[Senate Hearing 117-775]
[From the U.S. Government Publishing Office]




                                                        S. Hrg. 117-775

                    PROTECTING YOUTH MENTAL HEALTH:
                        PART II_IDENTIFYING AND
                      ADDRESSING BARRIERS TO CARE

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

                                HEARING

                               before the

                          COMMITTEE ON FINANCE
                          UNITED STATES SENATE

                    ONE HUNDRED SEVENTEENTH CONGRESS

                             SECOND SESSION

                               __________

                           FEBRUARY 15, 2022

                               __________

 
 
 




[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
 
 
 
 
 
 
 
 

            Printed for the use of the Committee on Finance
                             _________
                              
                 U.S. GOVERNMENT PUBLISHING OFFICE
                 
54-176-PDF               WASHINGTON : 2023 






















                          COMMITTEE ON FINANCE

                      RON WYDEN, Oregon, Chairman

DEBBIE STABENOW, Michigan            MIKE CRAPO, Idaho
MARIA CANTWELL, Washington           CHUCK GRASSLEY, Iowa
ROBERT MENENDEZ, New Jersey          JOHN CORNYN, Texas
THOMAS R. CARPER, Delaware           JOHN THUNE, South Dakota
BENJAMIN L. CARDIN, Maryland         RICHARD BURR, North Carolina
SHERROD BROWN, Ohio                  ROB PORTMAN, Ohio
MICHAEL F. BENNET, Colorado          PATRICK J. TOOMEY, Pennsylvania
ROBERT P. CASEY, Jr., Pennsylvania   TIM SCOTT, South Carolina
MARK R. WARNER, Virginia             BILL CASSIDY, Louisiana
SHELDON WHITEHOUSE, Rhode Island     JAMES LANKFORD, Oklahoma
MAGGIE HASSAN, New Hampshire         STEVE DAINES, Montana
CATHERINE CORTEZ MASTO, Nevada       TODD YOUNG, Indiana
ELIZABETH WARREN, Massachusetts      BEN SASSE, Nebraska
                                     JOHN BARRASSO, Wyoming

                    Joshua Sheinkman, Staff Director

                Gregg Richard, Republican Staff Director

                                  (II) 
                                  
                                  
                                  
                                  
                                  
                                  
                                  
                                  
                                  
                                  
                                  
                                  
                                  
                                  
                                  
                                  
                                  
                                  
                                  
                                  
                                  
                                  
                            C O N T E N T S

                              ----------                              

                           OPENING STATEMENTS

                                                                   Page
Wyden, Hon. Ron, a U.S. Senator from Oregon, chairman, Committee 
  on Finance.....................................................     1
Crapo, Hon. Mike, a U.S. Senator from Idaho......................     3
Casey, Hon. Robert P., Jr., a U.S. Senator from Pennsylvania.....     5
Hassan, Hon. Maggie, a U.S. Senator from New Hampshire...........     5
Cardin, Hon. Benjamin L., a U.S. Senator from Maryland...........     6

                               WITNESSES

Terrell, Trace, lead intervention and outreach specialist, 
  YouthLine, La Pine, OR.........................................     7
Benton, Tami D., M.D., psychiatrist-in-chief, executive director, 
  and chair, Department of Child and Adolescent Psychiatry and 
  Behavioral Sciences, Children's Hospital of Philadelphia, 
  Philadelphia, PA...............................................     9
Lubarsky, Jodie L., M.A., LCMHC, vice president of clinical 
  operations, Youth and Family Services, Seacoast Mental Health 
  Center, Inc., Portsmouth, NH...................................    11
Hoover, Sharon, Ph.D., professor, child and adolescent 
  psychiatry; and co-director, National Center for School Mental 
  Health, University of Maryland School of Medicine, Baltimore, 
  MD.............................................................    13

               ALPHABETICAL LISTING AND APPENDIX MATERIAL

Benton, Tami D., M.D.:
    Testimony....................................................     9
    Prepared statement...........................................    51
    Responses to questions from committee members................    58
Brown, Hon. Sherrod:
    Submission for the record....................................    59
Cardin, Hon. Benjamin L.:
    Opening statement............................................     6
Casey, Hon. Robert P., Jr.:
    Opening statement............................................     5
Crapo, Hon. Mike:
    Opening statement............................................     3
    Prepared statement...........................................    62
Hassan, Hon. Maggie:
    Opening statement............................................     5
Hoover, Sharon, Ph.D.:
    Testimony....................................................    13
    Prepared statement...........................................    62
    Responses to questions from committee members................    66
Lubarsky, Jodie L., M.A., LCMHC:
    Testimony....................................................    11
    Prepared statement...........................................    71
    Responses to questions from committee members................    73
Terrell, Trace:
    Testimony....................................................     7
    Prepared statement...........................................    75
Wyden, Hon. Ron:
    Opening statement............................................     1
    Prepared statement...........................................    77

                             Communications

American Hospital Association....................................    79
American Psychological Association...............................    82
American Therapeutic Recreation Association......................    89
Barrett, Stephanie...............................................    92
California Youth Connection et al................................    93
Children Now (California) et al..................................   100
Children's Health................................................   102
Children's Hospital Association..................................   105
Children's Trust Fund Alliance, Generations United, and 
  FosterClub.....................................................   108
Citizens Commission on Human Rights..............................   112
Driscoll Health System...........................................   116
First Focus on Children..........................................   118
FosterClub 



Healthy Schools Campaign.........................................   126
Juvenile Law Center..............................................   128
Mending Minds Village............................................   133
Mental Health Liaison Group......................................   135
National Advocacy on Serious Neurobehavioral Illness and National 
  Shattering Silence Coalition...................................   139
National Association for Children's Behavioral Health............   141
Nationwide Children's Hospital...................................   143
Nemours Children's Health........................................   146
Partnership to End Addiction.....................................   150
Primary Care Collaborative.......................................   152
Reed, Ethan J.S.H................................................   156
The Trevor Project...............................................   157
Voice for Adoption...............................................   162
Youth Villages...................................................   167

 
                    PROTECTING YOUTH MENTAL HEALTH: 
                        PART II--IDENTIFYING AND 
                      ADDRESSING BARRIERS TO CARE 

                              ----------                              


                       TUESDAY, FEBRUARY 15, 2022

                                       U.S. Senate,
                                      Committee on Finance,
                                                    Washington, DC.
    The hearing was convened, pursuant to notice, at 10:03 
a.m., via Webex, in the Dirksen Senate Office Building, Hon. 
Ron Wyden (chairman of the committee) presiding.
    Present: Senators Stabenow, Cantwell, Menendez, Carper, 
Cardin, Brown, Bennet, Casey, Whitehouse, Hassan, Cortez Masto, 
Crapo, Grassley, Thune, Portman, Cassidy, Lankford, Young, and 
Barrasso.
    Also present: Democratic staff: Shawn Bishop, Chief Health 
Advisor; Elizabeth Dervan, Health Counsel; and Michael Evans, 
Deputy Staff Director and Chief Counsel. Republican staff: 
Kellie McConnell, Health Policy Director; and Gregg Richard, 
Staff Director.

   OPENING STATEMENT OF HON. RON WYDEN, A U.S. SENATOR FROM 
             OREGON, CHAIRMAN, COMMITTEE ON FINANCE

    The Chairman. The Senate Finance Committee will come to 
order. And, during this morning's hearing on the youth mental 
health epidemic, we are going to have an opportunity to build 
on last week's superb discussion with the Surgeon General, Dr. 
Murthy.
    Last Tuesday, Dr. Murthy told us that mental health 
problems often show up first when we have people who are very 
young, but the average delay between the onset of mental health 
symptoms and the beginning of treatment is actually 11 years. 
Those are, in the Surgeon General's words, ``11 long, 
confusing, isolating, and painful years.''
    This obviously is a number worth a thousand words, and more 
than anything it says that America's approach to mental health 
care is way out of whack, and it starts failing America's young 
people early on. So, there are several priorities for today.
    Let's focus on how mental health care for young people 
starts much earlier--earlier screenings, earlier interventions, 
earlier discussions with primary care doctors. There is also a 
need to step up mental health efforts in schools and in our 
communities.
    Those are also places where trained professionals can get 
the symptoms right from the outset and refer young people to 
skilled practitioners when necessary. At present, we get told 
again and again that school counselors are overwhelmed, 
community-based programs are too few, and referrals are 
inconsistent. Mental health care simply does not start early 
enough, and it's not reaching young people where they are, 
especially kids in rural areas.
    Second, our country must have better crisis care. The 11-
year treatment gap is a sign that young people are struggling, 
going without the treatment they need, and heading on a path to 
crisis. In addition, America's mental health system too often 
fails the young when they are in crisis as well.
    The evidence shows that the pandemic has driven a shocking 
increase in self-harm among young people. Suicide attempts 
among young teen girls resulting in hospitalizations recently 
jumped more than 50 percent. Far too many of these young people 
in distress are spending days or even weeks boarded in 
emergency departments. For the bulk of the time, they are 
probably alone. Imagine, colleagues, feeling a sense of extreme 
isolation clashing with the chaos and commotion of the 
emergency department buzzing outside your door.
    Just yesterday I spoke with a group of Oregon health-care 
practitioners and physicians who told me they were concerned 
that in many of these crisis situations, young people who end 
up in the hospital emergency rooms are not even seeing 
practitioners who have training in mental health. The emergency 
room is no place for a child in crisis to spend day after day, 
but it is all too common. Young people simply deserve better.
    Third and finally, solving these problems is going to 
require creativity from the public and the private sector. The 
Children's Health Insurance Program and Medicaid, which is the 
largest single payer of mental health care for young people, 
can play a key role in sparking new solutions. These efforts 
will be essential to make sure mental health is treated with 
the same consistency and focus given to physical health.
    The bottom line is, no more mental health business as 
usual, because business as usual is failing too many young 
people at every single point, from the first sign of symptoms 
to the most critical moments of crisis.
    There is a lot for the committee to discuss today on these 
key issues. We are going to have a great panel whom I am going 
to introduce shortly. I want to thank Senators Carper and 
Cassidy for heading up our efforts on youth mental health care. 
And I also want to commend Senator Stabenow for her years and 
years of work on behavioral health issues that are so 
important, and that we will build on.
    [The prepared statement of Chairman Wyden appears in the 
appendix.]
    The Chairman. Now we will turn to Senator Crapo for his 
opening remarks. And then we will have introductions--and where 
is my friend, Senator Crapo?
    There he is. Senator Crapo?

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

    Senator Crapo. Thank you, Mr. Chairman, and thank you to 
our witnesses for joining us today as we discuss ways to 
respond to mental health challenges impacting children and 
adolescents across the country.
    According to recent reports from the CDC, the number of 
young people dealing with depression, anxiety, and suicidal 
thoughts has unfortunately risen during the pandemic, as social 
isolation has taken its toll on far too many children and 
adolescents. Although it appears the pandemic is subsiding and 
our return to normalcy may be imminent, we cannot ignore the 
lasting effects of the past 2 years on the social and emotional 
well-being of children.
    We should do all that we can, within our jurisdiction, to 
increase access to high-quality mental health services and 
reduce the causes of delayed and forgone treatment. While 
mental health issues affect people of all ages, children's 
needs are often different from those of adults, necessitating 
carefully tailored solutions.
    As this committee works in a bipartisan way to advance the 
conversation on mental health, we must not only identify the 
complexity and scope of the problems at hand, but also explore 
innovative, sustainable, and concrete policy solutions. I look 
forward to working with my colleagues on both sides of the 
aisle to develop meaningful measures to meet some of the 
Nation's mental health challenges, including by expanding 
access to telehealth services, supporting our mental health 
workforce, and better integrating physical and mental health-
care services.
    Children can and often do benefit from services delivered 
via telehealth. While we often focus our telehealth discussions 
on Medicare, where key access gaps and barriers remain, this 
committee should also prioritize clarifying and expanding care 
delivery options for children covered by Medicaid, regardless 
of geographic location.
    Additionally, we should work to maintain a strong mental 
health workforce with the capacity to care for all who need 
services. These efforts will prove particularly crucial as 
health-care professionals burn out, steep regulatory demands 
continue, and other strains jeopardize long-term provider 
retention and capacity.
    We have clear opportunities for improvement at every level. 
I regularly hear from front-line providers, as well as State 
policymakers, seeking the flexibility to innovate and craft 
targeted, local solutions to the challenges facing their 
communities.
    Their ideas and input will play a critical role in this 
process, especially as we look to bridge gaps in care, better 
integrate physical and behavioral health services, and promote 
value-based payment models that put patients first. If 
structured effectively, these reforms could prove game-changing 
for populations of all ages, including young people.
    Finally, no conversation on mental health-care reforms for 
children and young adults would be complete without input from 
those whom the policies intend to empower and support. To that 
end, Trace, thank you for your willingness to join us today to 
share your perspective.
    We have the opportunity to better support children, their 
families, and their providers, by enhancing mental health 
outcomes across the United States. Moreover, we can and must do 
so while honoring this committee's strong tradition of member-
driven, bipartisan, and fiscally responsible legislative 
solutions.
    Thank you to our witnesses for agreeing to share their 
expertise from across the continuum of care. They have provided 
invaluable service during these unprecedented times, and I look 
forward to hearing their testimony.
    Thank you.
    [The prepared statement of Senator Crapo appears in the 
appendix.]
    The Chairman. Senator Crapo, thank you for a very helpful 
opening statement. As you noted, we are going to do this in a 
bipartisan way. There is an awful lot of common ground here, 
and I am especially appreciative that you zeroed in on 
telehealth, because the Finance Committee is especially proud 
of the telehealth contribution we made at the beginning of the 
pandemic, during those early days when the Centers for Medicare 
and Medicaid Services, headed by Seema Verma, were trying to 
figure out how to proceed. And to a great extent, they took the 
telehealth provisions of the CHRONIC Care law that was written 
in a bipartisan way in our committee.
    So I appreciate your zeroing in on telehealth issues, and 
we are certainly going to build on them in our work this year. 
And also, thank you for giving a little bit of a send-off, as 
we move to introductions, to Trace Terrell, because he is one 
of our own, a student from La Pine, OR, a mental health leader, 
and an advocate in his community. He has volunteered with 
YouthLine, a peer-to-peer youth crisis service based in our 
State that receives 27,000 contacts each year from young people 
across the country. YouthLine is provided by Lines for Life, a 
nonprofit dedicated to suicide prevention and mental health 
support, and Oregon's home for the National Suicide Prevention 
Lifeline.
    Beyond YouthLine, Mr. Terrell has advocated for youth 
mental health through a number of other organizations, 
including the National Mental Health Advisory Board supported 
by Well Being Trust, Young Invincibles, and Active Minds.
    A high school senior--because I am on the Intelligence 
Committee, people sometimes tell me important little items 
about our guests, and I recently learned that Mr. Terrell has 
been accepted to Johns Hopkins University, and we all want to 
extend congratulations for that great achievement.
    With that, I am going to turn it over now to my colleagues 
to introduce witnesses that they have worked with and are very 
proud of. Senator Casey will introduce Dr. Tami Benton from the 
Children's Hospital of Philadelphia. Senator Hassan will then 
introduce Jodie Lubarsky from Seacoast Mental Health Center in 
New Hampshire. And then Senator Cardin will introduce Dr. 
Sharon Hoover from the University of Maryland School of 
Medicine's National Center for School Mental Health. And then 
we will hear their testimony.
    Senator Casey?

        OPENING STATEMENT OF HON. ROBERT P. CASEY, JR., 
                A U.S. SENATOR FROM PENNSYLVANIA

    Senator Casey. Mr. Chairman, thanks very much for this 
opportunity. I am pleased to introduce Dr. Tami Benton. And I 
appreciate Dr. Benton's expertise at this hearing today, in 
addition to her lifelong commitment to serving both children 
and families.
    Dr. Benton is psychiatrist-in-chief, executive director, 
and chair of the Department of Child and Adolescent Psychiatry 
and Behavioral Sciences. She is clinical director of child and 
adolescent psychiatry, and a psychiatrist in the 22q and You 
Center at the Children's Hospital of Philadelphia, which we 
often refer to by the acronym CHOP. She also serves as 
president of the American Academy of Child and Adolescent 
Psychiatry and as an associate professor of psychiatry at the 
Perelman School of Medicine at the University of Pennsylvania. 
Dr. Benton also serves on the board of the Juvenile Law Center, 
which advocates for children and child welfare in the juvenile 
justice system.
    Her expertise spans pediatric depression, suicide, and 
anxiety, particularly for minority youth and those with chronic 
diseases, as well as our mental health workforce shortage.
    So, Dr. Benton, thank you for being with us today. And 
thank you for all you have done to support families long before 
and throughout this pandemic. I look forward to your insights 
today.
    The Chairman. Thank you, Senator Casey, and we look forward 
to hearing from Dr. Benton.
    Senator Hassan is here to introduce Ms. Lubarsky.

