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

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

                                Abstract

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

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

                            Acknowledgements

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

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

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

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

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

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

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

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

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

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

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


                                              Table 7: Overview of Estimates From Studies of Specific NPIs
--------------------------------------------------------------------------------------------------------------------------------------------------------
                          Lockdown          Facemasks/      Business Closure
                         (Complete/       Employee Face        (/Bars And     Border Closure  (/  School Closures        Limiting           Quality
                          Partial)            Masks           Restaurants)       Quarantine)                            Gatherings         Dimensions
--------------------------------------------------------------------------------------------------------------------------------------------------------
Chernozhukov et al.                               -34.0%             -28.6%                                                                           4
 (2021)
 
Bongaerts et al.                                                     -31.6%                                                                           2
 (2021)
 
Chaudhry et al.                  0.0%                                                     0.0%                                                        2
 (2020)*
 
Toya and Skidmore                0.5%                                                    -0.1%                                                        3
 (2021)
 
Aparicio and                                                          -1.3%                                  0.5%               0.8%                  4
 Grossbard (2021)
 
Auger et al. (2020)                                                                                        -58.0%                                     2
 
Leffler et al.                   1.7%                                                   -15.6%                                                        2
 (2020)
 
Stokes et al.                                                          0.3%             -24.6%              -0.1%              -6.3%                  3
 (2020)
 
Spiegel and Tookes                                -13.5%             -50.2%                                                    11.8%                  3
 (2021)
 
Bonardi et al.                   0.0%                                                     0.0%                                                        1
 (2020)*
 
Guo et al. (2021)                                                     -0.4%              36.3%              -0.2%               5.7%                  3
--------------------------------------------------------------------------------------------------------------------------------------------------------
Precision-weighted               0.6%             -21.2%             -10.6%              -0.1%              -4.4%               1.6%
 average
 
Arithmetic average               0.6%             -23.8%             -18.6%              -0.7%             -14.4%               3.0%
 
Median                           0.3%             -23.8%             -14.9%               0.0%              -0.1%               3.2%
--------------------------------------------------------------------------------------------------------------------------------------------------------
4 of 4 quality                n/a [0]         -34.0% [1]          -2.9% [2]            n/a [0]           0.5% [1]           0.8% [1]
 dimensions
 
3 of 4 quality               0.5% [1]         -13.5% [1]         -21.5% [3]           0.0% [3]          -0.1% [2]           5.6% [3]
 dimensions
 
2 of 4 quality               1.7% [2]            n/a [1]         -31.6% [2]         -15.6% [2]         -58.0% [1]            n/a [1]
 dimensions or
 fewer
--------------------------------------------------------------------------------------------------------------------------------------------------------
* It is not possible to derive common estimates and standard errors from Chaudhry et al. (2020) and Bonardi et al. (2020). Chaudhry et al. (2020) states
  that the effect of the various NPIs is insignificant without listing the estimates and standard errors. Bonardi et al. (2020) states that partial or
  regional lockdowns are as effective as stricter NPIs but does not provide information to calculate common estimates. Instead, we assume the estimate
  is 0% when calculating arithmetic average and median, while the estimates are excluded from the calculation of precision-weighted averages because
  there are no standard errors.


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

[GRAPHIC] [TIFF OMITTED] T0822.007

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

5 Concluding Observations

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

6 Appendix A. The Role of Timing

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

    We need to provide a full spectrum of primary care wellness 
including both physical and mental health care in schools. The Hopeful 
Futures Campaign \9\ produces report cards that provide data on the 
provision of mental health care in all 50 States and in the District of 
Columbia.
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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 
---------------------------------------------------------------------------
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÷=
10&id=&page=.
    \13\ Pew Center on the States. (2011). ``State of recidivism: The 
revolving door of America's prisons.'' Washington, DC: The Pew 
Charitable Trusts. http://www.pewtrusts.org/en/research-and-analysis/
reports/0001/01/01/state-of-recidivism.
    \14\ Henrichson, C., and Delaney, R. (2012). ``The price of 
prisons: What incarceration costs taxpayers.'' New York: Vera Institute 
of Justice.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

        Emphasizing the Whole School, Whole Community, Whole Child 
\33\ framework to implement evidence-based strategies that improve 
physical and mental health, encompassing healthy in-school and out-of-
school time programs and staff wellness. The model is comprised of 10 
components that work synergistically, including two related to mental 
health: Counseling, Psychological and Social Services and Social and 
Emotional School Climate.
---------------------------------------------------------------------------
    \33\ https://www.cdc.gov/healthyschools/wscc/index.htm.
---------------------------------------------------------------------------
        Supporting 15 geographically diverse State education agencies 
(SEAs) through the CDC Healthy Schools FY21 COVID-19 Supplemental 
Funding. This support is designed to address COVID-19 within K-12 
settings by supporting the implementation of COVID-19 prevention 
strategies and additional COVID-19 needs of local education agencies 
(LEAs) and schools. This includes supporting social, emotional, mental 
health and well-being of students and teachers and school staff as they 
returned to in-person learning this school year. The supplement funds 
this cooperative agreement for the 12-month budget/performance period 
from June 30, 2021, to June 29, 2022, to allow for the acceleration of 
activities.
        Developing resources like the social and emotional climate and 
learning webpage, \34\ which houses the Toolkit for Schools: Engaging 
Parents and Families to Support Social and Emotional Climate and 
Learning \35\ and Tools \36\ for school employee wellness.
---------------------------------------------------------------------------
    \34\ https://www.cdc.gov/healthyschools/sec.htm.
    \35\ https://www.cdc.gov/healthyschools/sec/sec_toolkit.htm.
    \36\ https://www.cdc.gov/healthyschools/employee_wellness.htm.
---------------------------------------------------------------------------
        A social media campaign and videos to promote school health 
champions, including Supporting the Well-being of School Employees on 
the Frontlines to help maintain healthy schools.\37\
---------------------------------------------------------------------------
    \37\ https://www.youtube.com/watch?v=vfA52EohO8o.
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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.
---------------------------------------------------------------------------
    \38\ https://www2.ed.gov/documents/students/supporting-child-
student-social-emotional-behavioral-mental-health.pdf.
---------------------------------------------------------------------------
        Provide tools and resources to parents and caregivers. CDC 
developed a set of resources, called Parents for Healthy Schools,\39\ 
to assist schools, school groups, and school wellness committees with 
encouraging parent involvement in school health. Parents for Healthy 
Schools uses evidence-based strategies for parent engagement.
---------------------------------------------------------------------------
    \39\ https://www.cdc.gov/healthyschools/parentsforhealthyschools/
p4hs.htm?msclkid=bc3b367f
cfab11eca77127cce216be93.
---------------------------------------------------------------------------
        Implement equitable, trauma-informed disciplinary policies.

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

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

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

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

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

    The National Youth Sports Strategy (NYSS), released in 2019 by 
OASH, is a Federal roadmap designed to unify U.S. youth sports culture 
around a shared vision: that one day all youth will have the 
opportunity, motivation, and access to play sports. It provides a 
framework with actionable steps that communities, organizations, 
decision-makers, and policymakers can use to help improve the U.S. 
youth sports landscape. At launch, the HHS awarded 18 Youth Engagement 
in Sports (YES) Grants with the help of our Office of Minority Health 
and Office on Women's Health, totaling over $6.7 million to help 
increase youth participation in sports and reduce barriers to play, 
especially for youth populations with lower rates of sports 
participation and communities with limited access to athletic 
facilities or recreational areas. These grants provided 3 years of 
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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.
---------------------------------------------------------------------------
    \45\ https://www.ed.gov/news/press-releases/statement-us-secretary-
education-miguel-cardona-cdc-guidance-and-keeping-schools-safely-open.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

    If not, what are the barriers still in place?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

                                 1_____
                                 
                 Prepared Statement of Hon. Ron Wyden, 
                       a U.S. Senator From Oregon
    On behalf of Senator Crapo and myself, it's our hope that this 
morning's hearing on the state of mental health for our youth serves as 
a wake-up call. Millions of young Americans are struggling under a 
mental health epidemic. Struggling in school. Struggling with addiction 
or isolation. Struggling to make it from one day to the next.

