
    infrastructure that are currently distressingly underfunded. An
    emphasis should be placed on
    community-based, ambulatory systems across a wide array of settings
    including primary care offices, early childhood education programs,
    family therapy and, when warranted, inpatient care.
          Expand telehealth services to include audio-only services, the
    lifting of originating site restrictions and geographic limitations and
    the encouragement of state Medicaid programs to continue telehealth
    coverage and payment.
          Ensure strong implementation, oversight and proactive
    enforcement of the mental health parity and addiction equity act.
    Payers and plan administrators are failing to cover mental health and
    substance use disorder care through limitations in in-network care,
    limitations in provider networks and the establishment of non-
    qualitative treatment limits unseen in medical and surgical benefits.
    Both public and private payers routinely exclude payment for mental
    health services provided by a primary care provider.

    Our pediatricians, psychologists, child and adolescent psychiatrists
    and advanced practice nurses are eager to partner with you to advance
    policies that improve access to quality mental health services
    available to children. Please call on us as you develop policy
    improvements to address this national emergency for children's mental
    health.

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