           OPENING STATEMENT OF HON. MAGGIE HASSAN, 
               A U.S. SENATOR FROM NEW HAMPSHIRE

    Senator Hassan. Well, thank you so much, Chairman Wyden and 
Ranking Member Crapo, for holding today's hearing on protecting 
youth mental health. It is essential that we get our children 
the mental health support and resources that they need. And I 
would like to welcome a Granite Stater who is with us today to 
serve as an expert for today's hearing.
    Jodi Lubarsky is the vice president for clinical 
operations, Youth and Family Services, at the Seacoast Mental 
Health Center in Portsmouth, NH. She has a master of arts in 
mental health counseling and is a licensed clinical mental 
health counselor.
    At the community mental health center where Ms. Lubarsky 
works, she oversees the evaluation and treatment services for 
children, adolescents, and their families. These services 
include psychotherapy, psychiatry, community-based behavioral 
supports, targeted case management, substance use disorder 
treatment, 24/7 crisis intervention, and post-intervention 
services to schools and communities affected by suicide and 
loss.
    To say she is at the front lines of some of the toughest 
battles our children face would be an understatement. In her 
role as vice president and as mental health counselor, Ms. 
Lubarsky provides support to young people who are experiencing 
mental health challenges, and she has seen firsthand how the 
pandemic and the shortage of mental health services has 
increased the number of patients in her center.
    In fiscal year 2020, the Youth and Family Services team at 
Seacoast Mental Health Center provided more than 33,000 
services. In fiscal year 2021 alone, it provided more than 
41,000 services to children and families, a 25-percent 
increase. The number of patients seen in fiscal year 2021 was 
almost 13 percent higher than in the previous year.
    In response to the wave of children and young adults 
requiring services, Ms. Lubarsky has worked on innovative 
programs in New Hampshire that have been integrated into places 
like our schools and our summer camps.
    Given her extensive experience and expertise, she will be 
able to speak today about the challenges facing our children, 
the critical programs that she has helped to develop, and the 
persistent barriers that limit access to mental health care.
    Jodi, thank you for being here and for your work on behalf 
of New Hampshire's children and families. I look forward to 
hearing from you today.
    Thank you, Mr. Chairman.
    The Chairman. And thank you for all your help for this 
hearing, and for making sure we could have Ms. Lubarsky. And we 
are looking forward to working closely with you every step of 
the way as we tackle this issue.
    Senator Cardin is here to introduce Dr. Sharon Hoover.

         OPENING STATEMENT OF HON. BENJAMIN L. CARDIN, 
                  A U.S. SENATOR FROM MARYLAND

    Senator Cardin. Well, thank you, Mr. Chairman. Let me thank 
Senator Wyden and Senator Crapo for their leadership on this 
issue, and on so many others, bringing us together to deal with 
the critical problems.
    I first want to acknowledge Trace, and congratulations on 
your acceptance to Johns Hopkins, located in Baltimore, MD. We 
are proud to have you in our State.
    I am proud to introduce a fellow Marylander, Dr. Sharon 
Hoover. She is a licensed clinical psychologist and professor 
at the University of Maryland School of Medicine, Division of 
Child and Adolescent Psychiatry. She is also co-director of the 
National Center for School Mental Health, and director of the 
National Center for Safe Supportive Schools within the National 
Child Traumatic Stress Network.
    Dr. Hoover has led and collaborated on multiple Federal-
State grants, and is currently co-leading two large randomized 
trials of school mental health efforts. Since 2004 she has 
worked with the National Child Traumatic Stress Network's 
Treatment Services Adaptation Center for Resiliency, Hope, and 
Wellness in Schools to train school districts and school 
leaders, educators, and support staff in a multiple-tiered 
system of support for psychological trauma.
    Dr. Hoover is a certified national trainer for the 
Cognitive Behavioral Intervention for Trauma in Schools 
program, and the Support for Students Exposed to Trauma 
program.
    Last year she was kind enough to join the constituent event 
I hosted concerning youth and COVID-19, and I know that Dr. 
Hoover's input was extremely helpful to my constituents, and I 
know she will add greatly to our discussion today.
    Welcome, Dr. Hoover. It is a pleasure to see you.
    The Chairman. Thank you, Senator Cardin, and for your years 
of advocacy in the health-care area for vulnerable folks in 
Maryland and our country.
    So thank you all, colleagues.
    And, Mr. Terrell, we are glad to have your voice coming 
from La Pine, and please proceed.

  STATEMENT OF TRACE TERRELL, LEAD INTERVENTION AND OUTREACH 
               SPECIALIST, YOUTHLINE, LA PINE, OR

    Mr. Terrell. Thank you. Thank you Chairman Wyden, Ranking 
Member Crapo, and the other members of the committee, for the 
opportunity to represent the youth perspective as it pertains 
to mental health.
    My name is Trace Terrell, I use he/him pronouns, and I am a 
17-year-old from La Pine, OR. Before I share more about myself, 
I would first like to tell you some things I have heard from 
teens across the country.
    4:07 p.m.: I just need someone to talk to; 4:37 p.m.: my 
dad hit me, but you can't call the cops; 5:23 p.m.: I need 
therapy, but my family can't afford it; 8:07 p.m.: I just lost 
my dad, and I can't stop crying; 6:42 p.m.: I want to kill 
myself.
    These are just some examples of the many conversations that 
I respond to as a volunteer with YouthLine, a free, 
confidential, teen-to-teen crisis help support hotline located 
in Oregon. Whether helping someone navigate complicated 
feelings about their sexuality or working with others to 
develop comprehensive safety plans, I spend 3\1/2\ hours every 
week responding to a variety of mental health challenges 
experienced by teens across the country, with an emphasis on 
the fact that no problem is ever too big or too small.
    I became involved with YouthLine during my freshman year of 
high school. As someone who struggled with depression, suicidal 
ideation, eating disorder behavior, and anxiety throughout 
middle and early high school, I, for the longest time, believed 
that no one could relate to my experiences.
    However, as I became more involved, I realized that my 
challenges were a microcosm of public health issues that 
affected hundreds of thousands of teens across the country.
    As more and more teens start to have conversations about 
mental health and engage in help-seeking behaviors, the need 
for expansive and intersectional mental health efforts has 
never been so great.
    So, what can we do to address the youth mental health 
crisis?
    One, we must centralize our efforts in schools. From my 
experience and many of my peers, mental health efforts in 
schools are lacking. Day after day, I hear my friends and those 
on the line talk about how inaccessible school counselors are 
due to being overworked and overloaded. This has been an 
especially difficult challenge for the many teens who rely on 
school mental health professionals for crisis care. We have to 
address this staffing crisis.
    We must also create a streamlined approach to free mental 
health screenings and referrals. At my school, four of every 
five referrals to external resources are not carried out. Let 
that sink in: 80 percent of referrals go nowhere. Someone who 
needs help, should receive help.
    Last, we need a comprehensive and standardized mental 
health curriculum. All students should learn about engaging in 
real-world help-seeking behavior, developing systems of self-
care, and supporting our friends with mental health struggles, 
because statistics show that we turn to each other before 
anyone else.
    Two, we need to address the pressing challenges that young 
people continue to face in accessing mental health care. While 
I am no expert in policy solutions, I am someone with lived 
experience. I know what it is like to be a teen today 
struggling with mental health. And I know what it is like to 
offer support to teens in crisis.
    On and off the lines, the most common struggles I see 
expressed by my peers in regard to accessing mental health care 
are financial, transportation, and broadband barriers; the 
urban/rural divide in mental health care; the lack of mental 
health professionals and adequate follow-through care; and the 
stigma around mental health.
    These issues are incredibly real. My friends have struggled 
to receive professional mental health services because it is 
too expensive for their families, too far away, or inaccessible 
because of unreliable Internet access. We need to bring care to 
where people are. And for teens, that is in schools or at home.
    In addition, we know that the lack of mental health 
professionals in the United States prevents teens from 
receiving the help they need. One of the ways we can approach 
this issue is by funding a national YouthLine. We know that 
peer-to-peer support works, and that there is a substantial 
need for it.
    What youth need is to be able to call on the new 988 and 
have the opportunity to be connected with another trained teen.
    Three, we must invite youth to the table and value their 
insights as natural partners in this work. I am just one of 165 
YouthLine volunteers. What does that tell you? Youth are not 
afraid to talk about mental health. If anything, adults are. 
Across the country, young people are mobilizing and advocating 
for mental health like never before.
    Beyond YouthLine, I have been involved with organizations 
like Active Minds, for whom I and millions of my peers helped 
to change the narrative for how we talk about value and seek 
care for our mental health.
    My peers and I believe that we deserve a seat at the table. 
While there are many ways we can do this, it starts by ensuring 
that young people can meaningfully contribute to and be 
involved with legislative work on the local, State, and Federal 
levels.
    If there is anything I want to leave you with today, it is 
this. Teens are talking, and we need you to listen. At 
YouthLine, we know that the work we do makes a difference in 
the lives of young people across the country, and we know that 
because of what we hear from teens after we have connected them 
to help, after we have talked about self-care, and after we 
have helped them find a path forward.
    6:26 p.m.: I feel so much better talking; 8:34 p.m.: if it 
weren't for this conversation, I would not be here today.
    Thank you.
    The Chairman. Trace, thank you for getting us off to such a 
powerful start, and what I want you to know--you said that 
young people were mobilizing. Those are very welcome words, and 
I think you are going to see today the Democrats and 
Republicans in the U.S. Senate, the Finance Committee, are 
going to start mobilizing to move real reform. And make no 
mistake about it, you and young people are going to have a seat 
at that table when we are working on these reforms.
    So, thanks for getting us off to such a strong and powerful 
start.
    [The prepared statement of Mr. Terrell appears in the 
appendix.]
    Dr. Benton, let's see where you are. Dr. Benton from 
Children's Hospital of Philadelphia, you have the honor of 
trying to keep up with Trace. It is a big challenge, and you do 
wonderful work, as Senator Casey said.

   STATEMENT OF TAMI D. BENTON, M.D., PSYCHIATRIST-IN-CHIEF, 
    EXECUTIVE DIRECTOR, AND CHAIR, DEPARTMENT OF CHILD AND 
   ADOLESCENT PSYCHIATRY AND BEHAVIORAL SCIENCES, CHILDREN'S 
           HOSPITAL OF PHILADELPHIA, PHILADELPHIA, PA

    Dr. Benton. Chairman Wyden, Ranking Member Crapo, and 
members of the committee, thank you for this opportunity to 
testify.
    I wish there were no need for me to appear today, but 
children and adolescents are experiencing mental distress at 
higher rates and with more dire consequences than ever before.
    In the first half of 2021 alone, we reported cases of self-
injurious behavior and suicide in children ages 5 to 17 at a 
45-percent higher rate than during the same period in 2019. And 
for children under 13, the suicide rates for Black children 
have increased at twice the rate for White children.
    The pandemic has both highlighted and worsened disparities 
in pediatric mental health care. There are barriers to access, 
under-recognition, and under-treatment of mental health 
disorders. The burden of illness is worsened for children of 
color, who often have greater exposure to environmental 
traumas.
    It is also true that children with mental health challenges 
are overrepresented in the juvenile justice and child welfare 
systems, where higher rates of mental health disorders are 
often unrecognized and untreated.
    You have heard many of these statistics before, but I would 
like to share with you how these situations show up in my day-
to-day life as a physician.
    A 5-year-old in the emergency department who discloses 
suicidal feelings and plans to run into traffic in reaction to 
her parents' job loss, financial stresses, and her mother's 
depression.
    A 6-year-old boy suspended from first grade for kicking a 
desk after witnessing a shooting 20 feet away from him while 
walking home from school, too terrified to disclose the 
experience for fear that he would be the next victim.
    A 16-year-old honor student becoming depressed after a 
romantic breakup, eventually making a serious suicide attempt 
while waiting 6 weeks for treatment, and then hospitalized for 
2 weeks in a medical facility where he waited for in-patient 
psychiatric care. And then when it was available, financial 
barriers interfered with the smooth transition.
    It is situations like these that led the American Academy 
of Child and Adolescent Psychiatry, the American Academy of 
Pediatrics, and the Children's Hospital Association to sound 
the alarm for kids, and to declare a national emergency in 
children's mental health. But there are things that we know.
    Children and adolescents recover best when care is targeted 
to their needs, evidence-based, no more restrictive than it 
must be for safety, and close to home. And, while I can speak 
more directly to the shortage of child and adolescent 
psychiatrists, there are also severe shortages of other 
pediatric mental health providers, which all must be addressed.
    These shortages lead to increased emergency visits for 
things that are preventable. In my home institution at 
Children's Hospital Philadelphia, we have 20 to 30 patients 
boarding, awaiting acute psychiatric care. And this is true on 
any given day.
    We typically operate at full capacity, so occupied beds 
prevent children with complex medical needs from receiving 
care. But despite the things I have just shared, I remain 
optimistic. Effective strategies exist for preventing and 
treating pediatric mental and behavioral conditions while 
supporting the natural resilience of children and families.
    But success requires responses to two urgent tasks before 
us: first, addressing the immediate crisis that we are facing 
right now; and second, reframing our pediatric mental health 
system with the goal of preventing disrupted development and 
facilitating a successful transition to adulthood. Expansion of 
the workforce will take time, even if we start today. So I will 
focus more on immediate options to address the crisis.
    One of the best things that we can do is to support those 
on the front lines now by providing them with effective 
training. This should also extend beyond primary care 
pediatricians. Caregivers and educators can be empowered 
through training to better manage the situations they face. And 
we must act now to pivot mental health services from crisis-
driven care to prevention, and make sure that needed treatments 
are available where families are likely to be, such as 
pediatricians' offices, daycare, after-school programs, and 
schools.
    The pandemic has also taught us important lessons. 
Telehealth has been an important tool for providing care across 
State lines, in underserved areas, rural areas, local and 
distant communities, and for working families. It has had 
surprising therapeutic advantages such as seeing the whole 
family, and seeing them in their natural environment.
    This tool must continue as an adjunct to our current 
continuum of treatment. And I cannot conclude my remarks 
without noting that both coverage of the range of services kids 
need, and the appropriate reimbursement for these services are 
essential. The continuum of services needed for children for 
mental health are absent at every level. Children need to get 
the right treatment at the right time at the right place.
    And finally, I want to end by sharing an experience that 
reflects my hope for the future.
    Just last week I interviewed two fifth graders, Daniel and 
Kaitlin. They asked me, ``When can normal feelings like 
depression, anxiety, become bad for you?'' These are questions 
that all Americans should be asking at this time--and should be 
able to answer.
    I want to thank you again for allowing me to provide this 
testimony. I am confident that you will take this opportunity 
to secure our Nation's future by supporting our children 
through the crisis.
    Thank you.
    [The prepared statement of Dr. Benton appears in the 
appendix.]
    The Chairman. Dr. Benton, thank you very much for your 
helpful testimony. And I noted you talked about access to 
coverage and reimbursement. We think that is very much 
intertwined with some of these big insurance companies not 
following through on parity, which is so essential for mental 
health patients. So you gave us a lot of very valuable input, 
and we look forward to working with you.
    Now we will go to Ms. Jodie Lubarsky.