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

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

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

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

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

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

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

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

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

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

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

                                 ______
                                 

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

January 20, 2022

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

The Department's key 2021 accomplishments include:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

                                 ______
                                 

                             Communications

                              ----------                              


                 American Academy of Family Physicians

                 1133 Connecticut Ave., NW, Suite 1100

                       Washington, DC 20036-4305

                             (800) 794-7481

                             (202) 232-9033

February 8, 2022

The Honorable Ron Wyden             The Honorable Mike Crapo
Chairman                            Ranking Member
U.S. Senate                         U.S. Senate
Committee on Finance                Committee on Finance
Washington, DC 20510                Washington, DC 20510

Dear Chairman Wyden and Ranking Member Crapo:

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

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

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

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

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

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

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

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

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

Sincerely,

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

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

The challenges facing children's mental, emotional and behavioral 
health are so dire that our three associations, on behalf of the 
members we represent, declared a national emergency (https://
www.aap.org/en/advocacy/child-and-adolescent-healthy-mental-
development/aap-aacap-cha-declaration-of-a-national-emergency-in-child-
and-adolescent-mental-health/) in child and adolescent mental health 
last fall. We call on this committee to join us in recognizing the 
magnitude of the situation and advance meaningful and transformational 
solutions to address it. We strongly encourage the committee to put 
forward tailored and dedicated policies and support for children to 
better address their emotional, mental and behavioral health needs.

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

The COVID-19 pandemic continues to take a serious toll on children's 
mental health as young people face ongoing social isolation, 
uncertainty, fear and grief. Even before the pandemic, mental health 
challenges facing children were of great concern, and COVID-19 has only 
exacerbated them. Despite sizable federal funds allocated to address 
mental health in multiple COVID-19 relief packages, pediatric providers 
report that they are unable to access such funds due to very broad 
funding goals spread across multiple populations and the lack of 
specific designated funding to improve mental health care for children 
in their own practices and other health-care settings. As the single 
largest payer for children, Medicaid investment, through better support 
for services, integrated care and consistent implementation of the 
Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit, 
is critical to supporting children's mental health needs across the 
continuum and before diagnosis to prevent future and more serious 
problems.

The statistics illustrate an alarming picture for our children. Prior 
to the pandemic, almost half of children with mental health disorders 
did not receive care they needed.\1\ This is not limited to one state 
or one community--children in states across the country face the same 
challenges accessing the necessary mental health care to address their 
needs.\2\ Children's mental health conditions are common. One in five 
children and adolescents experience a mental health disorder in a given 
year,\3\ and 50% of all mental illness begins before age 14.\4\ For 
children needing treatment, it takes, on average, 11 years after the 
first symptoms appear before getting that treatment.\5\ Significant 
investments are needed now to better support and sustain the full 
continuum of care needed for children's mental health. These 
investments will significantly impact for the better our children and 
our country as we avoid more serious and costly outcomes later--
including suicidal ideation and death by suicide.
---------------------------------------------------------------------------
    \1\ Daniel G. Whitney and Mark D. Peterson, ``US National and 
State-Level Prevalence of Mental Health Disorders and Disparities of 
Mental Health Care Use in Children,'' JAMA Pediatrics 173, no. 4 
(2019): 389-391, doi:10.1001/jamapediatrics.2018.5399, https://
jamanetwork.com/journals/jamapediatrics/fullarticle/2724377.
    \2\ Ibid.
    \3\ Centers for Disease Control and Prevention (CDC), ``Key 
Findings: Children's Mental Health Report,'' March 22, 2021, https://
www.cdc.gov/childrensmentalhealth/features/kf-childrens-mental-health-
report.html.
    \4\ Substance Abuse and Mental Health Services Administration 
(SAMHSA), Adolescent Mental Health Service Use and Reasons for Using 
Services in Specialty, Educational, and General Medicaid Settings, 
March 5, 2016, https://www.samhsa.gov/data/sites/default/files/
report_1973/ShortReport-1973.html.
    \5\ National Alliance on Mental Illness, ``Mental Health 
Screening,'' accessed on November 10, 2021, https://www.nami.org/
Advocacy/Policy-Priorities/Improving-Health/Mental-Health-Screening.

Although the trends in pediatric mental health noted above were 
worrying before the COVID-19 emergency, demand over the past 18 months 
for pediatric inpatient mental health services, partial 
hospitalization, step-down programs and other levels of crisis care has 
risen significantly. Between March and October of 2020, the percentage 
of emergency department visits for children with mental health 
emergencies rose by 24% for children ages 5-11 and 31% for children 
ages 12-17.\6\ In the first three quarters of 2021, children's 
hospitals reported emergency room visits for self-injury and suicide 
attempts or ideation in children ages 5-18 at a 42% higher rate than 
during the same time period in 2019.\7\ There was also a more than 50% 
increase in emergency department visits for suspected suicide attempts 
among girls ages 12-17 in early 2021 as compared to the same period in 
2019.\8\
---------------------------------------------------------------------------
    \6\ Centers for Disease Control and Prevention, Mental Health-
Related Emergency Department Visits Among Children Aged <18 Years 
During the COVID-19 Pandemic--United States, January 1-October 17, 
2020, November 13, 2020, https://www.cdc.gov/mmwr/volumes/69/wr/
mm6945a3.htm.
    \7\ Analysis of Children's Hospital Association PHIS database, n=38 
children's hospitals.
    \8\ Centers for Disease Control and Prevention, Emergency 
Department Visits for Suspected Suicide Attempts Among Persons Aged 12-
25 Years Before and During the COVID-19 Pandemic--United States, 
January 2019-May 2021, June 18, 2021, https://www.cdc.gov/mmwr/volumes/
70/wr/mm7024e1.htm.

The challenges and limitations of the current mental health-care system 
are affecting all children, but the pandemic has exacerbated and 
highlighted existing disparities in mental health outcomes and access 
to high-quality mental health-care services for children of color. In 
2019, the Congressional Black Caucus found that the rate of death by 
suicide was growing at a faster rate among black children and 
adolescents, and that black children were more than twice as likely to 
die by suicide before age 13 than their white peers.\9\ Studies of 
Latino communities have found higher reported rates of depression 
symptoms and thoughts of suicide among Latino youth, but comparatively 
lower rates of mental health-care utilization. As the Senate Finance 
Committee weighs recommendations to promote children's mental health 
and strengthen access to care, the needs of children from racial and 
ethnic minority communities and the added barriers they frequently face 
must be addressed.
---------------------------------------------------------------------------
    \9\ Congressional Black Caucus, Ring the Alarm: The Crisis of Black 
Youth Suicide in America, December 17, 2019, https://youthtoday.org/
2019/12/ring-the-alarm-the-crisis-of-black-youth-suicide-in-america/.

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

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

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

We appreciate the Senate Finance Committee's recognition of the 
children's mental health emergency and continuing focus on this 
specific population and their unique needs. As you work to develop 
legislative solutions, we ask you to advance the following policy 
priorities that will result in improved access to mental health 
services for children, from promotion and prevention through needed 
---------------------------------------------------------------------------
treatments:

