[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
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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.
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\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'
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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
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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.
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\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\
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\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
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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\
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\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\
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\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.
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\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
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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.
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\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
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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.
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\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
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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.
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\15\ https://thinkculturalhealth.hhs.gov/.
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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.
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\16\ https://thinkculturalhealth.hhs.gov/clas/standards.
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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.
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\17\ https://aspe.hhs.gov/reports/hhs-implementation-guidance-data-
collection-standards-race-ethnicity-sex-primary-language-disability-0.
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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.
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\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
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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\
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\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
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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.
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\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,
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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.
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\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?
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\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
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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.
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\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
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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.
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\30\ https://www.hhs.gov/surgeongeneral/health-misinformation-rfi/
index.html.
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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\
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\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
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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:
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\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.
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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.
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\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.
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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\
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\37\ https://www.youtube.com/watch?v=vfA52EohO8o.
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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.
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\38\ https://www2.ed.gov/documents/students/supporting-child-
student-social-emotional-behavioral-mental-health.pdf.
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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.
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\39\ https://www.cdc.gov/healthyschools/parentsforhealthyschools/
p4hs.htm?msclkid=bc3b367f
cfab11eca77127cce216be93.
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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.
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\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
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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.
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\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
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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\
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\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
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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.
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\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
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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.
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\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
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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.
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\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.
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\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.
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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
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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.
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\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.
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\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.
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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.
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\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
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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.
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\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
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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:
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\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\
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\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.
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\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
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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.
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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.
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\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\
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\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.
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\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
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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.
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\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
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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.
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\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
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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\
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\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
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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\
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\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
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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.
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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\
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\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\
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\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-
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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.
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\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
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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.
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\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
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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\
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\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\
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\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
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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.
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\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.
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\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/.
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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\
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\1\ SAMHSA. ``Adverse Childhood Experiences,'' https://
www.samhsa.gov/capt/practicing-effective-prevention/prevention-
behavioral-health/adverse-childhood-experiences. Updated July 9, 2018.
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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.
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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.
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Individuals who experience Adverse Childhood Experiences and do
not receive treatment have elevated risks of early death.\5\
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\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
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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\
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\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\
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\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\
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\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.
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\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.
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\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.
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\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.
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\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
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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.
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\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
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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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