STATEMENT OF JODIE L. LUBARSKY, M.A., LCMHC, VICE PRESIDENT OF 
CLINICAL OPERATIONS, YOUTH AND FAMILY SERVICES, SEACOAST MENTAL 
              HEALTH CENTER, INC., PORTSMOUTH, NH

    Ms. Lubarsky. Good morning, Chairman Wyden, Ranking Member 
Crapo, Senator Hassan, and members of the U.S. Senate Committee 
on Finance. I want to thank you for the opportunity to testify 
today as a witness regarding pediatric mental health. I am both 
humbled and grateful for this opportunity.
    I currently serve as the vice president of clinical 
operations for Youth and Family Services at Seacoast Mental 
Health Center. We are one of 10 community mental health centers 
in the State of New Hampshire. I am also a Licensed Clinical 
Mental Health Counselor still actively seeing pediatric 
patients, a youth swim coach, and a parent.
    In March of 2020, life as we once knew it changed for all 
of us. As adults, we made many quick pivots to respond and 
adapt to the COVID-19 pandemic. As we made many adaptations in 
both our personal and professional lives, we had our past 
experiences to reflect upon. When faced with the new and often 
unpredictable challenges the pandemic created, we pulled from 
our toolbox of coping strategies. We knew who we could turn to 
for the extra support we might have needed as we navigated 
those challenges.
    But for most of the youth in our country, they were left 
feeling paralyzed, stymied, hopeless, and scared. For many 
youth, this was their first experience with grief, trauma, 
depression, or anxiety. Life for them had completely changed, 
and their worlds were turned upside down. The uncertainty, 
social isolation, and stressors related to the pandemic have 
left many kids unable to cope or understand the breadth and 
depth of this experience. And for some, there was no trusted 
adult to support them during this critical developmental period 
and their only means of symptom relief was contemplating death.
    We are learning that teenage girls have begun to 
demonstrate an increase in the acuity of their symptom 
presentation. Data from the Centers for Disease Control and 
Prevention indicates a 51-
percent increase in suicide attempts by teenage girls ages 12 
to 17. LGBTQ+ youth continue to have higher rates of suicide 
than their heterosexual peers. Data from 2020 demonstrated that 
the percentage of emergency department visits for mental health 
emergencies rose by 24 percent for children between the ages of 
5 and 11 and 31 percent for those ages 12 to 17, compared with 
2019.
    Youth mental health has become the secondary pandemic to 
COVID. As mental health needs rise for pediatric patients, the 
availability of services continues to become more scarce. Youth 
are presenting to hospital emergency rooms in a state of 
psychiatric crisis. Many who are assessed and meet the criteria 
for psychiatric inpatient level of care will be faced with 
boarding in an emergency room for days, weeks, and sometimes 
months before a bed becomes available.
    Emergency room boarding often creates more distress, 
decompensation in psychiatric symptoms, and increased traumatic 
exposure, while receiving no mental health care until the 
inpatient bed becomes available. Staffing shortages in both 
outpatient and inpatient settings due to an exhausted, 
depleted, and underpaid mental health workforce have only 
prolonged access to care for pediatric patients.
    Without adequate funding and reimbursement structures from 
both Medicaid and private payers, mental health providers are 
left with the difficult decision to leave the nonprofit world 
and enter a for-profit world in order to make a livable wage. 
During the pandemic, there were two 3-percent increases to 
Medicaid rates. And while that is appreciated, prior to those 
two increases there had not been meaningful increases in 
Medicaid rates in over 20 years. Without a realistic 
reimbursement structure based on the current cost of living, 
centers are losing staff who can no longer afford to work in 
mental health settings.
    Some mental health centers are reporting a 40-percent 
rolling 12-month turnover rate in staffing during the pandemic, 
leaving no workforce available to attend to the critical and 
fragile needs of pediatric patients. And for the mental health 
workforce that remains, they are often left supporting higher 
caseloads than their private-practice peers, with limited time 
while attending to significant administrative tasks that 
private mental health providers are not expected to complete.
    The community mental health workforce treats some of the 
most complex cases. The complexity of cases, the severity of 
need, and demand placed upon this workforce during the pandemic 
have left many professionals questioning their longevity in the 
mental health field. I feel many mental health professionals 
entered with an altruistic spirit and are now left feeling 
broken and tired.
    While we can discuss an ideal service array, evidence-based 
practices, and the ideal care setting, none of this can be 
provided without a robust, well-trained, adequately 
compensated, and sustainable mental health workforce from all 
professional disciplines and degree levels. Simply put, we need 
to be able to adequately reimburse mental health providers in 
order to compensate the mental health workforce. Adequate 
reimbursement will help to sustain a robust mental health 
workforce to provide high-quality, timely, adequate care to our 
pediatric population.
    I thank you for your time today.
    [The prepared statement of Ms. Lubarsky appears in the 
appendix.]
    The Chairman. Thank you very much, Ms. Lubarsky. You 
finished so powerfully with the workforce, I just wanted to 
come back for a moment and say ``thank you'' for mentioning at 
the outset, that in those first days of the pandemic, you 
reached for your mental health toolbox, because that is really 
what this is all about: making sure that practitioners, not 
somebody micro-managing in Washington, DC, can have an adequate 
array of tools.
    And as you know so well from your outstanding work, too 
often the toolbox is pretty barren in much of the country. And 
that is what Dr. Murthy told us last week. So, thank you. I 
know you are going to get some questions in a moment.
    Dr. Sharon Hoover is next, please.

    STATEMENT OF SHARON HOOVER, Ph.D., PROFESSOR, CHILD AND 
  ADOLESCENT PSYCHIATRY; AND CO-DIRECTOR, NATIONAL CENTER FOR 
    SCHOOL MENTAL HEALTH, UNIVERSITY OF MARYLAND SCHOOL OF 
                    MEDICINE, BALTIMORE, MD