      Increase investments to support the recruitment, training, 
mentorship, retention and professional development of a diverse 
clinical and non-clinical pediatric workforce, including funding for 
minority fellowship programs for mental health physician specialists. 
Currently, there are dire shortages of minority mental health providers 
that have only gotten worse due to the pandemic. More dedicated support 
for a larger and more diverse pediatric workforce is critical to 
addressing children's mental health needs now and into the future. 
Stronger Medicaid investments supporting children's mental health 
services will improve engagement in the program and encourage more 
people to enter these fields.
      Address low Medicaid payment rates for pediatric mental health 
services, ways to better support coordination and integration of care 
and access to services in schools. Low payment rates weaken provider 
engagement and participation in the Medicaid program and directly 
relate to the mental health workforce shortages and access challenges 
for children. At the same time, there is a benefit to better 
coordination and integration of care for children with mental health 
needs that is not supported consistently under Medicaid. This 
coordination results in demonstratable improvements in the health and 
well-being of children and their families. Children need to access 
services where they are, including in schools. Better assistance and 
technical guidance for schools to be reimbursed for health services 
delivered to Medicaid eligible and enrolled students will help address 
issues more effectively. Close to 40 million children receive their 
health insurance coverage through Medicaid and would be positively 
affected by advancement of these policies.
      Direct CMS to review how EPSDT is implemented in the states to 
support access to prevention and early intervention services, as well 
as developmentally appropriate mental health services across the 
continuum of care and provide guidance to states on Medicaid payment 
for evidence-based mental health services for children that promotes 
integrated care. The EPSDT benefit is tailored to children's unique 
needs and provides an important opportunity to support early 
identification even before diagnosis. We can do a better job of 
implementing this benefit more consistently for children to ensure they 
receive care as early as possible and at every point along the 
continuum if needed.
      Dedicate support for the pediatric mental health system and 
infrastructure, which is currently woefully underfunded. Support should 
focus on building a strong community-based system to address children's 
mental health needs across a wide array of settings, such as 
pediatricians' offices, early childhood educational programs, schools, 
outpatient individual or family therapy, intensive outpatient services, 
inpatient care when warranted and through telehealth.
      Facilitate access to mental health services through telehealth. 
Throughout the COVID-19 pandemic, greater state and federal regulatory 
flexibilities have increased the availability and convenience of 
telehealth services for children and families. Psychiatry continues to 
rely on telehealth at a far greater rate than any other physician 
specialty. Congress should extend these flexibilities past the COVID-19 
public health emergency, including coverage for audio-only services and 
lifting originating site restrictions and geographic limitations and 
encourage state Medicaid programs to continue telehealth coverage and 
payment.
      Ensure strong implementation, oversight and proactive 
enforcement of the mental health parity and addiction equity act. It is 
unacceptable that payers and plan administrators are failing to cover 
needed mental health and substance use disorder care by creating 
barriers to in-network mental health care, limited provider networks 
and establishing non-qualitative treatment limits not otherwise seen in 
medical and surgical benefits. In addition, public and private payers 
routinely exclude payment for mental health services provided by a 
primary care provider. Congress should work to remove payment barriers 
that hinder access to mental health services in the primary care 
setting.

Our organizations and our pediatricians, child and adolescent 
psychiatrists and children's hospital members are ready and eager to 
partner with you to advance policies that can make measurable 
improvements in children's lives. Please call on us and our members as 
you develop these important policy improvements to stem the tide of the 
national emergency for children's mental health. Children need your 
help now.

                                 ______
                                 
               Center for Adoption Support and Education

                     3919 National Drive, Suite 200

                         Burtonsville, MD 20866

                    301-476-8525 (general inquiries)

                 866-217-8534 (schedule an appointment)

                        www.adoptionsupport.org

                     [email protected]

February 8, 2022

U.S. Senate
Committee on Finance

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

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

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

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

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


     Definition of an Adoption-Competent Mental Health Professional
An adoption-competent mental health professional has:
     The requisite professional education and professional licensure.
     A family-based, strengths-based, and evidence-based approach to
     working with adoptive families and birth families.
     A developmental and systemic approach to understanding and working
     with adoptive and birth families.
     Knowledge, clinical skills and experience in treating individuals
     with a history of abuse, neglect and/or trauma; and
     Knowledge, skills and experience in working with adoptive families
     and birth families.
 
An adoption-competent mental health professional understands the nature
 of adoption as a form of family formation and the different types of
 adoption; the clinical issues that are associated with separation and
 loss and attachment; the common developmental challenges in the
 experience of adoption; and the characteristics and skills that make
 adoptive families successful.
 
An adoption-competent mental health professional is culturally competent
 with respect to the racial and cultural heritage of children and
 families.
 
An adoption-competent mental health professional is skilled in using a
 range of therapies to effectively engage birth, kinship, and adoptive
 families toward the mutual goal of helping individuals to heal,
 empowering parents to assume parental entitlement and authority, and
 assisting adoptive families to strengthen or develop and practice
 parenting skills that support healthy family relationships.
 
An adoption-competent mental health professional is skilled in
 advocating with other service systems on behalf of birth and adoptive
 families.
 


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

I appreciate the opportunity to provide this testimony.

Sincerely,

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

February 8, 2022

U.S. Senate
Committee on Finance

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

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

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

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

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

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

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

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

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

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

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

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

American Academy of Pediatrics

American Association of Child and Adolescent Psychiatry

American Psychological Association

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

Association of Maternal and Child Health Programs

Bazelon Center for Mental Health Law

Children's Hospital Association

Eating Disorders Coalition for Research, Policy & Action

National Association for Children's Behavioral Health

National Association of Pediatric Nurse Practitioners

Nemours Children's Health

REDC Consortium

School-Based Health Alliance

Society for Adolescent Health and Medicine

The National Alliance to Advance Adolescent Health

Youth Villages

                                 ______
                                 
                      Children and Family Futures

                  25371 Commercentre Drive, Suite 250

                         Lake Forest, CA 92630

                          Phone: 714-505-3525

                        Toll-Free: 866-493-2758

                   Website: https://www.cffutures.org

                       Email: [email protected]

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 
[email protected] if you are interested in more information on any 
of the above ideas.

Sincerely,

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

                               Citations

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

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

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

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

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

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

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

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

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

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

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

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

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

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

                                 ______
                                 
                             Fountain House

                            425 W. 47th St.

                           New York, NY 10036

February 21, 2022

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

Dear Chair Wyden and Ranking Member Crapo,

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

About Fountain House

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

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

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

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

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

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

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

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

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

Strengthening the Workforce

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

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

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

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

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

Increasing Integration, Coordination and Access to Care

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

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

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

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

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

Ensuring parity between behavioral and physical health care

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

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

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

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

Furthering the Use of Telehealth

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

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

Conclusion

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

Sincerely,

Mary Crowley
Interim President and Chief Executive Officer
Fountain House

                                 ______
                                 
                           The Jed Foundation

                       530 7th Avenue, Suite 801

                           New York, NY 10018

                         [email protected]

                              212-647-7544

                       https://jedfoundation.org/

February 8, 2022

The Honorable Ron Wyden
Chair
U.S. Senate
Committee on Finance
219 Dirksen Senate Office Building
Washington, DC 20510-6200

The Honorable Mike Crapo
Ranking Member
U.S. Senate
Committee on Finance
219 Dirksen Senate Office Building
Washington, DC 20510-6200

Re: Protecting Youth Mental Health: Part I--An Advisory and Call to 
Action

Dear Chair Wyden and Ranking Member Crapo:

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

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

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

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

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

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

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

If we can be of any further assistance on this or any other related 
matter, please feel free to reach out to our director of government 
affairs and advocacy, Manuela McDonough, at [email protected].

Sincerely,

John MacPhee, CEO

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

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

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

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

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

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

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

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

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

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

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

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

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

                                 ______
                                 
                  National Alliance on Mental Illness

                    4301 Wilson Boulevard, Suite 300

                          Arlington, VA 22203

                             (703) 524-7600

                     NAMI Helpline 1 (800) 950-NAMI

                          https://www.nami.org

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

Youth Mental Health: A Crisis

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

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

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

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

Prevention, Early Identification, and Early Intervention

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

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

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

School-Based Mental Health Services

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

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

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

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

Child and Adolescent Mental Health Workforce

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

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

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

Insurance Coverage and Access to Care

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

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

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

Conclusion

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

                                 ______
                                 
         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
[email protected]

                                 ______
                                 
              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 
([email protected]).

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 ([email protected]).

Sincerely,

Edo Banach, J.D.
President and CEO

                                 ______
                                 
                      Partnership to End Addiction

                711 Third Avenue, Fifth Floor, Suite 500

                           New York, NY 10017

                             T 212-841-5200

                             F 212-956-8020

                         https://drugfree.org/

February 24, 2022

The Honorable Ron Wyden
Chairman
U.S. Senate
Committee on Finance
221 Dirksen Senate Office Building
Washington, DC 20510

The Honorable Mike Crapo
Ranking Member
U.S. Senate
Committee on Finance
239 Dirksen Senate Office Building
Washington, DC 20510

Dear Chairman Wyden and Ranking Member Crapo,

Thank you for holding this month's hearings, ``Protecting Youth Mental 
Health: Part I--An Advisory and Call to Action'' and ``Protecting Youth 
Mental Health: Part II--Identifying and Addressing Barriers to Care,'' 
held February 8, and February 15, 2022, and for initiating a process to 
advance legislation to address the mental health and addiction crises. 
We appreciate the opportunity to have this letter entered into the 
hearing record.