    Dr. Hoover. Thank you. I want to express my thanks to you, 
Chairman Wyden, for the invitation to speak with the committee 
today, and for your leadership on the issue of mental health in 
our Nation, including the impacts on youth. I thank also 
Ranking Member Senator Crapo, and all of the committee members 
for your vision to improve the mental health and well-being of 
our young people, and for the opportunity to be here with you 
today to talk about these important issues.
    I am speaking to you from my perspective as co-director of 
the National Center for School Mental Health, which is funded 
by the U.S. Department of Health and Human Services, and as a 
professor of child and adolescent psychiatry. But I also speak 
to you through my lens as a parent to three teenagers, all of 
whom had their learning landscape significantly altered during 
COVID, with almost a year of virtual education.
    They, along with most children across the globe, had 
significant disruption to their learning and to their well-
being, though I am fortunate that my kids are now going to 
school, and they are doing well. But we know that many are 
suffering. Even before the pandemic, youth mental health 
challenges were rising, with suicide being the second leading 
cause of death for young people ages 10 to 24.
    As noted by Surgeon General Murthy during last week's 
hearing, one of the most central tenets in creating accessible 
and equitable systems of care is to meet people where they are. 
And for most young people, this is in schools.
    I often think back to a story that my dad, who is now 85 
years old, told me about his first day of school. He grew up in 
a small town in rural West Texas called Spur. They didn't have 
pre-K or Kindergarten, so it was first grade, and on that first 
day he recalled that his peers and he received toothbrushes 
from his first grade teacher. It was the first toothbrush that 
he had ever owned. And I remember asking him, ``You didn't have 
toothbrushes?'', to which he replied, ``No; my family wouldn't 
have spent the money on toothbrushes back then.'' Mind you, my 
dad went on to a long career in computer science, and he helped 
create coding to put our astronauts on the moon. But he often 
credits those teachers in his early years who cared about him 
with setting him on that path.
    And when I consider that moment when he received his 
toothbrush on the first day of school, I think of it really as 
a classic example of how our schools are a vital place to 
promote our children's health and well-being. We simply cannot 
rely on our health-care system alone to support the mental 
health and well-being of our young people.
    We know on average, as Senator Wyden noted in the 
beginning, that people do not get into care for over a decade 
after the initial onset of symptoms, and half of mental 
illnesses begin in the school-age years.
    Our traditional approach to mental health care has not 
leveraged the natural venues where our young people access 
support. It is really akin to waiting for toothaches, cavities, 
and abscesses until a child gets proper dental care. Instead, 
we should do the equivalent of passing out toothbrushes and 
providing preventive and early dental care, by offering every 
child in every school the social, emotional, behavioral, and 
mental health supports that they need to be successful.
    Increasingly, schools have comprehensive school mental 
health systems, which reflect partnerships between the 
education and behavioral health sectors to support a full 
continuum of mental health and substance use services and 
supports, from promotion to treatment. And when treatment is 
delivered in a school setting, youth are far more likely to be 
identified early and to initiate and complete care.
    Schools that have these systems in place recognize that 
poor mental health leads to poor learning, and positive mental 
health promotes academic and life success.
    There are many policy and funding opportunities, including 
strengthening full Medicaid programs that can help advance a 
continuum of mental health supports and services in schools. 
And Congress has the opportunity to support investment and 
technical assistance to ensure that young people can get the 
mental health support that they need.
    In my written testimony, I do provide detail on several 
steps that Federal and State leaders can take to advance 
comprehensive school mental health systems. And we have 
witnessed many States adopt new policies to advance school 
mental health.
    Tomorrow, the Hopeful Futures Campaign, a coalition of 
national organizations committed to ensuring that every student 
has access to effective and supportive school mental health 
care, is releasing the first ever ``America's School Mental 
Health Report Card and Action Center,'' with individual report 
cards for all 50 States and DC. And these school mental health 
report cards highlight accomplishments and provide important 
action steps to help address the children's mental health 
crisis in every State. They can serve as a great starting point 
for policymakers who want to strengthen school mental health 
supports and policies in their communities. You can find the 
report cards at hopefulfutures.us starting tomorrow morning.
    Today, Americans across the country are united in our 
concern about the mental health of our young people and the 
impact it has throughout their lives. I want to express my 
gratitude to you all for opening up this important discussion 
on youth mental health, for recognizing schools as an essential 
place to strengthen our children's well-being, and for 
committing to investing now to create hopeful futures for our 
Nation's youth.
    [The prepared statement of Dr. Hoover appears in the 
appendix.]
    The Chairman. Thank you very much, Dr. Hoover, and we are 
going to get you into this discussion in just a minute.
    Trace, you really make all of us in Oregon so proud, and 
you said it so well. And I want to get into an area that I 
really had not heard about from you. And that is, how serious 
this problem is with young people getting lost in the system, 
where they just do not get connected. And the figure you used 
is 80 percent of referrals from schools for mental health 
support just go nowhere--just get lost.
    How does this make students and young people feel when they 
just get lost in all of this red tape and bureaucracy?
    Mr. Terrell. That is a great question, Senator Wyden. And I 
want to clarify that that statistic was for my school. So, I do 
not actually know the national figure, but I imagine there are 
similar trends across the country.
    The Chairman. That was for your school, right, Trace?
    Mr. Terrell. Yes.
    The Chairman. Good. Please, go ahead.
    Mr. Terrell. But I think, when we talk about access to 
care, there has to be a conversation about what happens next, 
right? What happens next? Who is going to provide the follow-
through care? And I think for a lot of teens who get to this 
point and initially have that first conversation, not being 
able to get those accesses afterwards is incredibly isolating 
and incredibly defeating. And I think it really highlights some 
of the failures of our mental health-care system and things 
that need to be addressed. Because teens who need help should 
receive help, and that help should be meaningful and 
sustainable for as long as they may need it.
    The Chairman. Okay. Sit tight, Trace.
    Dr. Hoover, that 80-percent figure is really show-stopping. 
And my sense is, whether it is 80, or 60, or something, we are 
just losing a lot of young people at a really crucial time. 
What ought to be done about that?
    Dr. Hoover. I totally agree, and I would agree with Trace 
that it is probably not just in his school. We are seeing these 
figures across the Nation.
    So, the bottom line is that getting care to kids in some of 
our traditional outpatient settings really is a challenge. So, 
as you heard earlier, one of the first lines of action really 
is to bring services to where young people are in their 
schools. We know that every State, and many districts within 
each State, have examples of really effective school-based 
mental health care, right? So this includes expanding our 
school-employed workforce, including our school psychologists, 
school social workers, and counselors, but also helping 
facilitate partnerships with community behavioral health 
provider organizations to bring their services into schools. 
School-based health centers are also an ideal model of 
providing this type of onsite care. So, increasing support for 
school-based health centers is one avenue.
    We mentioned telehealth already. We know the expansion of 
telehealth offers incredible opportunity to expand the reach of 
specialists, not just in rural settings, although that is 
critical, but also into our urban settings. We have been 
providing telehealth from our hospitals into Baltimore City 
schools for a number of years now.
    We heard from Ms. Lubarsky about reasonable reimbursements. 
That is a critical way of getting services to schools and into 
outpatient care, and having providers there to receive students 
when they are referred.
    So those are some of the avenues.
    The Chairman. Well, thank you both.
    And, Trace, if ever there was an area, as you said, for the 
committee to work with young people, it is mobilizing, in your 
words, to make sure that we do not see as many of these 
referrals get lost in the system. It is just too important, 
because those are young people who are getting lost.
    I want to ask you one other question, Trace. And that is, 
you and I talked about barriers to care. And clearly, stigma 
associated with mental health challenges is a big part of this. 
I saw this with my brother who struggled with schizophrenia for 
years--and as I went off and played basketball and all kinds of 
things like that. And my concern is, I keep hearing from people 
in the schools, and students like yourself, that the stigma has 
clearly gotten worse as a result of the pandemic, causing more 
young people to be isolated from each other; that there is not 
enough peer-to-peer contact and the like.
    Can you give us your thoughts on that?
    Mr. Terrell. Of course; yes. I mean, I think we definitely 
saw how the pandemic increased rates of loneliness, isolation, 
and other high-acuity mental health struggles. But I think 
really the most important takeaway from the pandemic, and our 
response to the mental health-care crisis, is the fact that 
COVID-19 exacerbated disparities that were already there, 
right? We know that access to care was limited before COVID-19, 
and the pandemic only amplified those barriers.
    So, if a teen's only way of receiving mental health support 
was with a school counselor, that relationship was no longer 
there and they could no longer have that conversation about 
mental health. And that in and of itself is destigmatizing the 
stigma around mental health. And I just want to bring up, if a 
teen feels like the only way they can express their emotions is 
through the barrel of a gun, what have we become as a society 
in our perception of mental health for young people?
    And we really need to talk about mental health, and I think 
that first starts with having this conversation and recognizing 
how COVID exacerbated already existing disparities.
    The Chairman. Trace, we had high expectations for you this 
morning, and you went way over the bar. So, thank you so much. 
And you are going to have a seat at the table as we go forward 
on these big issues, and thank you.
    Senator Crapo is next.
    Senator Crapo. Thank you very much, Senator Wyden.
    And I agree, Trace, with Senator Wyden's comments. I am 
going to let you off the hot seat for a minute, though, and go 
back to Dr. Hoover, and then to some of our other witnesses.
    Dr. Hoover, for Idaho and other States with large rural 
communities, the mental health-care delivery system looks 
substantially different from other urban or suburban 
populations. Even though the need for mental health services is 
similar between rural and urban areas, it is harder for 
children in rural areas to access those same mental health 
services.
    In your work with the States, can you elaborate on some of 
the specific risks and challenges that younger Americans living 
in rural areas might confront with regard to mental health?
    And I ask this question in the context of, already you have 
indicated that our schools, many of them, have good programs in 
place, and that they are working well and need to be 
strengthened and enhanced and given more tools.
    But focus a little bit on rural areas. How are we doing 
there? And what role do schools play in providing mental health 
services to our youth?
    Dr. Hoover. Thank you, Senator Crapo, for the question. And 
frankly, school mental health is perhaps even more relevant and 
important in our more rural communities, just because of the 
workforce shortage, and also some of the stigma issues that 
Trace just spoke to.
    We know that, in rural communities, our young people and 
families often have a harder time accessing services, as you 
mentioned. And there often is more of a stigma associated with 
seeking out mental health supports. We hear often--I was just 
working with some rural counties in Maryland, and we often hear 
``everybody knows each other,'' right? So seeking mental health 
supports can be even more risky from a student perspective, or 
even from a family perspective.
    That being said, we know that schools can be a place where 
mental health can be destigmatized. So it is one step, I would 
say, that is critical in rural communities, and in all 
communities, to really make mental health part of the education 
that our young people experience.
    So, we can establish mental health as part of the K through 
12 curricula, and a number of States are doing that. I know New 
York, Florida, Virginia, have led the way to infuse mental 
health as part of what young people learn about. They learn 
about how to achieve positive mental health, how to recognize 
if there are some problems, and how to seek support when they 
actually need support for themselves or for a family member or 
a peer. So part of it, again, is reducing stigma, and that is 
particularly critical in our rural settings.
    I would say, in terms of the workforce, we know we have to 
get workforce into our rural communities. And some of that will 
require kind of reaching down into our high school, and 
certainly our undergraduate training environments. I worked 
with some groups in Nebraska that have done an excellent job of 
really fostering the high school interest in mental health 
specialties as they come into undergraduate and then graduate 
training, but also really working with other providers in 
schools, including our school nurses and other health 
providers, and even our front-line educators, to do some task 
shifting, to adopt some of the skills that they can equip young 
people with.
    We do not have to--we really simply cannot rely exclusively 
on our specialty mental health providers, especially when we do 
not have enough.
    So those are some of the solutions that I look forward to 
working with you on.
    Senator Crapo. Well, thank you very much.
    Let me move next to Ms. Lubarsky. I am not going to have 
time to get to all the witnesses. I apologize. But we have lots 
of questions, and we will give you some even after the hearing.
    Ms. Lubarsky, your experiences can provide a deeper 
understanding of the range of services provided across the 
continuum of mental health care. One of the most common 
concepts discussed in the stakeholder responses we have 
received is the need for increased coordination and case 
management to lead to better outcomes.
    In your role as a community mental health leader, can you 
explain exactly what ``targeted case management'' means in 
practice when you are caring for the kids and their families?
    Ms. Lubarsky. Yes. Thank you, Senator Crapo, for your 
question. Targeted case management I really view as a 
fundamental important service for every youth who is receiving 
clinical services at a mental health center.
    When we think about Maslow's hierarchy of needs and that 
ability to meet your most basic needs in life, that is why we 
utilize case management with our pediatric patients and their 
families. If you cannot feel food secure, housing stable, able 
to access your education in a meaningful way, and really be 
able to be socially connected to your community in a manner so 
that, when you are done with your mental health care, you are 
moving to your supports in your community, then you are not 
going to be able to reach that final goal, which may be your 
therapeutic goal when you are coming in for mental health care.
    So providers here at the center--for every youth who is 
eligible for mental health services, they have the ability to 
receive targeted case management as well. So we are doing that 
very nice balance between providing the clinical mental health 
care, while also looking at their needs outside of mental 
health to make sure we are bringing those worlds together.
    Senator Crapo. Well, thank you. And I will submit my 
questions for the record to the other witnesses I did not get 
to. Thank you to all of you for your testimonies.
    [The questions appear in the appendix.]
    The Chairman. Thank you, Senator Crapo. And as we said at 
the outset, we are going to make this a bipartisan effort. This 
is one of the most important undertakings the Finance Committee 
has been part of, and we thank you for your leadership.
    And also, to focus on bipartisanship, Senator Stabenow--who 
for years has worked relentlessly to improve behavioral health 
with our colleague, Senator Blunt of Missouri--is with us.
    Senator Stabenow, your questions.
    Senator Stabenow. Well, thank you, Mr. Chairman. I just 
want to say ``thank you'' to you and ``thank you'' to Senator 
Crapo. This is so important. Spending not one hearing but 
multiple hearings on mental health is absolutely critical and 
has not been done since I have been in the Senate, and I am 
very grateful for all of your leadership.
    And yes, this is an area of bipartisanship where we have 
begun a process of changing to address health care above the 
neck the same way we address health care below the neck--in the 
funding and so on. We have models that work now, and we've just 
got to move forward and get it done. And there is a lot more to 
do.
    And I want to also just give a shout-out to Trace. Thank 
you so much. Thank you for coming forward and sharing your 
experience, and for now being a part of really making a 
difference in young people's lives. And part of overcoming the 
stigma is all of us just telling our own story, the story of 
someone in our own family, so that we are treating anxiety, or 
mental illness, the same way we would if somebody was a 
diabetic, or had a broken leg, a broken arm, that it is just 
part of health care. And I hope we are going to work together 
and we are all going to get there.
    So let me--and by the way, I also wanted to say, Trace, in 
your written testimony, I appreciate your mentioning both our 
school-based health clinics, which I think are the model for us 
in the school setting, and our Certified Community Behavioral 
Health Clinics, which really are the model for quality, 
comprehensive care in the community now that are fully funded, 
where professionals are fully funded, so that we can move 
forward.
    So, Dr. Benton, I wanted to ask you particularly about that 
point, because I appreciate all of our witnesses and their 
wonderful testimony, but our Certified Community Behavioral 
Health Clinics, which we now have demonstrated in 10 States, 
are fully funded. What can happen--if we are funding behavioral 
health like our FQHCs, our community health centers, with high 
standards, full funding--is health care where we are seeing now 
the difference that that can make. And we are working hard to 
have this be the structure across the country really, which I 
believe can really transform the services we are talking about.
    But the CCBHCs, as we call them, really make help available 
where children are. And we nearly have about 25 percent so far 
of the community services being given to children. And there is 
a lot more that we can do.
    So I wonder if you might speak a little bit more--I know 
you discussed this in your testimony, but highlight the 
importance of these comprehensive community clinics, 
particularly on under-served communities.
    Dr. Benton. Thank you so much, Senator Stabenow, for that 
question. The Certified Community Behavioral Health Clinics are 
key components of the mental health continuum. And a 
significant component of the problems we faced this year 
related to those services being overwhelmed by the number of 
patients and limited numbers of providers.
    It is vitally important to address equity for all children 
to have care in their communities where they are everyday that 
is accessible to their families, that is culturally competent, 
and integrates principles of cultural humility. And in academic 
centers like the children's hospitals, we partner very strongly 
with the community centers to expand access. And so we should 
be able to provide and fill in the gaps where they exist in 
those clinics.
    So, for example, because the reimbursement is not always 
what it should be, they tend to run with a lower number of 
providers. And it is our responsibility in centers where there 
are more resources to be able to provide that support to the 
communities.
    But without a strong partnership, we will never be able to 
successfully address the concerns of young people in our 
country.
    Senator Stabenow. Absolutely. I totally agree. And we can 
do this. We have done this on physical health, and so we 
absolutely can do this.
    I know my time is running out. The time is too short. I 
have many questions I will submit. I did want to also just 
indicate that I am excited to be leading the committee's 
working group on workforce issues, which each of you have 
raised and are so critically important. And I am working with 
Senator Daines, my colleague, on this, and we will be reaching 
out to each of you to ask for your further input.
    So, thank you, Mr. Chairman.
    [The questions appear in the appendix.]
    The Chairman. Thank you, Senator Stabenow. I was about to 
mention the good work that we know you are already beginning 
with Senator Daines.
    So our guests have an understanding of how we are going to 
work, we have a Democrat and a Republican serving on each of 
the key areas that we have to tackle. And because Senator 
Stabenow's expertise in this area and her advocacy is so 
important, I think we are especially lucky to have her handling 
the workforce issue, which I think we have all heard people 
mention repeatedly.
    So, Senator Stabenow and Senator Daines are going to be 
playing a key role, and we thank her for all of her leadership.
    Senator Grassley is next. And we welcome him.
    Senator Grassley. Thank you, Mr. Chairman.
    I am going to lead into a question for Dr. Benton. In 
September, the DEA issued its first Public Safety Alert since 
2015. It warned of a significant nationwide surge in 
counterfeit pills that are mass-produced by criminals in labs, 
deceptively marketed as legitimate prescription drugs. These 
counterfeit pills are killing unsuspecting Americans, 
particularly young people, and at an unprecedented rate. Many 
youth are getting illicit pills knowingly or unknowingly 
through Snapchat or TikTok. This use of illicit drugs is driven 
by mental health challenges, anxiety, suicidal thoughts, and is 
resulting in accidental overdose deaths.
    So, do you believe that kids dying of suicide or accidental 
drug overdose is driven by mental health challenges?
    Dr. Benton. Well, thank you for that question, Senator 
Grassley. It is a complicated one. And so, definitely there are 
increases in rates of mental health conditions that contribute 
to suicide. But mental health conditions are not the only 
factors that contribute to completed suicide, which is one of 
the reasons it has been so difficult to prevent.
    So, environmental factors, other things that you just 
identified, exposure on the Internet, all kinds of unregulated 
advertisements for young people, all contribute to those 
challenges.
    I also want to call out something else that you were 
highlighting with your question, which is that the focus on 
medications and the focus on pill treatments for young people 
with mental health conditions discounts the fact that most 
young people actually need psychosocial intervention.
    So there are multiple environmental factors, psychosocial 
factors, and other treatment factors that we need to consider 
when thinking about treatment--not just emphasizing 
pharmacologic treatments that are available, which I think 
would diminish some of the focus on young people obtaining 
medications.
    Senator Grassley. I am going to go on to another subject, 
Dr. Benton. In your written testimony you mentioned the 
importance of patient-centered medical homes for kids to 
improve access. In 2019 we passed the bipartisan ACE Kids Act 
establishing pediatric home health for kids with complex 
medical conditions.
    Last fall, the Centers for Medicare and Medicaid Services 
issued guidance for ACE kids and is working with Medicaid 
programs in the same way.
    For you, Dr. Benton: is access to out-of-State providers a 
challenge for kids with complex medical needs? And let me 
follow it up with what might be my last question. For kids with 
these needs, what does coordinated mental and physical health 
care look like? And describe medical home.
    Dr. Benton. Thank you, Senator Grassley, for your 
leadership in this area. So for patients, the medical home has 
provided significant support for young people with complex 
medical conditions. But we still have work to do in the area of 
integrating the medical and mental health benefits and 
treatments.
    And so, for the patients in our medical home, we do better 
at providing mental health support for young people, but we 
still face challenges around parity for mental health and 
medical services.
    So, within our own institutions, when young people come to 
us locally or from out of State, frequently the medical benefit 
is accepted and easily accessible, but when those same 
youngsters need mental health treatment, they frequently find 
themselves in a situation where they are being billed for a 
service that is out of network, or they are not paid at all. 
And it poses significant challenges for families who deserve 
the care that their child needs, but the parity issues remain 
barriers.
    We have made significant progress, and I look forward to 
your continued work in this area in leading us through these 
complex co-morbid conditions. We have made progress, but we 
still have more work to do.
    Senator Grassley. For Mr. Terrell, you will have to give a 
short answer to this because my time is up, but what efforts 
should be taken to address unique rural mental health needs?
    Mr. Terrell. Like I said, access to care is super 
important. And I really appreciate this question, just because 
I think that you have had so much stewardship and insight about 
this issue. So I think if we can really bring--personally, I 
live in a rural community, and what I think would be really 
helpful would be to bring care to where people are. And that 
means funding school-based health centers, CCBHCs, and other 
community-based mental health supports that really help teens 
to just get the support that they need.
    It is easier to be on a school campus and get medical 
services than it is to be at home, have to coordinate 
transportation, and get there, which is a barrier that so many 
teens in rural communities face.
    Senator Grassley. Thank you.
    Thank you, Mr. Chairman. I will submit questions in 
writing.
    [The questions appear in the appendix.]
    The Chairman. Very good.
    Senator Cantwell is next, our Northwest partner.
    [No response.]
    The Chairman. Senator Cantwell, are you on line?
    [No response.]
    The Chairman. I will give this just a quick moment, because 
I think she is.
    [Pause.]
    The Chairman. Senator Thune would be after Senator 
Cantwell.
    [No response.]
    The Chairman. Senator Menendez?
    [No response.]
    The Chairman. Senator Portman?
    [No response.]
    The Chairman. Senator Carper?
    [No response.]
    The Chairman. And for our guests, you should know that this 
is a particularly hectic day in the Senate, so members are 
going to be coming in and out.
    Senator Carper?
    [No response.]
    The Chairman. Senator Cassidy is here. Senator Cassidy is a 
very valued member, with his expertise on health care as a 
physician. Senator Cassidy?
    Senator Cassidy. Thank you very much for that. By the way, 
I thought I had 15 or 20 more minutes to listen, and everybody 
else is out. So, anyway, thanks for doing that.
    Dr. Hoover, I used to work with a school-based clinic to do 
hepatitis B immunization, and I am very aware of how well they 
can function bringing care.
    Now first, I think we have to acknowledge that if the child 
is not in school, it is difficult for the child to be 
evaluated. But that said, now kids are back in school, so there 
is some progress there. But let me ask--and you may have 
covered this while I was in another committee hearing.
    Now my understanding is that the schools and the school 
systems would benefit when CMS gives them updated guidance as 
to the possibility of providing these services in that venue. 
Any comments on that, Dr. Hoover?
    Dr. Hoover. That is exactly right, Senator Cassidy. And I 
appreciate the question. And you are correct that it is easier 
to get the school-based care to young people when they are 
actually in schools.
    And one of the things that we are hoping Congress can 
support is really urging CMS to modernize the existing school 
guidance for Medicaid in schools. This guidance has not been 
updated since 2003, and it is critical for State education and 
State Medicaid agencies to work together to actually be able to 
support and resource mental health providers.
    Senator Cassidy. Let me ask you--I have limited time--what 
is the problem with the current guidance, or lack thereof, that 
limits the ability to expand mental health services through the 
school-based clinics?
    Dr. Hoover. So just quickly, a lot of States do not want to 
move forward with implementing the current Medicaid-supported 
mental health services in schools. They are worried. They are 
hesitant that expanding their programs may put them at audit 
risk. The guidance really is not updated to reflect 
improvements in telehealth. It is not updated to reflect the 
free care policy reversal in 2014. So there are a number of 
updates to Medicaid that would need to be reflected in this 
guidance for States to feel comfortable moving forward.
    Senator Cassidy. And specifically, you mentioned tele-
mental health. I am really struck. If you look at adolescent 
psychiatrists in my State, they are in the cities. They are not 
in the rural areas.
    So one, the infrastructure bill expands Internet services 
throughout the State. That will be huge. But secondly, you have 
to get the adolescent psych who is in Shreveport to be able to 
communicate to the child who might be in Winn Parish. You do 
not know the geography of my State, but it is urban to rural. 
What impediments right now does the rule give as regards the 
utilization of that tele-mental health?
    Dr. Hoover. So as you know, during COVID we saw a huge 
expansion of telehealth. And we know that providers and 
families need guidance and technical support to actually use 
the telehealth equipment. But more important than that, we need 
to see the continued expansion of reimbursement and policies 
that support teleproviders to be able to not only provide 
services within their communities, but even across State lines 
as necessary, to address some of the workforce shortages.
    Senator Cassidy. Now, if you gave advice to this 
committee--because we have jurisdiction over Medicare, 
Medicaid, CMS--one thing is to urge CMS to update this 
guidance. And again, is there any single point--you are talking 
to Senators Wyden and Crapo right now [laughter]. They are the 
straws that stir the drinks of Medicaid, Medicare, and CMS. So, 
if you had to kind of just sit down and pound your hand on the 
table, what would you say to our chair and ranking member that 
we have to get done before we move on?
    Dr. Hoover. Absolutely I would say that Congress should 
encourage all States to cover all medically necessary mental 
health services, including prevention services for all 
Medicaid-enrolled students, and simultaneously ensure that 
school Medicaid programs have the updated guidance, best 
practices, and technical assistance that they need.
    Senator Cassidy. Mr. Terrell, can you just put the dot on 
the ``I'' as regards the importance of school-based clinics 
with regard to the provision of mental health?
    Mr. Terrell. Of course; yes. Like I said, this is a great 
question, because I think it is so relevant. And when the teens 
are able to get care where they are, it just encourages health-
seeking behaviors. It promotes developing systems of self-care. 
And it really promotes general health and well-being outcomes.
    I think the fact that teens are sometimes able to just walk 
over to a medical clinic and get the help that they need is so 
essential, especially if they are not able to at home and they 
do not have reliable Internet access. So when we concentrate 
our efforts on schools, it is really important to make sure 
that we build these natural partnerships and kind of leverage 
the power within those.
    Senator Cassidy. I would just add to that, from my 
experience working with school-based clinics, sometimes there 
are issues which should not be--for example, abuse by a parent, 
which can be discussed in the safe setting of a school-based 
clinic with a licensed health-care provider. And so it also, 
frankly, helps the business model of the school-based clinic. 
In some States they have a very difficult time keeping their 
doors open, so that they cannot provide a needed service that 
actually benefits.
    With that, I yield back, Mr. Chair.
    The Chairman. Thank you, Senator Cassidy.
    And for our guests, Senator Cassidy and Senator Carper are 
going to be leading the task force on young people, so they are 
going to be invaluable on the issue we are dealing with.
    We now have an order of Senator Cantwell, Senator Thune, 
and Senator Menendez. And members have been coming in and out. 
Senator Cantwell is next in the order.
    Senator Cantwell. Thank you, Mr. Chairman.
    And continuing on that same theme of young people, Ms. 
Lubarsky, the Surgeon General's December advisory on mental 
health stated that one in three high school students and half 
of the female students reported persistent feelings of sadness 
and hopelessness during the COVID pandemic.
    So we already know what our challenges are. The Washington 
Hospital Association reported that, during the past 2 years, 
major depression disorders are leading youth inpatient 
diagnoses in my State. So, when it comes to seeking treatment, 
not everybody gets a fair shot at that. The number on 
individuals with lower incomes is that they are nearly 20 
percent higher than the rate for those people with higher 
incomes. So affordability is a factor.
    I know my colleague, Senator Stabenow, had a chance to ask 
questions earlier, but I am very supportive of her Certified 
Community Behavioral Health Clinics. These have been great 
programs.
    There are five community clinics in my State that serve 
low-
income populations. And this grant over the past 2 years has 
been used to enhance the care of those experiencing mental 
illness. So we really are building capacity. Clinics like 
Comprehensive Health Care in Yakima were used for innovative 
purposes, creating a program to offer mental health first aid 
training, critical incident stress debriefings, and helping to 
receive support.
    So do you think that these programs such as the Certified 
Community Behavioral Health Clinics and their grants have been 
helpful in reducing the barriers for treatment of youth and 
families, particularly in some of our less accessible areas in 
more rural parts of the United States? And should Congress 
consider expanding these programs to address disparity in 
access? And what would you prioritize within that system?
    Ms. Lubarsky. Senator, thank you very much for your 
question. I am so pleased that you mentioned mental health 
first aid. As a youth mental health first aid instructor, I 
think it is also a vital component of our prevention efforts in 
youth mental health.
    In regards to the CCBHCs and other health-care facilities, 
I think they are one of many ways that we reduce the barriers 
to accessing mental health care for our pediatric population.
    There really is no one-size-fits-all for the right delivery 
model. And so, where some youth and their families are 
comfortable coming into an outpatient clinic, because of the 
stigma that is often attached with mental health services, I 
think having the ability to access your mental health care at a 
community health center, at a pediatric office, at your school 
setting, or through a telehealth device, is crucial to make 
sure that we have mental health care accessible to everybody.
    In our community, it may be hard for some of our families 
who lack adequate transportation to get to our offices. Yet one 
of our federally funded health-care facilities is on the bus 
line. And so, we worked in partnership with the health-care 
facility to have mental health staff there so if that is the 
only means of using public transportation to get to the 
appointment, families can still access their health care. So I 
think it is critical.
    Senator Cantwell. And what about this issue that you bring 
up of integrated health care--so, you know, treating mental 
health and other physical health in the same location? Because 
most times people come with both issues, or things that 
exacerbate one or the other, like you said. So there is less 
stigmatization in treating the whole person.
    Ms. Lubarsky. Absolutely. It is critical, because I really 
do think physical health and mental health occur together. And 
when our mental health is not doing well, we will see a 
decompensation in our physical health system, whether that is 
poor sleep, poor diet, isolating from others, not engaging in 
physical activities that can promote good mental wellness. So 
we really do have to bring the physical and mental health 
worlds together for the whole self.
    Senator Cantwell. Well, thank you. Is there anything you 
would prioritize in the improvement of that program if we had 
more dollars for the certified program?
    Ms. Lubarsky. I think, as I spoke to in my verbal 
statement, it is really around those reimbursement rates, and 
making sure that we are reimbursing centers, individuals, 
organizations in a meaningful way to sustain the workforce in 
order to deliver the crucial care.
    Senator Cantwell. Okay; great.
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Cantwell. The Northwest is 
going to be very united in this effort, and I look forward to 
working with you.
    I believe Senator Menendez will be next. Senator Menendez, 
are you out there online?
    [No response.]
    The Chairman. We may have lost Senator Menendez. Senator 
Menendez?
    [No response.]
    The Chairman. Senator Portman is next then.
    Senator Portman. Thank you, Mr. Chairman.
    I appreciate the testimony and the fact that you all are in 
the trenches every day doing great work with our young people.
    Dr. Hoover, you talked about telehealth, and I just want to 
be sure that we are also focused on the broader behavioral 
health, and specifically substance abuse. It seems to me that 
telehealth is one of the few silver linings in an otherwise 
dark cloud of COVID, and with regard to substance abuse 
treatment, that there has been some real improvements. Would 
you agree with that?
    Dr. Hoover. I would agree with that. I mean, certainly the 
opioid crisis has brought attention to that, and it has been 
exacerbated during COVID. So the funding provided by the 
Federal Government to States and communities to support the 
opioid crisis has been tremendous, and certainly there has been 
an improvement in care. Tele-mental health has improved that as 
well.
    Senator Portman. This is why we have to continue the 
reimbursement under Medicare and Medicaid--and Medicaid 
particularly--for substance abuse, at a time when we had 
100,000 drug overdose deaths in the period from April of last 
year to April of this year; so, during 1 year, a record level. 
That was a 28\1/2\-percent increase in overdose deaths. That is 
really heartbreaking, because we had made great progress in 
2018 and 2019.
    Now we are, unfortunately, seeing more and more people 
dying of overdose deaths. The report we have about young 
people--because that is the topic today--shows that we have 
seen an increase of anywhere from three times higher number of 
overdose deaths to thirteen times higher in 2021 compared to 
the numbers we had from 2019--and by the way, dramatic 
increases among Black youth in terms of overdoses that are 
particularly concerning.
    Our State has done a report. It recently looked at it from 
a different perspective. They said how many years have been 
lost. So their analysis is that, beyond the numbers we already 
know, the loss of years lived for more than 21,000 young people 
who died from overdoses show that adolescents and teenagers 10 
to 19 lost, cumulatively, 200,000 years of life. And when they 
expanded the study to include 10- to 24-year-olds, it grew to 
more than 1 million years lost.
    So it is a shocking way to look at it, but think of all 
that lost potential, and all that God-given potential being 
ruined. So this is a huge reason why we need to figure out, as 
a Congress, how to get back on this issue. And deadly fentanyl 
is killing, we think, about two-thirds of these kids. So this 
is synthetic opioids streaming across the border.
    We have done a lot more in terms of the prevention side and 
the treatment and recovery side, but obviously not enough. And 
what we see in Ohio is that this deadly fentanyl is often 
masked as other substances. So it looks like a pain medication, 
or an anti-anxiety medication, or an ADHD medication, and we 
have had parents approach me in Ohio and talk to me about this 
issue because they believe that their son or daughter died of 
an unintentional overdose by being deceived about what was in a 
pill.
    So, Dr. Hoover, talk to us a little about that. And anybody 
else can jump in. What do you think the reasons are for this 
big jump in overdose deaths? And how much of it do you think is 
attributable to these cartels putting fentanyl into other 
medications?
    Dr. Hoover. Well, to jump in quickly and defer to Dr. 
Benton on the impact of drugs and the medical side of that, 
certainly in terms of the co-morbid mental health issues, we 
know that the substance abuse issues we are seeing increasing 
in young people are likely very related to their increase in 
depression, anxiety, and post-
traumatic stress.
    Not only were we seeing increases in that pre-pandemic, but 
we are seeing real exponential growth in that in the context of 
COVID. So we know when that happens, we see increases in 
substance use, and so it is not surprising when you get those 
really tragic numbers.
    I will defer my time over to Dr. Benton with respect----
    Senator Portman. You are talking about self-medication 
because of other behavioral health and mental health 
challenges?
    Dr. Hoover. That is a piece of it, absolutely, that self-
medication to address anxiety, depression, trauma, and just to 
really cope with the isolation and loneliness that our children 
have experienced over the last couple of years.
    Senator Portman. Dr. Benton, can you talk a little about 
the synthetic opioid issue of the fentanyl getting into other 
medications?
    Dr. Benton. So what I can say is that we are seeing 
increases in utilization across the country. And unfortunately, 
I have to say that in many mental health programs, there is not 
the robust substance use and addiction treatments that we would 
like to see. And a major focus of expansion of resources in 
treatment for young people needs to focus on increasing the 
integration of substance use and mental health treatment 
services.
    We know that for young people with any mental health 
condition, the co-morbid use of substances only makes the 
outcomes worse. And the substance use is associated with worse 
outcomes, including suicide and other impulsive behaviors that 
land young people in bad situations.
    And so, that has to be a focus. Right now, they run almost 
as two separate systems in some ways. And that really needs to 
be a focus of our efforts going forward if we are going to 
address the substance-related morbidities that we are seeing 
right now.
    Senator Portman. Okay.
    I think my time has expired, but, Trace, I would love to 
hear from you on this, if we can have a minute, Mr. Chairman, 
if Trace has any thoughts.
    Mr. Terrell. Yes, I would love to. Thank you, Senator. I 
think when we talk about all these statistics, it is really 
alarming. But I also think that there is a beacon of hope. 
Since YouthLine's inception, we have experienced an annual 
increase in contact volume of about 15 percent annually, with 
an additional increase of 3 to 5 percent since the COVID-19 
pandemic.
    And obviously, while that proves that there is a need for 
mental health care, there are also so many teens reaching out 
for help. And I think that that is really inspiring, and I 
think it shows the resilience of teens in regard to mental 
health challenges and substance use challenges. And so I think, 
if we can really ensure that the people reaching out for help 
are able to receive help, we will get really far on this issue.
    Senator Portman. Thank you, Mr. Chairman.
    The Chairman. Thank you, Trace.
    Next is Senator Menendez.
    Senator Menendez. Well, thank you, Mr. Chairman.