Partnership to End Addiction is a national nonprofit uniquely 
positioned to reach, engage, and help families impacted by addiction. 
With decades of experience in research, direct service, communications, 
and partnership-building, we provide families with personalized support 
and resources--while mobilizing policymakers, researchers, and health-
care professionals to better address addiction systemically on a 
national scale.

We greatly appreciate the Committee dedicating two hearings to the 
issue of youth mental health. We are also concerned by this growing 
crisis, as untreated mental illness is a significant risk factor for 
substance use, and mental illness and substance use disorder frequently 
co-occur. As highlighted by many witnesses and committee members, 
school-based mental health services are critically needed to reach more 
youth. We urge the Senate to advance the Mental Health Services for 
Students Act (S. 1841), the Pursuing Equity in Mental Health Act (S. 
1795), and the Suicide Training and Awareness Nationally Delivered for 
Universal Prevention (STANDUP) Act (S. 1543). We encourage Congress to 
facilitate an earlier and broader approach to substance use prevention 
that includes mental health, as well as other fields that promote child 
health and resilience and structural changes that facilitate healthy 
and stable families. As described in our blog published by Health 
Affairs, there are a number of policy initiatives to improve family 
stability and security and child health and resilience that Congress 
has recently undertaken in COVID-19-related legislation or is currently 
exploring in the Build Back Better Act. While these policy changes are 
seemingly outside the realm of substance use, they are critically 
important for prevention and will also reduce the risk for other 
negative mental and behavioral health outcomes that have the same risk 
and protective factors as substance use. As explained by the Surgeon 
General in response to questions from Sen. Warren, increasing access to 
affordable child care, for example, is important for improving 
children's mental health, along with other early investments in health 
and well-being. Sen. Casey and the Surgeon General similarly 
highlighted that children's mental health does not exist in a vacuum, 
and that broader family, community, and societal circumstances must 
also be addressed in order to protect youth. We encourage the Committee 
to consider such policies for inclusion in a legislative package.

To address many of the issues raised during the hearing, including the 
lack of access to evidence-based treatment and barriers to care, 
inadequate insurance coverage, inappropriate crisis response, and the 
need to meet people where they are with services and integrate services 
into the many systems with which youth interact, we encourage you to 
advance the following bills currently before your committee:
Medicaid Reentry Act (S. 285)
As noted in the hearings, youth with mental health disorders are 
overrepresented in the juvenile justice system. While using Medicaid to 
cover school-based mental health services was repeatedly discussed, 
another place Medicaid can have a role in expanding access to care is 
the criminal justice system. Individuals in jails and prisons have 
disproportionately high rates of mental health and addiction, and they 
face significant risk upon release. Individuals released from 
incarceration are often unable to afford or access care due to a lack 
of insurance coverage, as they lose their Medicaid benefits upon 
incarceration, and it can often take weeks or months to reinstate 
coverage. The Medicaid Reentry Act would help ease connections to 
community-based mental health and addiction services by allowing 
Medicaid-eligible individuals to restart coverage 30 days prior to 
release.
Crisis Assistance Helping Out On The Streets (CAHOOTS) Act (S. 764)
As both Chairman Wyden and Sen. Cortez Masto highlighted in the 
hearings, the CAHOOTS program in Eugene, Oregon, can serve as an 
exemplary model for other states and localities to improve their 
behavioral health crisis response systems by sending trained behavioral 
health providers to address such crises, rather than police. People in 
crisis related to mental illness and substance use disorder are more 
likely to encounter police than get medical attention, resulting in 
millions of people with mental health and addiction being jailed every 
year. As you know, mental health and substance use disorders are 
health-care issues, not crimes, and an appropriate crisis response 
should connect people to care, not jail. We encourage the Committee to 
advance the CAHOOTS Act to provide states with enhanced Medicaid 
funding and grants to adopt community-based mobile crisis services.
Non-Opioid Prevent Addiction in the Nation (NOPAIN) Act (S. 586)
Despite the existence of effective non-opioid pain management options, 
availability remains limited due to misaligned reimbursement policies 
that incentivize the use of opioids over the use of non-opioid 
alternatives. Under current law, hospitals receive the same payment 
from Medicare regardless of whether a provider prescribes an opioid or 
non-opioid, which leads hospitals to largely rely on opioids dispensed 
at a pharmacy after discharge at little or no cost to the hospital. The 
NOPAIN Act would help address this by directing the Centers for 
Medicare and Medicaid Services to provide separate Medicare 
reimbursement for non-opioid treatments used to manage pain in the 
hospital outpatient department and ambulatory surgery center settings. 
This can help ensure that safe, non-addictive therapies are available 
and reduce unnecessary exposure to opioids and the likelihood of opioid 
misuse or addiction.
Tobacco Tax Equity Act (S. 1314)
While tobacco and nicotine were not directly discussed during the 
hearing, nicotine is one of the most commonly used addictive substances 
among youth. One of the most effective ways to reduce tobacco use among 
youth is to increase the price of tobacco products. The Tobacco Tax 
Equity Act currently before the Committee would increase the federal 
tax rate on cigarettes, peg it to inflation to ensure it remains an 
effective public health tool, and set the federal tax rate for all 
other tobacco products at the same level (including e-cigarettes, which 
are particularly popular among youth).

We also encourage you to address:
Insurance Parity
As several witnesses and members, including Chairman Wyden, noted, lack 
of parity creates many barriers to behavioral health care for youth. 
Existing parity law must be better enforced, as insurance companies 
continue to violate it, as highlighted by the administration's recent 
report cited by the Surgeon General. Further, despite Congress's prior 
work to improve insurance coverage for mental health and addiction 
treatment, it will be impossible to ensure parity unless the Mental 
Health Parity and Addiction Equity Act is fully extended to Medicare, 
all of Medicaid, and TRICARE. In addition to leaving millions of people 
without adequate mental health and addiction coverage, Medicare's 
exclusion from parity laws is additionally problematic because Medicare 
serves as a benchmark for other forms of health coverage.

Thank you again for your commitment to addressing the mental health and 
addiction crises and for considering the above bills for inclusion in a 
legislative package. We would be happy to answer any questions or 
provide additional information to assist in your work.

Sincerely,

Partnership to End Addiction

                                 ______
                                 
                       Rainbows for All Children

                       614 Dempster St., Suite C

                           Evanston, IL 60202

                         https://rainbows.org/

The state of youth mental health is in crisis. There is a shortage of 
mental health professionals in the United States and financial barriers 
for families seeking mental health services for their children. This is 
especially prevalent in minority and vulnerable communities. 
Intervention is needed now in order to mitigate the potential for 
another public health emergency if we ignore the mental health needs of 
an entire generation of children.

Approximately 68% of children living in the United States (or 51 
million children) will experience a life-altering event triggering 
profound grief before they turn 18, including death in the family, 
divorce, abandonment, military deployment of a loved one, 
incarceration, or diagnosis of a life-threatening illness. Children who 
experience trauma and grief are at an increased risk for learning, 
emotional, and behavioral issues; physical health problems; aggression; 
and substance and alcohol abuse. These statistics have not been updated 
to recognize the 140,000 children who have experienced a major loss due 
to the COVID-19 pandemic, and time will only tell how our children will 
respond to the shared trauma of the pandemic.

There is an entire generation of children that are facing loss; loss of 
their loved ones, loss of crucial time in school, loss of routine and 
relationships, and a loss of their childhood due to the COVID-19 
pandemic. Rainbows for All Children helps children and youth 
successfully navigate grief and heal from loss or trauma, leading to 
improvements in development, problem-solving skills, behavior, anger 
management, school attendance and academic performance, depression and 
anxiety, emotional pain and suffering, communication, and destructive 
behavior such as involvement with gangs, alcohol, and substance abuse.

Death isn't the only traumatizing loss caused by the pandemic. Pre-
pandemic, 68% of children in the United States experience one or more 
traumatic event, also known as an Adverse Childhood Experience, at some 
point during their childhood. Some of these Adverse Childhood 
Experiences include being the victim of or witness to community or 
school violence, divorce or separation, sudden loss of a loved one, 
military family-related stressors, incarceration of a parent, living 
with a person who has a problem with alcohol or drugs, domestic 
violence, and psychological, physical, or sexual abuse.

      25% of children will experience the breakup of their parents' 
marriage and 25% of that group will also experience the breakup of a 
parent's second marriage.
      1 in 15 children will experience the death of a parent or 
sibling.
      1 in 10 children will experience a parent's diagnosis of a 
serious medical condition.
      8% will experience a parent or guardian being incarcerated, and 
half of these children will be under 10 years old.
      3% will experience at least one parent being deployed.

These 51 million children will experience an Adverse Childhood 
Experience, and that is outside of the trauma of the COVID-19 pandemic 
that is impacting all children. Children often do not have the ability 
to cope with their feelings and experiences around a traumatic event or 
a loss. It can be difficult for children to process and understand what 
they have experienced. When children are exposed to Adverse Childhood 
Experiences, their neurodevelopment can be disrupted. As a result, the 
child's cognitive functioning or ability to cope with negative or 
disruptive emotions may be impaired. The child's reactions to Adverse 
Childhood Experiences can interfere with his or her daily life and 
ability to function and interact with others. Symptoms can include 
nightmares, depression, physical symptoms such as stomachaches and 
headaches, self-harm, insomnia, fatigue, appetite disturbances, abrupt 
changes in personality, poor emotional control, lack of motivation, 
substance abuse, truancy, academic problems, peer problems, anxiety, 
and more. Other children may hide their emotions, acting as though 
nothing has happened, but are still negatively impacted. Long-term 
effects can continue to surface for decades to come. Assuming children 
are naive, ``they don't know what's going on'' or that they are 
resilient is a neglect of a child's mental and emotional healing and 
development that may cause severe consequences.

Adverse Childhood Experiences have negative, lasting effects on a 
child's health and well-being. We have yet to see how the ongoing 
COVID-19 pandemic will impact this generation of children. Research has 
shown that Adverse Childhood Experiences are strongly related to the 
development and prevalence of a wide range of behavioral and health 
problems throughout a person's life span, including substance abuse, 
mental health issues, depression, obesity, learning and behavioral 
issues, aggression, and more.

      Each Adverse Childhood Experience increased the likelihood of 
illicit drug use by 2- to 4-fold.\1\
---------------------------------------------------------------------------
    \1\ SAMHSA. ``Adverse Childhood Experiences,'' https://
www.samhsa.gov/capt/practicing-effective-prevention/prevention-
behavioral-health/adverse-childhood-experiences. Updated July 9, 2018.
---------------------------------------------------------------------------
      Four or more Adverse Childhood Experiences puts a child at a 
twelve-time greater risk of committing suicide as a young adult. In one 
study, individuals who reported 6 or more Adverse Childhood Experiences 
had 24.36 times increased odds of attempting suicide.\2\
---------------------------------------------------------------------------
    \2\ Ibid.
---------------------------------------------------------------------------
      Adverse Childhood Experiences may increase the risk for long-
term physical health problems (e.g., diabetes, heart attack) in 
adults.\3\
---------------------------------------------------------------------------
    \3\ Ibid.
---------------------------------------------------------------------------
      Exposure to Adverse Childhood Experiences may increase the risk 
of experiencing depressive disorders well into adulthood.\4\
---------------------------------------------------------------------------
    \4\ Ibid.
---------------------------------------------------------------------------
      Individuals who experience Adverse Childhood Experiences and do 
not receive treatment have elevated risks of early death.\5\
---------------------------------------------------------------------------
    \5\ Velitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., 
Spitz, A. M., Edwards, V., . . . Marks, J. S. ``Relationship of 
childhood abuse and household dysfunction to many of the leading causes 
of death in adults: The adverse childhood experiences (ACE) study.'' 
American Journal of Preventive Medicine, 14(4), 245-258. DOI: 10.1016/
S0749-3797(98)00017-8.

However, the negative effects of Adverse Childhood Experiences are 
preventable, and children can be taught coping skills to help them 
develop greater resiliency. Rainbows for All Children works to address 
Adverse Childhood Experiences as soon as possible after they occur to 
allow children to grow into flourishing and healthy adults. Rainbows 
creates a safe place for children to openly discuss their feelings with 
understanding and validation and provides the tools they need to 
process their experiences and their feelings. Children journey through 
---------------------------------------------------------------------------
a curriculum carefully designed support their emotional needs.

Children going through adverse experiences have shown a significant 
improvement by participating in Rainbows programs, including 
improvements in the areas of anger and stress management, stress level, 
and overall happiness. Evaluation of our programs has revealed the 
following results:

      The number of children who agreed or strongly agreed they knew 
healthy ways to be less stressed nearly doubled (increased 91%).
      The number of children who agreed or strongly agreed they were 
stress free most or all of the time nearly doubled (increased 91%).
      The number of children who strongly agree they can go through 
hard times and still be okay increased 154%.
      82% of children agree or strongly agree helping others can help 
them too.
      The number of children who strongly agree they are happy most or 
all of the time nearly doubled (increased 95%).
      The number of children who strongly agree the divorce was not 
their fault increased by 68%.
      90% of children attend school regularly.
      87% of children believe they were listened to in their groups.

Every day, we receive calls from families in communities across the 
U.S. looking for a Rainbows site for their grieving child in need, 
where no sites are active. We are working to garner funding to open 
Rainbows sites in schools in highly vulnerable communities, and to 
provide support and training to enhance currently existing Rainbows 
groups. In several communities, there are youth who need our programs, 
willing partnerships, and community volunteer facilitators. All that is 
needed is funding to launch these new sites and bring our programming 
to children and communities that would greatly benefit from our 
volunteer-led, peer-to-peer support model of care.

A Note on Surgeon General Vivek Murthy's Recommendations

Dr. Murthy gave four key recommendations in his statement to the 
committee:

      Ensuring that every child has access to high-quality, 
affordable, and culturally competent mental health care.
      Focusing on prevention by investing in school and community-
based programs that have been shown to improve the mental health and 
emotional well-being of children at low cost and high benefit.
      Developing a better understanding of the impact that technology 
and social media has on mental health.
      Taking steps to guarantee that no child should feel ashamed of 
their hurt, confusion, or isolation, and no one should feel too ashamed 
to ask for help.

Rainbows programming aligns with three of Dr. Murthy's four 
recommendations. Rainbows programming has been developed over the past 
38 years and we have a community of over 10,000 Rainbows-trained 
Facilitators with a repository of resources designed to guide youth in 
their grieving process. We have peer-support sites meeting in 38 states 
and 13 countries. Our programming is provided at no cost to 
participants and takes place in their own communities where they feel 
most understood--whether it be their school, community center, place of 
worship, or other location comfortable to our participants.

Recent studies have shown that peer support for children with mental 
health conditions can result in:\6\
---------------------------------------------------------------------------
    \6\ SAMHSA. ``Peer Support Recovery,'' https://www.samhsa.gov/
sites/default/files/programs_campaigns/brss_tacs/peers-supporting-
recovery-mental-health-conditions-2017.pdf.

      Increased social functioning
      Increased empowerment and hope
      Increased quality of life and life satisfaction
      Reduced use of inpatient services
      Decreased costs to the mental health system
      Decreased hospitalization
      Decreased self-stigma
      Increased community engagement
      Increased engagement and activation in treatment

The growth children see in peer support groups helps them to understand 
and cope with their grief and feel less isolated, as well as lessening 
the burden on an already burdened public health system. Finally, there 
are many benefits to group support that is not seen in individual 
settings, such as:\7\
---------------------------------------------------------------------------
    \7\ Mayo Clinic. ``Support groups: Make connections, get help,'' 
https://www.mayoclinic.
org/healthy-lifestyle/stress-management/in-depth/support-groups/art-
20044655/. Updated August 29, 2020.