    Across the Congress, we all talk about the provider 
shortages the Nation is facing, especially mental health 
providers who are available for Black and Latino communities. 
And the pandemic has taken a disproportionate toll on minority 
communities, and the provider shortage has only grown more 
dire.
    More dedicated support for a larger and more diverse 
pediatric workforce is critical, I believe, to address 
children's mental health needs now and into the future.
    So, Dr. Benton, what are three things this committee can do 
to address the recruitment, training, retention, and 
professional development of a diverse clinical and nonclinical 
pediatric mental health workforce?
    Dr. Benton. Thank you for that question, Senator.
    It is one of the issues that I struggle with every day as a 
training director and as a physician. One of the things that we 
could do now is developing pipelines at a much younger age.
    So, in my testimony I mention the 5th graders interviewing 
me. They were interviewing me about why did I become a child 
psychiatrist? And I was really pleased that they were asking 
these kind of questions in 5th grade. So starting a pipeline 
where we are present and we are reaching out to communities of 
color is really important.
    Education and destigmatizing mental health conditions in 
the Black community, and the Latino community, by partnering 
with trusted community organizations--loan repayment is an 
incredible issue. Many of my physicians say, ``I cannot afford 
to work for you because I have loans to repay, and you don't 
pay enough.''
    And so loan repayment for all the mental health 
professionals, I think is important. And incentives for people 
to choose mental health could be part of loan repayment--or 
some other payment measure would be really helpful. And then 
reaching into the communities where minority populations are 
would be extremely important.
    So we tend to recruit from communities that are affiliated 
with academic centers, and we do not reach into the communities 
where patients are actually receiving services.
    Those are some of the things that we could do now to 
support diversification of our workforce.
    Senator Menendez. Well, I appreciate those insights. And we 
may reach out to you to build upon them as we explore the 
initiatives here.
    And part of the reason I raise this--I look at the first 
half of 2021 alone. Children's hospitals reported cases of 
self-injury and suicide in ages 5 to 17 at a 45-percent higher 
rate than during the same time frame in 2019. And for children 
under 13, the suicide rate is twice that for Black children 
than for White children.
    So what can we do to reduce the likelihood of suicide in 
children and adolescents, particularly minorities? And how do 
we better target our resources?
    Dr. Benton. Senator Menendez, this is one of my areas of 
passion. So among minoritized youths across ethnic groups, the 
rates of suicide attempts are higher than they are among non-
minority groups. And one of the challenges has been 
identification among minoritized youth and access to services 
that are culturally competent and/or a demonstration of 
cultural humility.
    The data demonstrates pretty strongly that culturally 
concordant therapists and patients have better retention and 
treatment, and better outcomes in treatment over time. And 
certainly it will never be the case that we will have one-to-
one matching for patients by ethnic group, nor am I sure that 
is the goal, but the goal is, for groups where there is not 
concordance between the patient and the therapist, that there 
be cultural humility, that we train individuals to learn to 
inquire and understand the cultural experiences of others when 
we are engaged in treatment.
    And so the training opportunity is there. But it is 
essential because we are seeing, for youth across each ethnic 
group, increasing rates of suicide, while they are declining 
for non-minoritized populations. So it is vitally important.
    Senator Menendez. And finally, about roughly 17,000 3- and 
4-year-olds are expelled from their preschools each year. And 
despite Black children making up only about 18 percent of the 
school population, they make up 40 percent of all expelled 
children. And even more troubling is that, within the high rate 
of expulsion for Black toddlers, how often Black boys are 
expelled.
    So how can we better support training for pre-K teachers 
and child-care providers in basic behavioral health techniques 
to combat bias and give these important social and emotional 
regulation tools to children from their earliest ages? And I am 
happy to entertain anybody who can answer that.
    Dr. Benton. Well, thank you. Thank you, Senator Menendez. I 
would hope that Dr. Hoover would respond as well.
    Prevention and education are key. Addressing bias among 
school personnel is essential to address this--and providing 
more resource supports in centers where children appear every 
day in day care, and in primary care, with some preventive 
education around what is normal and abnormal development.
    I am sorry, Dr. Hoover; I wanted to give you an opportunity 
to comment.
    Dr. Hoover. Not at all. I know the time is short, and I 
will just quickly add that investment in early childhood mental 
health consultation programs across States is critical--and as 
you alluded to, culturally responsive teaching practices. There 
is a lot of evidence to suggest that those can help in reducing 
discipline referrals and expulsions.
    Senator Menendez. Thank you all.
    The Chairman. Thank you, Senator Menendez.
    Senator Cardin is next.
    Senator Cardin. Thank you, Mr. Chairman. And let me thank 
all of our witnesses. I think this panel has been extremely 
helpful. This is an area, as you can tell by the questions, 
where you do not know who the Democrats or the Republicans are 
on the committee. We have a mutual desire to try to get this 
right, and we recognize we have a real challenge in mental 
health in this country, but particularly with our youth with 
the experiences of COVID-19. We know that we have a greater 
challenge than ever before.
    So I want to talk about the school setting for one moment, 
what we can do. I am responsible--as one of the co-chairs of 
the groups that Senator Wyden has been talking about--to deal 
with telehealth, and I am curious.
    You have all talked about the importance of expanding 
telehealth, but what are the challenges within the school 
setting of expanding telehealth services? Where do we need to 
try to put our attention, either change in policy or resources, 
in order to expand the productive use of telehealth in the 
school setting?
    Either Dr. Hoover, or whoever would like to respond to 
that. Perhaps start with Dr. Hoover.
    Dr. Hoover. I am happy to jump in. Thank you, Senator 
Cardin, for your leadership on this issue of mental health 
across the Nation, and specifically in the area of parity and 
tele-mental health.
    We know tele-mental health has actually been in the schools 
for years. Our child psychiatrists were delivering tele-mental 
health across schools in Maryland and in Baltimore City back 
when I was delivering services in the early 2000s.
    We know that there are continued infrastructure 
improvements that are necessary to improve tele-mental health 
services in schools, and that would include enhanced broadband 
systems, up-to-date telehealth delivery equipment, Internet 
connectivity services, especially to some of our rural 
communities. We know that policy expansion is important, 
including reimbursement parity for tele-mental health and 
expanded access to Medicaid and children's health insurance 
telehealth programs.
    So there are a number of areas that we have seen 
improvements in during COVID that we need to continue and to 
expand. And that applies to physical health as well.
    Senator Cardin. If I could get either your view or Dr. 
Benton's view, we have made a lot of resources available to our 
school systems in response to COVID. Have they been used to 
expand the connectivity that you are talking about for mental 
health services?
    Dr. Hoover. Some have, and again I am happy to defer to Dr. 
Benton here as well, but some have. One of the things we know, 
though, is that some of the COVID-related funding, for example, 
is creating kind of a one-and-done, or some hiring--you know, 
short-term hiring fixes. But we know that it is critical to 
make some of these Medicaid policy adjustments so that we can 
allow for sustainable funding for telehealth and other mental 
health services.
    Dr. Benton?
    Dr. Benton. Yes, I would concur with Dr. Hoover. I think 
many of the systems have used the resources well, but many of 
them were under-staffed before the pandemic and did not have 
access to adequate resources.
    They have reached out for telehealth, but there are a 
variety of factors that impact their ability to optimize its 
use. One of them is the privacy standard. So communications 
between mental health providers and schools, through HIPAA and 
FERPA, are issues that really need to be addressed in 
communicating about mental health concerns.
    Some schools may have one or two school counselors, but not 
necessarily access to a provider team of psychiatrists that can 
partner with the schools, as Dr. Hoover described, to provide 
that additional level of care that is not necessarily available 
in the schools.
    And then in addition to that, you know, we do need to think 
about our care models very differently. So, for example, there 
are services that are cheaper to set up that are available 
right now, such as school-based crisis services, so when a 
school is under-resourced and there is a crisis, it is very 
possible to send someone to that school to see that youngster 
on site with the family, or urgent cares that are on-site at 
schools.
    So there are some other things that we could do to support 
our schools. So I thank you for your leadership in supporting 
the schools through the pandemic. We should retain those 
things, and there are other things that we could do to expand 
them.
    Senator Cardin. So, Dr. Benton, you talked about the need 
to have improved screening in regards to mental health for our 
students. Can telehealth be helpful in dealing with screening, 
recognizing that you need personnel in the school itself? But 
can that be better utilized than we are using it today for 
screening?
    Dr. Benton. Yes, Senator. That is an excellent 
recommendation. And yes, it would be very helpful. One of the 
challenges for schools is they screen, and then they cannot 
respond. And so, having telehealth allows them to screen 
youngsters for problems or challenges before they become major 
problems. And telehealth can be used to address some of the 
more acute things on site.
    Currently, screening is not viewed enthusiastically 
because, if you find something, you cannot do anything about 
it. The utilization of telehealth to connect with a crisis 
provider would allow the school to be able to respond in a safe 
and effective way.
    Senator Cardin. Thank you, Mr. Chairman. I appreciate it.
    The Chairman. Thank you, Senator Cardin, and we appreciate 
your leadership on these issues as well.
    Next I believe--Senator Lankford, are you out there?
    [No response.]
    The Chairman. Senator Brown?
    [No response.]
    The Chairman. Senator Barrasso, and then Senator Bennet.
    Senator Barrasso. Well, thanks, Mr. Chairman.
    First I want to congratulate and compliment you on your 
opening statement. I thought you really hit the point on the 
head in terms of how long this is often brewing before we know 
of the problems. I am an orthopedic surgeon, and I have worked 
with many people as president of the Wyoming State Medical 
Society. I think you were absolutely right in the comments that 
you made.
    But being from Wyoming, rural health is a big issue for us. 
And Senator Crapo started by talking about that. And then 
telehealth is something we have used from a mental health 
standpoint long before the pandemic. I think the pandemic has 
brought mental health, as well as other kinds of health care, 
to the fore in terms of the ability to try to use telehealth 
much more productively. I think we are, hopefully, fast-
forwarding, as Senator Cardin was just saying, the acceptance 
of telehealth.
    My question is about trying to just get enough providers on 
site in rural America, which is what Senator Crapo talked 
about. So, for Dr. Benton and Dr. Hoover and Ms. Lubarsky--you 
know, when I was in the State Senate in Wyoming, we were very 
blessed with additional revenue that we were not expecting, but 
we had it. And the commitment we made was to mental health.
    So we put in a lot of financial resources and made a 
deliberate effort to train, to recruit, and to attract more 
mental health providers to Wyoming. But in spite of our best 
efforts, Wyoming and other rural States that have tried to make 
those similar commitments continue to face huge shortages of 
all types of mental health providers.
    So the money was there, and we still had the challenge. So, 
can you discuss some solutions related specifically to 
workforce development that you believe may help improve our 
ability to attract and maintain staff into rural and sometimes 
remote areas?
    Ms. Lubarsky. If I may--and I think it is a great question, 
Senator. I think one of the challenges that occurs within our 
State of New Hampshire is some of the licensure requirements 
for professionals.
    We have a lot of silos with our Board of Mental Health 
Practice about who is allowed to provide licensure supervision 
for an individual who comes from their master's degree program. 
And that at times creates the barriers to who we are able to 
hire. Because, if we have to have a specific credentialed 
professional to provide supervision to that same category of 
professionals, and we do not have them employed at our center, 
then that candidate no longer looks at us as a place that they 
want to be employed at.
    I have talked to colleagues across our State who have lost 
employees who went to other States because, not only could they 
make a higher income, but they needed to get the licensure 
supervision from a particular person. So I think we need to 
make licensure requirements create more flexibility on who can 
provide that supervision in order to attract the staff that are 
needed to provide the care.
    Senator Barrasso. Anyone else?
    Dr. Benton. I was----
    Senator Barrasso. Yes, go right ahead. No, please.
    Dr. Benton. I was going to say, I would echo your comments. 
Telehealth also adds another opportunity, and it is for 
training remotely. And so, for areas where there is a shortage 
of providers, we have been able to partner using telehealth to 
expand skills and to train people.
    You know, thinking about Ms. Lubarsky's comments about task 
shifting, it is an excellent opportunity for us to provide 
skills for master's-level clinicians, clinicians who need 
supervision and may be in another State, for backup 
consultation across counties. But also, by allowing us to 
continue with licensure across State lines, we can actually 
also provide support for clinicians in those areas.
    I also just want to mention, a quick win is really 
educating the people that we already have. So the 
pediatricians, the nurse practitioners, other mental health 
clinicians, master's-level people, peer navigators like Trace--
all of those resources in communities can be utilized to 
support individuals.
    We have programs where we are teaching grandmothers to do 
cognitive behavioral therapy for their anxious grandchildren. 
And so I think, thinking about how we provide care differently 
could provide us more opportunities for mental health support.
    Senator Barrasso. Well, thank you, Dr. Benton.
    And to Ms. Lubarsky, to your point of the--actually, I am 
working with Senator Smith; it is a bipartisan bill on marriage 
counselors who do some mental health work as well. And they are 
not able to be reimbursed through Medicare, and different 
Federal issues too where they provide health care but--so it is 
the siloing by State, but also the Federal Government sometimes 
gets in the way as well.
    And then--I know I am running out of time. You know, we 
have a commitment in my family to working with families who 
have lost someone to suicide, what we can do along those lines. 
We are continuing to look, not just to raise awareness, but for 
best practices.
    And, Dr. Benton, I see you are shaking your head ``yes'' on 
this. It is a big issue for all of us. So I do not know if you 
have some final thoughts on that.
    Dr. Benton. Yes, thank you, Senator, for that question. So, 
in addition to the suicides, you know that over 160,000 young 
people have lost parents to COVID. And of course, the threat is 
always not just grief, but traumatic grief. And we are not 
ready for it.
    Fortunately, there are quite a few support services 
available to families who have lost family members to suicide, 
and for those who are suicide survivors. So the American 
Foundation for Suicide Prevention is a resource for all 
families that provides a lot of support and information 
nationally for families who have experienced that loss.
    But we have to pay particular attention to those 
populations who have experienced traumatic grief, because 
traumatic grief is more closely associated with the onset of 
depression. And in order to be preventive, we need to develop 
early interventions and support for youngsters who have lost 
their parents during COVID, and for individuals who have lost 
their families to events like suicide and homicide.
    So, thank you for that.
    Senator Barrasso. Thank you for that.
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Barrasso. And we are very 
much going to focus on the best practices that you mentioned. 
It is a very solid way forward.
    We are having colleagues come and go. So we are going to 
have Senator Thune, Senator Bennet, and Senator Lankford, and 
we are going to lock in those three, okay?
    Senator Thune?
    Senator Thune. Thank you, Mr. Chairman and Senator Crapo, 
and I appreciate your continued focus on youth mental health, 
and I appreciate the panel for joining us today.
    As I discussed last week, when I talk to parents, teachers, 
and school administrators across South Dakota, addressing the 
behavioral health needs of students is a big priority.
    Dr. Hoover, in your testimony you mentioned that we need to 
be looking for more formal partnerships with community 
behavioral health providers. We have multiple cooperatives in 
place in my State where schools are in close enough proximity 
to share a provider, but in some circumstances distance is a 
barrier.
    Do you know of instances where the partnerships you 
referred to have been formed using telehealth, or a combination 
of in-person and telehealth services? And what are the biggest 
barriers that schools or school boards encounter in forming 
these types of partnerships?
    Dr. Hoover. Thank you for the question, Senator Thune. 
Absolutely. We have seen, actually, tremendous partnerships 
that rely almost exclusively on telehealth, especially for some 
of our rural communities. Some of the best examples started in 
South Carolina several years back, where they have the Medical 
University of South Carolina providing telehealth services to 
schools across some of their most rural districts in South 
Carolina.
    So we have seen these community behavioral health 
partnerships with schools through kind of the standard 
memorandum of understanding with schools and community 
behavioral health, where sometimes they will do some onsite 
supports, but really much of the service that is provided is 
through telehealth.
    As we mentioned earlier, some of the real barriers to that 
are reimbursement. Sometimes schools are not allowable as sites 
of service, and certain provider types are not allowable, which 
really does require taking a look at State Medicaid plans and 
thinking about how to expand school health programs under 
school Medicaid--and certainly just a lack of awareness of some 
of the guidelines for how you can set up these partnerships and 
get reimbursed and supported.
    Senator Thune. Thank you.
    Doctors Benton and Hoover--and Dr. Benton, if you want to 
take this first--youth mental health in Indian Country has been 
a significant challenge for some time now. Some of the stories 
are heartbreaking. There was a 2017 Department of Education 
report that confirmed that kids in public schools on the 
reservations have a greater risk of behavioral health 
challenges, including increased risks of suicide.
    Do you have suggestions for how this committee can help 
improve access to culturally appropriate care on the 
reservations, especially how we could grow the workforce there, 
which is a challenge? Finding providers, recruiting, and then 
being able to retain providers in Tribal communities has really 
been a challenge.
    Dr. Benton. Well, thank you, Senator, for that question. 
And we too struggle with the challenges that you identified. 
The Certified Community Behavioral Health Clinics are an 
excellent way to attract clinicians of diverse backgrounds. 
Clinicians like myself of diverse background tend to focus on 
supporting populations that are similar. And so, the chances of 
working in your community are greater if you are a member of 
the community.
    How do we increase providers in those communities? By 
targeting the communities who need the treatment, identifying 
individuals in those areas, and providing the support needed.
    So many of the challenges for minority populations relate 
to finances: high student loan burdens, low support for strong 
academics in the community. Those are all areas where we would 
be able to support education, increase interest, and support 
individuals who would go on to get education in those areas.
    And some of our focus could be on supporting them in their 
communities. So many times in academia, we are all familiar 
with the idea that we recruit people away from their 
communities, as opposed to providing resources in that 
community to educate young people through their high schools, 
the community colleges, training programs, and then 
diversifying opportunities for support.
    So, in line with Dr. Hoover's comments about task shifting, 
it is teaching people to provide services at the bachelor's 
level, or other levels that would allow them to expand support 
for care in their communities.
    Senator Thune. Thanks.
    Dr. Hoover. To piggyback on that, in addition to recruiting 
members within communities and retaining them in their 
communities to support their communities, also investing in 
technical assistance and training centers and resources within 
their communities. A great example of that is the National 
American Indian and Alaska Native Mental Health Technology 
Transfer Center, which is funded as part of the Substance Abuse 
and Mental Health Services Administration.
    And then I will just also add, really expanding the Federal 
workforce development programs that we have already mentioned, 
including loan repayments, but also things like the Minority 