      Feeling less lonely, isolated or judged
      Reducing distress, depression, anxiety or fatigue
      Talking openly and honestly about your feelings
      Improving skills to cope with challenges
      Staying motivated to manage chronic conditions or stick to 
treatment plans
      Gaining a sense of empowerment, control or hope
      Improving understanding of a disease and your own experience 
with it
      Getting practical feedback about treatment options
      Learning about health, economic or social resources

Conclusion

Assuring the healthy development of all children is essential for 
societies seeking to achieve their full health and potential. Finding 
early remedies to shared trauma and loss is critical to the flourishing 
of our communities. Rainbows for All Children works to promote 
conditions that reduce or eliminate risky behavior and develop healthy 
children. At Rainbows for All Children, we know first-hand the 
important work we are doing, and it has been a joy to see children on 
their journey of restored health. Our founder once said that she, 
``would never stop until every grieving child had a voice.'' We are 
committed to ensuring her mission lives on with the same compassion and 
commitment.

                                 ______
                                 
                                  REAP

                             P.O. Box 86341

                           Portland, OR 97286

                           Phone 503-688-2784

                           Fax 1-888-473-2963

                          https://reapusa.org/

U.S. Senate
Committee on Finance

REAP is a multi-cultural youth leadership non-profit organization 
focused on developing the next wave of leaders for the future now. 
Based in the state of Oregon, REAP serves culturally students across 
four counties, eight school districts in 24 schools.

REAP values mental health initiatives and social emotional learning as 
a dimension of support in our service to students. REAP has worked to 
elevate student voice around this topic since the formation of the 
organization whether through Mental Health Summits or collaborating 
with various local and state organizations to develop groundbreaking 
research and training concerning suicide prevention.

REAP is in support of the work Sen. Ron Wyden is doing to increase 
access to mental healthcare. REAP recently connected our students with 
the Sen. Wyden's Mental Health Listening Session on January 31st. 
Students spoke of their experience with the lack of access to mental 
health support. Many students reported not having enough access to 
counselors in their schools, preventing timely care for student needs. 
This need is disproportionate among racially and culturally diverse 
students.

It is imminently vital to the lives of our youth that we strive to 
improve access to timely mental healthcare in effort to elevate the 
current and the next generation of leaders for a better future. REAP 
supports the bipartisan work that Sen. Ron Wyden and the U.S. Senate 
Committee on Finance to improve mental health systems in our country.

Sincerely,

Mark Jackson
Executive Director

                                 ______
                                 
                Statement Submitted by Ethan J.S.H. Reed
Honorable Chairman Wyden, Ranking Member Crapo, and members of the 
Finance Committee, I share to express my support for today's hearing on 
tackling the mental health and substance use crisis we are currently 
facing across America. As an 18-year old youth activist, I had begun my 
civic engagement shortly after my community of Douglas County, 
Colorado, was ravaged by a school shooting at a STEM school in 
Highlands Ranch, Colorado, and one of my good friends happened to be in 
the classroom where it had begun. Fortunately, he had made it out alive 
to safety, however he had to witness a classmate of his get shot in the 
back while attempting to run outside of the school. To this day he 
still suffers from several mental health issues, including anxiety, 
PTSD, etc. I've unfortunately lost two friends to suicide as well--
their names were Hannah and Olivia. Since these tragedies, it brought 
me to the realization of just how severe the mental health among young 
Americans truly is.

I have had the privilege to serve my home state of Colorado by 
championing two mental health bills in the state legislature, and it is 
with great hope I further mental health legislation and its priorities 
in Congress. I am currently working with congressional leadership and 
other members of Congress on the priorities of mental health and 
substance use legislation, and so I applaud the efforts by this 
esteemed committee to begin hearings on tackling this crisis.

I remain optimistic that by the end of this session of Congress, we 
will have passed several pieces of legislation, and a potentially 
landmark mental health package that will further provide benefits and 
support for mental health services for young Americans to continue to 
have adequate access for support. It is with good intentions that I 
will continue to work with Congress and this esteemed committee to get 
legislation prioritized for the millions of young Americans across this 
country suffering and struggling with mental health and substance use 
issues.

One thing is made clear--the young people are NOT okay. We need 
reliable and adequate services and support from adults and our elected 
officials to provide us the benefits and funding that is so desperately 
needed right now. The COVID-19 pandemic has only exacerbated this 
crisis, and the youth are in dire need of help. I urge all American 
families and parents to check up on their children and youth, because I 
can guarantee that we need to be asked more about how we are feeling 
and whether we are okay or not.

Thank you so much for giving me this privileged opportunity to share my 
shared experiences as a young American, and for my voice to be on this 
platform with the Finance Committee. Let's get to work on immediate 
mental health and substance use legislation.

                                 ______
                                 
                     Sandy Hook Promise Action Fund

                             P.O. Box 3489

                           Newtown, CT 06470

              Statement of Mark Barden, Co-Founder and CEO

I would like to begin by thanking Chairman Wyden, Ranking Member Crapo, 
and the members of the Senate Finance Committee for holding this 
important hearing today. I am grateful for your commitment to 
addressing the United States' growing mental health crisis and 
specifically, the mental health needs of our nation's youth.

My name is Mark Barden, and I am one of the co-founders of Sandy Hook 
Promise. On December 14, 2012, the youngest of my three children, my 
sweet little Daniel, was murdered in his first-grade classroom at Sandy 
Hook Elementary School. The pain my family has endured every day since 
Daniel was taken from us is impossible to fully convey to you.

Following the shooting, I began working with other family members whose 
loved ones were killed that day to find a way to prevent other parents 
from experiencing the senseless, horrific death of their child due to 
gun violence. The result was Sandy Hook Promise, a national nonprofit 
organization dedicated to honoring all victims of violence by turning 
our tragedy into a moment of transformation. By empowering youth to 
``know the signs'' and uniting all people who value the protection of 
children, we can take meaningful action in schools, homes, and 
communities to prevent violence and stop the tragic loss of life.

Youth in this country are facing a mental health emergency. Since 2010, 
suicide has been the second-leading cause of death for young Americans 
aged 10-24.\1\ Mental Health America's 2021 State of Mental Health 
report showed that 77,470 youth, over one third of whom identify as 
LGBTQ+, are experiencing frequent suicidal ideation.\2\ Additionally, 
youth between the ages of 10 and 17 are now more likely than any other 
age group to score for moderate to severe symptoms of anxiety and 
depression.\3\
---------------------------------------------------------------------------
    \1\ Ten Leading Causes of Death and Injury Charts, Center for 
Disease Control and Prevention. Available at https://www.cdc.gov/
injury/wisqars/LeadingCauses.html.
    \2\ Mental Health America. (2021). The State of Mental Health in 
America. MHA. Retrieved from https://mhanational.org/get-involved/
download-2021-state-mental-health-america-report.
    \3\ Ibid (4).

Certain communities have borne the brunt of this tragic escalation. 
Suicide rates among American Indian and Alaskan Native adolescents ages 
15-19 are 60% higher than the national average for all teenagers.\4\ 
Suicide and suicidal behaviors for Black youth are also rising; Black 
boys ages 5-12 are twice as likely to die by suicide as compared to 
their white peers.\5\
---------------------------------------------------------------------------
    \4\ Ibid (4).
    \5\ Bridge, J., Horowitz, L., Fontanella, C., Sheftall, A., 
Greenhouse, J., Kelleher, K., and Campo, J. (2018). Age-Related Racial 
Disparity in Suicide Rates Among U.S. Youths From 2001 Through 2015. 
JAMA Pediatrics, 172(7), 697. doi: 10.1001/jamapediatrics.2018.0399.

The ongoing COVID-19 pandemic has only exacerbated these already 
alarming trends. Last fall, the American Academy of Pediatrics (AAP), 
the Children's Hospital Association (CHA), and the American Academy of 
Child and Adolescent Psychiatry (AACAP) declared a national emergency 
in child and adolescent mental health, specifically citing the toll of 
the pandemic.\6\ This was followed by a December 2021 U.S. Surgeon 
General advisory calling for a unified response to the mental health 
challenges facing young people.\7\
---------------------------------------------------------------------------
    \6\ AAP, AACAP, CHA declare national emergency in children's mental 
health (October 2021), https://publications.aap.org/aapnews/news/17718.
    \7\ U.S. Surgeon General Issues Advisory on Youth Mental Health 
Crisis Further Exposed by COVID-19 Pandemic, U.S. Department of Health 
and Human Services (December 2021), https://www.hhs.gov/about/news/
2021/12/07/us-surgeon-general-issues-advisory-on-youth-mental-health-
crisis-further-exposed-by-covid-19-pandemic.html.

To address this crisis, it is crucial that all children and youth have 
access to mental health care and resources. When Sandy Hook Promise's 
15-year-old Youth Advisory Board (YAB) member Arriana Gross testified 
before the Energy and Commerce Committee in June 2020, she discussed 
having to travel almost 2 hours from her home and school in Covington, 
Georgia to receive mental health services. Too many young people 
---------------------------------------------------------------------------
currently have similar barriers to accessing mental health care.

Schools can serve as one of the best mechanisms to offer mental health 
care for youth, particularly for those living in provider shortage 
areas and low-resourced communities. Current availability of school-
based mental health professionals remains low, particularly in schools 
where many students come from low-income households.\8\ To expand 
access to school-based mental health services, we recommend allowing a 
payment model to fund mental health professionals to provide services 
in schools through Medicaid. By creating a funding model that allows 
local education agencies (LEAs) and schools to coordinate Medicaid 
payments for school mental health services, we can start to address the 
gap in access to youth mental health care.
---------------------------------------------------------------------------
    \8\ https://nces.ed.gov/programs/digest/d19/tables/
dt19_233.69b.asp?current=yes.

We also recommend guaranteeing reimbursements for pediatricians who 
conduct suicide-risk screenings through Medicaid. Screening for risk of 
suicidal behavior can be a crucial first step in preventing suicide 
among young people. In December 2021, the Health Resources & Services 
Administration (HRSA) accepted an update to the AAP's Bright Futures 
Periodicity Schedule, adding screening for suicide risk for youth aged 
12-21 to the current Depression Screening category.\9\ Many major 
health insurance companies reimburse providers for use of suicidal risk 
measures under CPT Code 96127 and, while many state Medicaid plans 
allow payment for adolescent health risk assessments, including 
depression screenings as a preventative service, it is important that 
we ensure that this extends to suicide-risk screenings.
---------------------------------------------------------------------------
    \9\ https://mchb.hrsa.gov/programs-impact/programs/bright-futures.

We know that funding access to mental health care and resources has the 
power to save lives and help protect our children and youth. Thank you 
for your committee's commitment to making youth mental health a top 
priority and for the opportunity to submit testimony today on this 
---------------------------------------------------------------------------
critical issue.

                                 ______
                                 
                Sports and Fitness Industry Association
The Sports and Fitness Industry Association (SFIA) applauds the Senate 
Finance Committee for its leadership in bringing attention to the 
pandemic's egregious effects on mental health. The December 2021 
Surgeon General's report, Protecting Youth Mental Health, sounded the 
alarm in terms of what is happening in our schools and what families 
are experiencing at home.

We agree with U.S. Surgeon General Vice Admiral Vivek H. Murthy's 
findings that Americans are not protecting their mental and physical 
health enough. Equally troubling, we also agree with the Centers for 
Disease Control and Prevention report recent January 2022 findings on 
the sedentary lifestyle that is becoming all too common throughout 
America. Together, the rise in obesity and diabetes rates, as well as 
adult substance abuse and adolescent depression, anxiety, and suicide 
provide a fatal combination that will have longstanding repercussions 
for our nation's health-care system.

As the leading active lifestyle trade association in the U.S., we are 
responsible for tracking physical activity levels for Americans each 
year--data that is shared with the U.S. Department of Health and Human 
Services. Given the annual survey, we know firsthand how these rates 
have declined over time and their corresponding spike in behavioral 
health issues.

This lens provides important insight into the vital role that sports 
and exercise play in mental, social, and physical development. It is 
why SFIA has been working steadfastly on solutions to help Americans 
recover and reconnect. Those two words are behind our daily mission 
touting the benefits of exercise for all age groups. No matter the 
challenge, physical fitness is a key ingredient to healthy body and 
mind. The Surgeon General's report highlights this aspect and 
specifically, the stress that children experience when sports are 
canceled and conversely, the stress levels that are mitigated when a 
child exercises.

It comes as no surprise that we need policies to make exercise more 
accessible and affordable. This ranges from school and community-based 
programs to expanding the use of pre-tax medical accounts to encourage 
healthy lifestyles. For example, the U.S. Tax Code does not acknowledge 
exercise as a form of prevention despite overwhelming evidence on the 
health benefits of activity, yet endless medical treatments are 
deducted. It's time to hit reverse and allow families to use their own 
money for the sake of staying mentally and physically fit. These 
accounts continue to grow in popularity with over 96 million Americans 
having access to either a health savings account or flexible spending 
account.

Legislation known as the Personal Health Investment Today (``PHIT'') 
Act embraces this approach. This bipartisan bill is led by Senators 
John Thune (R-SD) and Chris Murphy (D-CT), as well as Representatives 
Ron Kind (D-WI) and Mike Kelly (R-PA). The measure passed 
overwhelmingly in the House back in 2018 by a vote of 277 to 142. With 
over 4,000 industry stakeholders all in support, the PHIT Act serves as 
a multigenerational ``win-win'' designed to take on the pandemic's 
aftershocks.

As the Senate Finance Committee strives to address this important 
issue, we encourage you to consider all available remedies including 
broader treatment of physical activity as preventative care. SFIA looks 
forward to working with the Committee and serving as a data resource.

We respectfully submit the enclosed statement. If you have any 
questions or need additional information, please feel free to contact 
Tom Cove, SFIA President, at [email protected], 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 
[email protected] or Emily Felder, Shareholder, Brownstein 
Hyatt Farber Schreck, at [email protected].

Sincerely,

Karin L. Price, Ph.D.
Chief of Psychology

                                 ______
                                 
               UCLA Center for the Developing Adolescent

                    760 Westwood Plaza, Semel B7-435

                         Los Angeles, CA 90095

U.S. Senate
Committee on Finance

As developmental scientists and Co-Executive Directors of the Center 
for the Developing Adolescent,\1\ professors of psychiatry and 
psychology, and scientists at the Jane and Terry Semel Institute for 
Neuroscience and Human Behavior, all at UCLA, we have spent years 
studying adolescent development and well-being. We appreciate the 
Senate Finance Committee's commitment to addressing the youth mental 
health crisis and working toward policy solutions focused on 
prevention. As the Committee hearing made clear, the issue of youth 
mental health is real and serious, and predates the pandemic, with 
increases in loneliness, depression, and anxiety beginning at least a 
decade ago. The pandemic has been a strong reminder that as a society, 
we need to prioritize the well-being of our young people and give this 
issue the attention it deserves. We are pleased to submit a statement 
for the record as the Committee continues it's work on this issue.
---------------------------------------------------------------------------
    \1\ https://developingadolescent.semel.ucla.edu/.

The adolescent years--from about 10 to around 25--are a period of 
remarkable learning and adaptation.\2\ At the beginning of puberty, our 
brains are changing rapidly in response to our experiences, forming and 
strengthening connections between neurons (brain cells) faster than 
they ever will again. These changes make us especially sensitive to the 
world around us. As we engage with that world, our relationships and 
experiences in turn provide feedback that further shapes our developing 
brain.
---------------------------------------------------------------------------
    \2\ https://www.researchgate.net/profile/Ronald-Dahl/publication/
230698133_Understanding_
adolescence_as_a_period_of_social-
affective_engagement_and_goal_flexibility/links/00463524c73
9f89085000000/Understanding-adolescence-as-a-period-of-social-
affective-engagement-and-goal-flexibility.pdf.

The learning potential of this time of life creates enormous 
opportunity, opening a pivotal window to impact not only mental health, 
but life trajectories. With the right kinds of opportunities and 
support, we can leverage \3\ the remarkable adaptivity of these years 
to support positive learning and discovery and even mitigate the 
effects of earlier adversity.
---------------------------------------------------------------------------
    \3\ https://www.nature.com/articles/nature25770.

Research on adolescent social and cognitive development tells us the 
kinds of opportunities and support that adolescents need to promote not 
only their mental health but their broader capacity to thrive. These 
include safe and satisfying ways to explore the world and test out new 
ideas and experiences, real-world scenarios in which to build and hone 
problem-solving and decision-making skills, avenues to develop a sense 
of meaning and purpose by helping and supporting families and 
communities,\4\ access to social interactions that support a positive 
sense of identity, and warmth and support from parents and other caring 
adults.
---------------------------------------------------------------------------
    \4\ https://journals.sagepub.com/doi/10.1177/1745691618805437.