Fellowship Program, the National Health Service Corps, can 
really help in this regard.
    Dr. Benton. And I would add to that some of our national 
organizations that support children's mental health, like the 
American Academy of Child and Adolescent Psychiatry. All those 
programs actually have minority-focused fellowships to support 
the development of other mental health professionals. And 
partnering with the HBCUs for Black families, for programs and 
educational systems that primarily serve Hispanic and Native 
American youth, would be places that we would be able to 
support development of professionals who remain in those 
communities.
    Senator Thune. Thank you, both.
    Mr. Chairman, my time has expired. Thank you.
    The Chairman. Thank you.
    Senator Bennet is next.
    Senator Bennet. Thank you very much, Mr. Chairman. Can you 
hear me?
    The Chairman. We can.
    Senator Bennet. Great. I really appreciate you and the 
ranking member for continuing this series of hearings on mental 
and behavioral health for youth. We are having a crisis in 
Colorado. In fact, Colorado's Children's Hospital was the first 
hospital in the country, I think, to declare a state of 
emergency in mental health for youth.
    So I want to thank the witnesses for being here to testify, 
and I am particularly grateful for having Mr. Terrell here 
advocating on behalf of his peers and his generation.
    I have a second question for him, but let me start first 
with this on reimbursement and prevention. Last week the 
Surgeon General was here, and I raised the importance of 
reimbursement for mental and behavioral health services, 
something our committee has jurisdiction over, through CMS. And 
while I was going through your testimony, the common theme was 
that we need improved reimbursement for services across the 
continuum of care, and meeting youth where they are. And I 
wholeheartedly agree with this.
    So I would ask Dr. Benton, first maybe, what kind of 
services should be reimbursed by Medicare or Medicaid or 
private payers that are not usually covered? And what services 
need increased reimbursement? Can you highlight where you 
believe reimbursement parity is failing the American people?
    Dr. Benton, let's start with you and anybody else who would 
like to add after that.
    Dr. Benton. Well, thank you. Thank you, Senator, for that 
question. So currently, most of the early childhood services 
are not reimbursed. So there are services that are required in 
the medical and mental health setting that are comprehensive 
services that should start from birth through adulthood. But 
services that do not necessarily have a psychiatric diagnosis 
attached are frequently not reimbursed.
    So, for example, if a mother who was having difficulties 
attaching or parenting her newborn, those services are not 
necessarily reimbursed by traditional mental health providers.
    Furthermore, for pediatricians--who are typically the best 
people to identify early childhood problems, because children 
have frequent visits in the first year of life--they are not 
reimbursed for the time it takes to provide the level of 
counseling that is needed for new parents who have new infants.
    And so, if we target it, the reimbursement for those 
services, the pediatricians would be allowed to do their jobs. 
The nurse practitioners could do their jobs. People who are 
working with young children could do their jobs. And for young 
children who are not yet impaired by a mental health condition, 
preventive services would allow families to seek that care in 
appropriate facilities, and reimbursement could occur at the 
same time.
    So I think that early childhood services currently are 
under-
reimbursed for the ones that are available. And for children 
who do not necessarily have a mental health condition already, 
they are not able to seek the services they need and get the 
payment that is required.
    Senator Bennet. Thank you for that answer. I very much 
appreciate it.
    Let me ask my second question, because I know time is 
short. As I mentioned, it is so important to have a young 
person here, Mr. Chairman--and thank you for doing that--to 
give their perspective on the crisis. We should think about 
things, including young people, here more often. As you know, 
the National Suicide Prevention Lifeline will be transitioned 
to 988 by July 16, 2022. In Colorado, we are having, I am sad 
to say, an epidemic of teenage suicide. The numbers are just 
staggering. And Senator Cornyn and I have introduced 
legislation to increase funding to make sure that this 
transition to the prevention lifeline is successful. And we are 
thinking about how to incorporate texting to connect 
individuals with services. They call or text in to make it more 
effective.
    And I just wonder, Mr. Terrell--could you share your 
thoughts on all of this, and what types of resources and 
improvements we should be thinking about that would be most 
meaningful, in your mind?
    Mr. Terrell. Yes, thank you, Mr. Bennet. That is a great 
question, and I think one that takes a lot of conversation to 
actually get to a good policy solution. But statistics show 
that teens talk to their friends more than anything. So the 
more that we can empower and equip youth with the skills needed 
to support their friends in crisis, I think the more we will 
see kind of general health and well-being trends for youth 
increase.
    All YouthLine volunteers get the opportunity to go through 
pretty extensive training. So I personally went through 63 
hours of training, where I got suicide alert training, applied 
suicide intervention skills training, youth mental health first 
aid, and CPR. And those are all master's kind of clinician-
level training.
    And so we know that youth have the capacity to take on this 
role if supported in their communities. And so, like I 
mentioned in my testimony, I think the idea of a national 
YouthLine where we expand across the country, and we really 
invite youth from all different communities to be involved in 
this process and help destigmatize the conversation around 
mental health, would be really helpful. And I think I would be 
really happy to connect with you later on that.
    Senator Bennet. Very good. I will take you up on that. I 
know the chairman has your contact information, so I will track 
you down. And I very much appreciate it.
    Thanks, Mr. Chairman; I know I am out of time.
    The Chairman. Thank you for all your leadership, Senator 
Bennet.
    The next two are Senator Lankford and Senator Brown.
    Senator Lankford. Mr. Chairman, thank you. And to all our 
witnesses, thanks for being here as well, and talking through 
this important conversation.
    Dr. Benton, I do want to be able to start with you. For 
individuals within the school, whether it be a school counselor 
or a teacher who may discover some mental health challenges the 
child would have, are there any barriers to communicating right 
now in the system, whether it be HIPAA issues, or legal issues, 
or just process issues, with that individual communicating with 
parents, other school counselors, or engagement with law 
enforcement or outside medical entities? Are there barriers 
that are there that we need to be aware of?
    Dr. Benton. Yes; thank you, Senator Lankford, for that 
question. And I will start my comments then defer to Dr. 
Hoover, who has more expertise. But yes, there are barriers 
currently. So you are not able to have a conversation between a 
mental health clinician, who actually may be caring for a 
youngster, and his teacher or school counselors without 
permission, either through FERPA for the school, and for HIPAA 
for the provider. And those two groups do not often communicate 
with each other, posing barriers for care.
    It creates a situation where, for teachers and for 
counselors, addressing mental health concerns may require 
sending that young person off to an emergency department in 
order to get the care that they need. So yes, there are 
definitely barriers in communication related to privacy laws.
    Dr. Hoover, I don't' know if you have further----
    Dr. Hoover. I agree. The good news is that many school 
systems, in partnership with behavioral health systems, have 
really navigated those HIPAA-FERPA privacy issues, for example, 
by initially sending paperwork home to families, even at the 
start of school years, to inquire about whether they are 
willing to give consent for communication to occur when in the 
best interests of the child's health and well-being and 
academic success, allowing for some of that communication to 
occur--again, with privacy in mind, but also supporting 
academics.
    The other area that I would say is critical is really 
expanding data systems that allow for the seamless sharing of 
data between health and education sectors. And that has been 
done well in several districts and States. So there are good 
examples. It is just not widespread enough yet.
    Senator Lankford. So are there needs that we have as far as 
a change in statute to allow more of that communication to 
occur at this point? Or do you think the statute is 
appropriate, we just need additional permissions and access 
points?
    Dr. Hoover. Good question. I mean, frankly I think that 
technical assistance and training, and just raising awareness 
that HIPAA and FERPA do not have to be barriers to 
communication as long as you have family engagement and 
consent, that may be enough. It has been enough in several 
communities to actually bridge the divide here.
    Dr. Benton. I will say, there are also State laws that 
govern who actually can release information. And so that also 
becomes a barrier, because sometimes the young person actually 
has control over that information, and the parents don't. And 
so, I think in some places it works, but I think greater 
guidance and standardization of these processes would help all 
of the communities.
    Ms. Lubarsky, I know that this must come up for you, often.
    Ms. Lubarsky. So, it does come up for us quite a bit, but I 
think the training involved, I think making sure that schools 
and the mental health providers--I think about our examples of 
where we are integrated in over 25 schools in our region, 
providing mental health care, where we are delivering that for 
our staff and working collaboratively with the school, with the 
family system, parent, guardian, and caregiver, to make sure 
everybody is involved. I think honestly, where we see this as a 
barrier, where it comes up as a challenge is when there is 
failure to communicate with the family system about the youth's 
needs, and making sure in advance of providing care or 
suggesting care, that those conversations are happening as 
well.
    So I think that is where training is a big component.
    Senator Lankford. I would agree. In Oklahoma, we just had a 
law passed within our State that has allowed for training for 
everyone with the school on suicide prevention. We have 13,000 
people in schools who have been trained just in the last couple 
of years, just to be able to help with suicide prevention and 
to be able to know how to engage, and then the next steps on 
that.
    So in our State, we have been very forward-leaning to be 
able to do what we can to be able to help.
    Mr. Chairman, a conversation that we could have at some 
point, to be able to have on this whole issue as well, is the 
``whys'' and the prevention behind the scenes. We always, on 
the Finance Committee, we look at it and say, ``What can we do 
with more Medicare or Medicaid, and the tools that we have?'' 
The next big question behind it is--as we watch suicide rates 
rise 57 percent among teenagers and young adults over just the 
last 15 years, as we watch all these other things occur--to ask 
the practical question of ``why?''
    Our Nation has been through difficult challenges in the 
past: World War II, the Great Depression, all these other 
things. Why are we watching some of the rise now? What is 
happening in technology? What is happening in engagement? And 
for myself personally, I worked with students for 22 years 
before I came to Congress, working with middle school and high 
school students. This is an area I worked with extensively, and 
I think there are a lot of questions that we have not asked, 
the ones behind the issue--not just how do we fix it, but why 
are we seeing the rapid rise? And what do we need to be able to 
do it? The issue of technology and telehealth is really 
important, but there is another angle with technology as well 
that is driving comparisons among individuals that is pretty 
toxic.
    So we have to be able to help resolve some of these issues 
in the days ahead as well.
    The Chairman. Thank you, Senator Lankford. A very important 
point with respect to suicide. And Senator Barrasso took note 
of how important it was as well. This is an area he is going to 
focus on. So I think this will be another opportunity for both 
sides to work together, and I appreciate both you and Senator 
Barrasso bringing it up.
    Senator Brown is next.
    Senator Brown. Thank you, Chairman Wyden. Mr. Chairman, I 
ask that written testimony offered by the director of pediatric 
psychiatry and psychology at the Akron Children's Hospital be 
included in the record for today's hearing.
    The Chairman. Without objection, so ordered.
    [The statement appears in the appendix beginning on p. 59.]
    Senator Brown. Thank you, Mr. Chairman.
    Dr. Benton, as you probably recall from your time, some 
time ago, spent in my State for medical school, Ohio has 
excellent children's hospitals in almost every part of the 
State: Cincinnati Children's, Nationwide Children's in 
Columbus, Akron Children's, and Rainbow Babies and Children's 
in northeast Ohio, home to several outstanding centers of 
excellence.
    Despite the resources our State has, Ohio's children and 
health workers are still struggling during this pediatric 
mental health crisis. Ohio is just like counterparts across the 
country: our children's hospitals need our support to rise to 
meet the needs of children and adolescents in addressing this 
serious, serious public health crisis.
    Experts tell me that one of the biggest challenges is 
meeting the needs of a multi-system youth. Could you talk about 
actions, Dr. Benton, actions Congress can take to better 
support children's hospitals and their work to support youth 
served by multiple systems? For example, those who are in 
foster care or justice-involved, or have a developmental 
disability in addition to a mental health diagnosis--how can we 
ensure effective communications between and among juvenile 
justice and child welfare systems to best support these 
children, who so often just get left out?
    Dr. Benton. Thank you, Senator Brown, for that question. 
And just so you know, Cincinnati is my home town. So I am an 
Ohioan. So I just wanted to say that that is an excellent 
question, and one of the greatest challenges that we face in 
mental health care now.
    So the systems in which children exist, as you have 
highlighted--child care education, juvenile justice, foster 
care, and others--have little or no collaboration. And systems 
are actually not in place to facilitate that collaboration. The 
attempts to coordinate it are either stifled by bureaucratic 
challenges or unwillingness to acknowledge that the systems are 
actually connected.
    And so what would be required is a focus on requirements 
among those organizations that there is better coordination. 
You know, we talk often about case management as a broad term, 
but those individuals are often the ones who are facilitating 
communication between organizations that do parallel work 
caring for the same kids, but do not necessarily have an 
effective means for coordination.
    You know, some of the data shows us pretty clearly that 
about 50 to 75 percent of the over 2 million children who are 
adolescents in juvenile detention actually have had limited 
mental health treatment, or limited mental health support.
    So essentially, communicating expectations that those 
agencies collaborate around the care of the same kids by 
establishing systems that facilitate that, could go a long way. 
For children's hospitals, we struggle at times with children 
who are admitted to the children's hospital with a medical 
condition and a mental health condition. The medical condition 
is resolved. The mental health issues are resolving, yet they 
are waiting for placement in foster care, sometimes remaining 
in the hospitals for up to a year.
    And at that juncture, payers are not accountable. The 
agency who acts as the parent is not accountable. And then the 
hospital is accountable for providing all of those services 
that require multi-agency collaboration. Expectations of 
accountability for those agencies that are often managed by the 
Federal Government and States would be essential for being 
responsible for coordinating care of young people.
    Senator Brown. Thanks, Dr. Benton.
    I have a question that I would like all of you to answer, 
but very briefly, because my time is short--and the chair is 
always tolerant, but his patience probably wears thin.
    I asked the Surgeon General last week how we better 
integrate mental health resources within our schools. And my 
question to each of you is, based on--actually, in Dr. Benton's 
home town, there is a community school in Cincinnati, Oyler, 
which has become a bit of a template for the whole State, and 
the whole country.
    Briefly describe, if you had a chance to offer a 
suggestion, one thing schools can do to leverage relationships 
with community partners, State or local health departments, 
hospitals, service centers, whatever. Give one simple 
recommendation of what we can do better, schools can do better 
to leverage----
    Dr. Hoover, do you want to start, and then Ms. Lubarsky and 
then Trace, and then finish with Dr. Benton, briefly.
    Thank you.
    Dr. Hoover. Happy to. Thank you, Senator Brown, and I am 
familiar with the school in the Cincinnati area that does this 
well. And as you said, it serves as a model for the Nation.
    So one simple thing that can be done is, there are good 
templates for memoranda of understanding and requests for 
proposals that can go out to districts to solicit community 
behavioral health partners to come in and engage in school 
behavioral health provider services in the schools. Instead of 
it just being kind of a hodgepodge of services, it can be 
organized through a request for proposals process with 
standardized memoranda of understanding with community 
behavioral health.
    Senator Brown. Thank you.
    Ms. Lubarsky next, and then Trace.
    Ms. Lubarsky. Sure. First of all, I say, ``Go Bearcats,'' 
as a graduate of the University of Cincinnati. This is 
something we have done really well in our community. It is 
really establishing, not only those agreements of 
understanding, but it is really finding a standardized 
assessment tool that schools will feel comfortable utilizing in 
order to be able to do that screening, to pass it on to the 
behavioral health-care providers, whether it is utilizing our 
mobile crisis team at the Center for youth who are going into 
crisis in the school setting, or being accepting of the 
behavioral and mental health supports that our staff can 
provide. Frankly, using some standardized screens that school 
districts feel comfortable with is one step in that direction 
as well.
    Senator Brown. Thank you.
    Trace?
    Mr. Terrell. I also think a part of the big reason is we 
need to invite youth and kind of see what they actually need 
and what resources would be helpful for them. Because it is one 
thing to offer resources, and it is another for teens to 
actually access them.
    So, when we conduct needs assessments and really see what 
works for youth, I think we will experience better outcomes in 
that regard.
    Senator Brown. Well said.
    Dr. Benton, we will close with you. Thank you, Mr. 
Chairman.
    Dr. Benton. Thank you. I just want to say that I support 
all of those things that were just mentioned--and putting a 
system in place to make sure those things can happen easily and 
accessibly.
    Senator Brown. Thanks, Mr. Chairman.
    The Chairman. Thank you, Senator Brown. And thank you for 
having brought me to Ohio over the years to meet with a number 
of your health-care providers. And we have seen his advocacy in 
action.
    Next is Senator Casey.
    Senator Casey. Mr. Chairman, thanks very much. In light of 
all the references to Ohio that Senator Brown made possible, I 
want to make sure that we emphasize that Dr. Benton is now at 
the Children's Hospital of Philadelphia. So we are honored that 
she settled, at least most recently, in Pennsylvania.
    But, Dr. Benton, I wanted to start with you, and start with 
a critically important program that so many Americans know the 
name of, and so many Americans have a sense of what it does, 
but maybe none of us fully appreciate how important it is, and 
that is Medicaid.
    I have often said that Medicaid often tells us who we are 
as a Nation, but maybe more importantly, it tells us whom we 
value, whether it is children, or people with disabilities 
including children, or older Americans who need skilled care in 
nursing homes paid for by Medicaid. We also know that Medicaid 
is the largest insurer for children, but it pays, 
unfortunately, significantly lower Medicaid rates than 
commercial rates, which has terrible consequences often for the 
pediatric health workforce in equitable access to care.
    I know in your testimony you highlighted low reimbursement 
rates in mental health-care access, the concerns that you have 
about that, particularly with regard to underserved 
communities. On page 7 of your testimony you said, quote, 
``Better reimbursement for mental health services in Medicaid 
would make it possible to resource the full continuum of care 
our children and youth need,'' unquote.
    So the additional years to specialize in child psychiatry 
are not financially rewarded in the current payment structure 
with Medicaid, where a provider could earn more providing care 
to adults. So this makes it hard for a child-focused provider, 
and particularly challenging for families covered by Medicaid.
    So how would aligning Medicaid reimbursement for children's 
mental health services with Medicare levels impact kids' access 
to care?
    Dr. Benton. Well, thank you for that question, Senator 
Casey. You know, aligning those incentives would increase the 
reimbursement for Medicaid at a rate that would be more 
acceptable to most institutions. And that is key. Community 
mental health centers really struggle to meet the needs of 
young people based on reimbursement. Children's hospitals 
really struggle to meet the care for children with 
reimbursement.
    And in addition to that, lower pay for providers is 
discouraging for subspecialists not only to serve the 
populations of young people, but to even train to serve the 
populations of young people. You know, general psychiatry 
training takes 4 years. Child psychiatry training takes 6 
years. Six years of accumulated debt, which has resulted in 
mental health professionals opting out of payment structures 