As Surgeon General Dr. Vivek Murthy shared in his Advisory and 
reiterated in his February 8 testimony, the COVID pandemic has created 
barriers to many of the opportunities that young people need for 
positive development. The pandemic has also exacerbated long-standing 
social inequities, disproportionately imposing these developmental 
barriers on youth of color and those from low-income families. It is 
not surprising that Dr. Murthy and the advisory flags these youth as 
---------------------------------------------------------------------------
being at higher risk of mental health challenges during the pandemic.

In his December 2021 Advisory, Dr. Murthy called for ``policy, 
institutional, and individual changes in how we view and prioritize 
mental health.'' As the Committee's work on youth mental health moves 
forward, we see an opportunity to not only address youth well-being at 
the crisis level, but to set a higher goal of helping youth to flourish 
by prioritizing adolescence itself. As you consider policy solutions 
and work to establish the interventions and supports all youth need to 
protect their mental health, we urge you to ensure that your 
recommendations regarding funding, programs, and policies are grounded 
firmly in what science tells us is crucial to establishing the 
foundations for life-long health and well-being for all adolescents, 
including:

      Exploration and Healthy Risk Taking--During adolescence, we are 
uniquely motivated toward new and intense experiences. This increased 
motivation to explore and pursue novel experiences is fundamental to 
learning during this window of development. Inequities in our society 
often limit opportunities for healthy risk taking and amplify negative 
consequences of mistakes for young people from traditionally 
marginalized groups. We urge the Committee to prioritize investments in 
programs that provide safe opportunities for positive exploration and 
risk taking.
      Contribution--Opportunities to provide ideas, resources, and 
help that impact their social worlds support adolescents to build 
autonomy, identity, and intimacy, while providing real benefits to 
society. All adolescents need opportunities to make meaningful 
contributions to their families, peers, schools, and wider communities 
and to have those contributions recognized. As the Committee's work 
moves forward, we encourage you to center this principle in both policy 
and practice, including ensuring that young people are at the table to 
share their lived experiences and ideas for solutions as part of the 
Committee's work.
      Emotional regulation and decision making skills--Adolescence is 
a time when we are developing the skills to manage our emotions, 
control our behavior, and make good decisions. We must support young 
people in the development of these skills by providing opportunities to 
learn and observe coping skills, see examples of healthy emotional 
expression, have avenues to make real-world decisions, and receive 
support to learn from mistakes.
      Identity--During adolescence, we're figuring out who we are, 
what we value, and who we want to be. This makes it a period of time 
when racism and other forms of discrimination can have a strong impact 
on a young person's sense of self. We urge the Committee to prioritize 
efforts proven to support a positive sense of identity, including 
addressing racial disparities in discipline and access to messages and 
spaces that affirm a healthy racial-ethnic identity.
      Connections--Supportive relationships with parents and other 
caring adults are still extremely important in adolescence, even as 
peer relationships become a more central focus. Policies and programs 
that support the whole family are essential to the well-being of all 
adolescents, particularly those facing adverse experiences. We urge the 
Committee to prioritize investments in research-
informed programs that support parents of adolescents, including within 
youth-serving systems such as the child welfare and youth justice 
systems.

Thank you for your commitment to addressing the youth mental health 
crisis and working toward policy solutions focused on prevention. As 
your work moves forward we hope you will consider funding, programs, 
and policies that are grounded firmly in what science tells us is 
crucial to ensuring that our youth can thrive in ways that ensure a 
bright future for us all. Please don't hesitate to contact us (agalvan
@ucla.edu and [email protected]) should you like to discuss the 
research on adolescent development and well-being or our 
recommendations.

Adriana Galvan, Ph.D., and Andrew J. Fuligni, Ph.D.

                                 ______
                                 
      University Hospitals Rainbow Babies and Children's Hospital

                            11100 Euclid Ave

                           Mailstop MPV 6003

                          Cleveland, OH 44106

In follow-up to the February 8, 2022 hearing, ``Protecting Youth Mental 
Health: Part I--An Advisory and Call to Action,'' Rainbow Babies and 
Children's Hospital strongly endorses the positions taken by the 
American Academy of Pediatrics (AAP), the American Academy of Child and 
Adolescent Psychiatry (AACAP) and the Children's Hospital Association 
(CHA) in their statement for the record.

Since the fall of 2021, the above member organizations have declared a 
national emergency in child and adolescent mental health. The 
situation, already dire prior to the Pandemic \1\ has only worsened 
with increased social isolation, fear and grief amongst our children 
and adolescents. Twenty percent of children and adolescents experience 
a mental health disorder in a given year.\2\ For children needing 
treatment, it takes on average 11 years after the first symptoms appear 
before getting that treatment.\3\ There is also alarming signal of 
inequity in mental health outcomes and access to high-quality mental 
health care services for children of color. Significant investments are 
needed now to better support and sustain the full continuum of care 
needed for children's mental health. These investments will 
significantly improve the mental health of our children and our country 
as we avoid more serious and costly outcomes later--including suicidal 
ideation and death by suicide.
---------------------------------------------------------------------------
    \1\ Daniel G. Whitney and Mark D. Peterson, ``U.S. National and 
State-Level Prevalence of Mental Health Disorders and Disparities of 
Mental Health Care Use in Children,'' JAMA Pediatrics 173, no. 4 
(2019): 389-391.
    \2\ Centers for Disease Control and Prevention (CDC), ``Key 
Findings: Children's Mental Health Report,'' March 22, 2021.
    \3\ National Alliance on Mental Illness, ``Mental Health 
Screening,'' accessed on November 10, 2021.

Rainbow Babies and Children's Hospital is appreciative of the Senate 
Finance Committee's recognition of the children's mental health 
emergency and focus on the unique needs of this population. As the 
Committee works on legislative solutions, we echo the AAP, AACAP and 
CHA conclusions that the following policy priorities are critical to 
---------------------------------------------------------------------------
improve access to mental health services for children:

      Increased investments to support the recruitment, training, 
mentorship, retention and professional development of a diverse 
clinical and non-clinical pediatric workforce, including funding for 
minority fellowship programs for mental health physician specialists. 
We currently face dire shortages in mental health providers with an 
even more significant dearth of minority providers. We need to 
encourage more people to enter these fields.
      Address low Medicaid payment rates for pediatric mental health 
services, ways to better support coordination and integration of care 
and access to school-based services. These low rates result in lower 
provider engagement and participation in the Medicaid program as well 
as contribute to the mental health worker shortage with consequent 
limitations in access to services.
      Direct CMS to review how Early and Periodic Screening, 
Diagnostic and Treatment (EPSDT) is implemented in the states to 
improve access to early intervention services, developmentally 
appropriate mental health services and to provide guidance to states on 
Medicaid payment for evidence-based mental health services that promote 
integrated care. As noted earlier, delays in identification and 
treatment of mental health issues is a substantial problem. The EPSDT 
benefit is tailored to children's unique needs and ensures that 
children receive care as early as possible.
      Dedicate support for the pediatric mental health system and 
infrastructure that are currently distressingly underfunded. An 
emphasis should be placed on 
community-based, ambulatory systems across a wide array of settings 
including primary care offices, early childhood education programs, 
family therapy and, when warranted, inpatient care.
      Expand telehealth services to include audio-only services, the 
lifting of originating site restrictions and geographic limitations and 
the encouragement of state Medicaid programs to continue telehealth 
coverage and payment.
      Ensure strong implementation, oversight and proactive 
enforcement of the mental health parity and addiction equity act. 
Payers and plan administrators are failing to cover mental health and 
substance use disorder care through limitations in in-network care, 
limitations in provider networks and the establishment of non-
qualitative treatment limits unseen in medical and surgical benefits. 
Both public and private payers routinely exclude payment for mental 
health services provided by a primary care provider.

Our pediatricians, psychologists, child and adolescent psychiatrists 
and advanced practice nurses are eager to partner with you to advance 
policies that improve access to quality mental health services 
available to children. Please call on us as you develop policy 
improvements to address this national emergency for children's mental 
health.

                                   [all]