for reimbursement for mental health care.
    And so, increasing the Medicaid reimbursement rates to be 
on par with Medicare, and medical rates, would increase our 
opportunity to address the gaps in the continuum. So there are 
areas in the United States where there are no services on any 
continuum available to young people.
    Medicaid reimbursement would allow us to develop a full 
continuum of care, not just emergency and inpatient crisis 
services, but ambulatory services, home-based services, day 
hospitals, intensive outpatient programs where young people 
could be with their families and be at home getting the level 
of services that they need.
    And so, the current Medicaid reimbursement rates impact all 
of those things. And increasing them to be better, which would 
be consistent with the Medicare rates, would allow us to 
provide the services that we need, and would allow us to 
encourage young people to pursue careers where they provide 
mental health care for young people.
    Senator Casey. Doctor, thanks very much. I might submit an 
additional question for the record for Dr. Benton.
    [The question appears in the appendix.]
    Senator Casey. And I will give back time, but I did want to 
again thank the panel for their testimony today. In particular 
I wanted to thank Mr. Terrell for coming forward on behalf of 
his generation, and I hope there are other opportunities for us 
to engage. But thanks very much, Mr. Chairman.
    The Chairman. Thank you, Senator Casey.
    Trace, you are now clearly the people's choice, because 
both Democrats and Republicans are praising you to the skies, 
and it is richly deserved.
    Okay, Senator Hassan, we welcome you and all your good 
work.
    Senator Hassan. Well, thanks so much, Mr. Chairman. Thanks 
to you and the ranking member, again, for this hearing. And I 
will add my thanks to Trace as well, and also just note that 
the good news for America is Trace is representative of his 
generation, and there are lots of wonderful young people in my 
State, and I know across the country, really advocating for the 
mental health of their peers.
    In New Hampshire, it is very true. I actually had a 9-year-
old look at me one day and say, ``What are you doing about 
mental health, Senator?'' And so, thank you all for just being 
the kind of advocates that make a difference.
    I want to touch on a few topics that have been discussed, 
but I want to drill down a little bit. Let me start with Ms. 
Lubarsky.
    In New Hampshire, a small pool of mental health providers 
is working overtime to help the growing number of children with 
mental health needs. And it is just not sustainable. And we 
have all talked about that. Following up on the testimony you 
have already given, what are the main causes for this mental 
health workforce shortage in New Hampshire? And what can we do 
to help alleviate the crisis?
    Ms. Lubarsky. Thank you very much, Senator Hassan. I mean, 
I think we have all spoken to this very well this morning, and 
now going into the afternoon. It is really the ability for 
centers to reimburse their staff at a rate that they can 
survive on.
    When we look at the cost of living--and we just spoke about 
Medicaid rates being significantly low. So we have a workforce 
that is burdened because of other providers in our community 
and within our State and country who could accept Medicaid and 
choose not to because reimbursement is so low, and we burden 
those providers who are accepting of it. But the facilities 
themselves cannot reimburse to sustain the staff long-term. We 
hear that all the time in our exit interviews.
    Senator Hassan. Thank you.
    Dr. Hoover, you have also touched on this, but I want to 
drill down on mental health in schools. Schools are often the 
only place that children can receive mental health care, but 
many schools lack the personnel and infrastructure to meet 
demand. What are the barriers that schools face, particularly 
when it comes to recruiting and retaining mental health 
providers?
    Dr. Hoover. Thank you, Senator Hassan, for your leadership 
on this and for the question.
    We know that we suffer from the same issues the general 
workforce shortage reflects as well. So simply put, we do not 
have enough providers. They are not trained well enough, and 
they are not paid enough.
    And what I mean by that, really, is that not only do we 
have shortages in workforce coming into the field, but they do 
not really represent the population being served in terms of 
race, ethnicity, language spoken, so we have to do a better job 
of recruiting and retaining diverse and representative 
providers.
    They are not trained well enough. And what I mean by that 
is that we have many mental health providers--not enough but 
many--but they are not trained to specialize in child and 
adolescent mental health, nor to work in schools. And as we 
have already said, they are not paid well enough. So 
reimbursement rates are a large issue.
    Again, I go back to that we also need to reenvision how we 
think about our mental health workforce, and think about all of 
the other professionals, and even nonprofessionals, who can do 
this work well. I love the idea of a grandmother providing 
cognitive behavioral therapy to grandchildren, as our child 
psychiatrist, Dr. Benton, mentioned. But also our peer and 
family navigators; we need to be doing more to invest in that 
workforce as a way to support mental health.
    Senator Hassan. Thank you. And I know in New Hampshire, 
peer-to-peer training and student empowerment has been really, 
really critical as well.
    Ms. Lubarsky, mental health resources need to meet children 
where they are. And during the school year, that is in the 
classrooms, but mental health does not end when the school year 
does.
    So, you have led an innovative program based on that 
insight, working with the Community Behavioral Health 
Association and the State Government. Your clinic offered 
mental health training for camp counselors and provided onsite 
resources at summer camps throughout the State.
    So kind of following up on where we were just going with 
Dr. Hoover, what was the impact of this program? And how can we 
scale up this model so that more children have support year-
round?
    Ms. Lubarsky. So, I was so excited about this program. Our 
Commissioner of Education labeled it ``rekindling curiosity.'' 
And it was really a means to tackle the mental health needs of 
students, after being isolated from their peers.
    So we began last summer by training summer camp staff in 
recreation programs in camps across our State. And we are 
allowed to carry that funding into the school year. So we have 
continued to utilize it to provide professional development 
days to educators, to do mental health youth training for 
educators. I have staff right now who are planning for February 
vacation week here in New Hampshire to go out and support young 
people to be maintained in camp settings or recreation settings 
that may otherwise not be able to be maintained because of 
their behavioral health needs.
    So, rather than excluding them or expelling them from these 
programs, we have staff going onsite to support the counselors 
and the youth to stay with their peers and really get a 
meaningful camp or recreation experience.
    Senator Hassan. Well, thank you so much. It is a great 
program. Thank you for everything you are doing for New 
Hampshire. We really, really appreciate you.
    And the last thing is, I am going to follow up, Dr. Benton, 
with a question for the record for you. I am particularly 
concerned about the isolation of children who are 
immunocompromised right now during the pandemic, and whether 
there are specific ways we can help those kids. So I will 
follow up with you on that.
    [The question appears in the appendix.]
    Senator Hassan. Thank you all. What an excellent panel.
    The Chairman. Thank you, Senator Hassan. And that last 
question is particularly important, and it has not gotten 
enough attention, and thank you for asking.
    Senator Cortez Masto is next, and then Senator Young, and 
we will wrap up one of the best hearings I have certainly been 
to.
    Senator Cortez Masto?
    Senator Cortez Masto. Mr. Chairman, I agree. I just have to 
thank the witnesses for being here. It has been a long morning, 
but a fruitful discussion. I thank you, Mr. Chairman, and the 
Ranking Member of the committee so much for having this 
hearing.
    You know, let me just say, I hear every day that one of the 
most critical ways we can protect kids' mental health is by 
keeping our schools open. And that is one of the reasons why I 
have been working to make sure that our schools stay open and 
have what they need to keep and help our kids in the classroom 
and provide the important services and support that we are 
talking about today.
    One of the areas though--and I am going to start, Ms. 
Lubarsky, with you--is stigma. My goal has been to tear down 
that barrier and do away with stigma. I think that anybody who 
goes to a doctor and talks about their physical health, and has 
a funding source for that, that should be on par with mental 
health. It should be the same thing. You walk in, get help for 
your mental health, and it should be funded, and there should 
be no stigma associated with that.
    But, Ms. Lubarsky, let me ask you. Can you talk about the 
impact that telehealth has had there? Do you see patients more 
inclined to follow through on the course of treatment through 
telehealth? And does that knock down some of the stigma 
associated with receiving services for mental health?
    Ms. Lubarsky. Absolutely, Senator. Thank you for your 
question. And when I hear your question, it makes me think of a 
young lady I worked with years ago, and at the conclusion of 
every one of our sessions, regardless of the weather, she would 
pull over her hooded sweatshirt, sunglasses, and a hat, and 
say, ``I don't want anybody to see me walking out of this 
building, with a giant sign that says `Mental Health Center' 
out front.''
    So for a youth like her, having that option to sit in the 
comfort of her home behind a screen, and nobody knowing that 
she was accessing care with me, I think would be a complete 
game changer for many of the youth in our world.
    So yes, I think the addition of telehealth not only knocks 
down barriers to giving care, but eliminates the stigma that 
many youth and families see around mental health care.
    Senator Cortez Masto. Thank you.
    And one of the things that everybody has been talking 
about, and I so agree, is access to the resources, the funding 
to support your services when you seek those for mental health. 
That is one of the reasons why I partnered with Senator Daines 
on legislation that actually enabled families with high-
deductible health plans to access no-cost telehealth services 
before they meet their deductible. What I find is, that is 
often a barrier as well, just accessing the payment funds, the 
resources to pay for these services. So, thank you.
    Let me ask you this, Mr. Terrell, because I saw you nodding 
your head. Based on your work with YouthLine, can you talk a 
little bit about the value that peer-to-peer relationship has, 
as well as how these kids feel less isolated and more willing 
to seek services for their mental health?
    Mr. Terrell. Absolutely. Thank you, Senator.
    I think that is a really great question, because part of 
the reason that YouthLine works so well is that it is peer-to-
peer. And we know from statistics that youth are more likely to 
turn to their friends than anyone else.
    So, when we foster that natural partnership, it really 
helps to destigmatize mental health in that regard. But I also 
think YouthLine works so well because it is a crisis support 
service. And there is a difference in that, right?
    So a lot of times when we talk about mental health, there 
is this conception that you only have to be suicidal or 
experiencing kind of acute high-stress situations, when that is 
not true, right? We know that mental health encompasses a lot 
of things. And so, when we talk about support, YouthLine is one 
of the only crisis lines in the country that offers teens the 
ability to talk about their mental health struggles without the 
fear of the problem being too small or too big. We really 
emphasize that there is no problem that is too big or too 
small. And when we talk about mental health, we really need to 
recognize that. And just something that my supervisor always 
says is that we teach young people to call 911 when they are in 
emergency settings. And unfortunately that permeates over to 
how we view the national suicide prevention line, 988. So the 
sooner we can teach children that it is okay to call a crisis 
line, that it is okay to reach out for support for mental 
health, I think the better we will see this issue become in the 
future.
    Senator Cortez Masto. Thank you, and I could not agree 
more. I just so appreciate the comments today on the need for 
more robust crisis services for kids.
    The chairman and I have worked on this. I truly believe 
that when they are in crisis mode, there should be a place to 
call. And it is not law enforcement on the phone, it is a 
mobile crisis intervention. That is why--the chairman knows 
this--the bill that he and I worked on together is based on the 
best practices in Oregon, in his State.
    I think really, the focus for me is directing that crisis 
mode and bringing those essential services at that time. You 
know, Senator Cornyn and I have introduced legislation that 
would actually set flexible standards for crisis services and, 
again, provide insurance coverage, which we see as lacking as 
well.
    So I know my time is up. I cannot thank you enough for this 
conversation, Mr. Chairman. I am hoping that, with telehealth 
services and so many other areas that we have to focus on, we 
are actually going to implement more work around bringing 
essential mental health services to so many in our community.
    Thank you again, everyone.
    The Chairman. Well, I thank my colleague for her 
leadership. And you made mention of the fact that, working 
together, we were able to put together a model that brings 
together mental health folks and law enforcement folks.
    And so, if you go off and you talk to Senator Booker, he is 
really interested in the program. If you go off and talk to 
Senator Scott, which I have done repeatedly, I know my 
colleague is very interested in the program. So the Finance 
Committee is really trying, as you sugggest, to break some new 
ground and fill in these gaps. I just thank my colleague for 
all her leadership on these issues. She has just been 
invaluable, and I thank her.
    Senator Young, you are next.
    Senator Young. Thank you, Mr. Chairman. And I want to thank 
all of our panelists today. It is such an important hearing.
    While we may not fully understand the pandemic's long-term 
impact on America's youth, early data is alarming, especially 
to this father of four teens. According to the Indiana Youth 
Institute, teen suicide deaths in my State increased 73 percent 
in 2020 compared to 2019, while teen deaths by overdoses 
increased 66 percent from the previous year.
    Dr. Hoover, what additional research do you believe is 
needed to better understand these trends and identify effective 
evidence-based interventions?
    Dr. Hoover. Thank you, Senator Young, for that important 
question, and for raising awareness again about the dire 
statistics that we are seeing, both with respect to mental 
health and suicide and also substance use. We cannot forget 
substance use in this conversation on mental health, but I 
appreciate you lifting that issue up.
    With respect to research, we are fortunate that we are 
seeing greater investments in research, in both mental health 
prevention and intervention, and also in the substance use 
arena. So we would certainly urge Congress to continue 
supporting research in those areas.
    Some of the areas that we think we need more investment in 
would be novel treatments, specific to certain populations--
racial, ethnic populations, immigrant populations, different 
student populations in rural versus suburban versus urban 
settings--so really thinking about how we develop and implement 
interventions that are specific and tailored to the community.
    We also need to understand who is actually thriving or 
succeeding in these environments of adversity, trauma, and 
stress. So often, the research looks at those who are suffering 
and how we can provide treatment, but it is really important 
that we also look to research to understand what are the 
protective factors, whether it is individual protective factors 
or community factors, that actually promote thriving and 
flourishing, and how we can bolster those through school-based 
centers and other community interventions.
    Senator Young. Well, thank you. That is quite helpful.
    I would open this up to our panel, if you can keep your 
response really brief, if you have one, panelists. What steps 
can the Federal Government take right now--right now--to help 
reach at-risk teens at their individual moment of crisis?
    Dr. Benton. I have two brief suggestions. One would be 
educating our front-line providers right now around addressing 
mental health challenges. And the second is setting up more 
crisis programs--mobile crisis services that can go into 
families' homes and their environments and provide crisis 
intervention.
    Ms. Lubarsky. I would add to that, Senator, having worked 
with school educators recently, they are feeling like mental 
health is walking through their classroom doors every day. So I 
think we need to afford educators the professional development 
time, and give them that fundamental training in something like 
youth mental health first aid so they can recognize the signs 
and symptoms and know how to bring that young person over to 
the next level of mental health care that they need.
    Mr. Terrell. I think we should also make sure that this is 
not the last conversation that we have about teen mental 
health. As a teen, we need you to continue to have these 
conversations, and to continue to involve us in this work. We 
deserve a seat at the table, and I think that's it.
    Senator Young. Trace, I think that is really important. I 
mean, all our solutions need to be grounded in the realities of 
individual human beings, folks on the front line of this 
crisis, right, which is our teens.
    Dr. Benton, in your testimony you discussed the web of 
systems beyond health care that impact the well-being of 
children and adolescents, such as foster care, education, food 
programs, and how these systems rarely collaborate--or, when 
they try, they are foiled by bureaucratic barriers or an 
unwillingness to acknowledge their interconnected nature.
    Research has indeed shown that addressing these types of 
factors, which we often refer to as social determinants of 
health, can positively impact the health and well-being of the 
most vulnerable Americans, including our Nation's youth.
    Doctor, how can we better leverage existing programs to 
help children and their families address the barriers to 
coordination between mental health and social services 
programs?
    Dr. Benton. Well, thank you for that question, Senator. One 
of the things that we could do right now is demand a higher 
level of accountability for agencies responsible for 
coordinating these services. And I will just take child welfare 
as an example.
    So child welfare, as the parent, is acting in loco parentis 
for any child in their custody, and is responsible for 
coordinating schools, mental health, medical care, and all the 
services. And I am assuming there are barriers to them doing 
that, because it is challenging to make that happen. But I 
think for those agencies, there needs to be clarity and 
reinforcement around expectations that that coordination 
happens.
    And from where I sit, the greatest challenge that I am 
facing in the care of young people at Children's Hospital right 
now, is the child welfare system.
    Senator Young. We need accountability metrics, and we need 
to identify who is responsible for achieving these metrics. Is 
that accurate?
    Dr. Benton. You summed it up well. Thank you.
    Senator Young. Thank you, much, Mr. Chairman.
    The Chairman. I thank my colleague. And there is a vote on 
the floor, so I am going to have to be very brief, but I just 
want to say this has been one terrific panel. I mean, each of 
you has really made the case that Trace started talking about 
2\1/2\ hours ago. Trace Terrell of La Pine, OR, basically said, 
``Look, what we've got to do in America, and we students are 
starting it, is mobilize. Get active and mobilize for real 
reforms of America's health care.''
    And each of our witnesses, Trace, in their own way sort of 
reaffirmed what you are saying. And so the first thing I want 
to say is, Trace, we are going to dedicate our efforts for 
mobilizing the Congress for these fundamental reforms the way 
you have said you are mobilizing young people. So that is 
number one.
    Number two is, the message of so many young people getting 
lost in the system is another extraordinary takeaway from 
today's hearing. I noted in your testimony you said that at 
your school, with respect to referrals to mental health 
services, 80 percent of them went nowhere. And what was so 
striking to me, Trace, is the number of experts from around the 
country who said, ``Hey, Trace is speaking for his school but, 
by the way, that is pretty much the pattern around the country. 
It might not be 80 percent, but we are just losing too many 
young people.'' And by the way, that is what Dr. Murthy said 
last week: we are just losing too many young people.
    So I am going to close with this, and we will dedicate this 
to you, Trace, because this is a hearing on young people, and I 
want to thank all our experts for being so helpful. Trace, I 
want you to know, right at the heart of our work is our 
judgment, Democrats' and Republicans', that our country is 
better than this. We are better than this. And as we go 
forward, you are going to have a seat at the table. You are 
going to have a seat at the table. We are going to reach out to 
young people across the country, and we are going to stay at 
our work until we find some real solutions to the issues we 
have talked about.
    Big thanks to everybody. It was just a terrific hearing, 
one of the best I have been part of, and I just want to thank 
all of you, because you have really laid out the path that we 
have to follow, and we are determined to do it.
    Thank you all. The Finance Committee is adjourned.
    [Whereupon, at 12:35 p.m., the hearing was concluded.]

                            A P P E N D I X

              Additional Material Submitted for the Record

                              ----------                              


  Prepared Statement of Tami D. Benton, M.D., Psychiatrist-in-Chief, 
   Executive Director, and Chair, Department of Child and Adolescent 
Psychiatry and Behavioral Sciences, Children's Hospital of Philadelphia
    Chairman Wyden, Ranking Member Crapo, and members of the committee, 
my name is Dr. Tami Benton. I am psychiatrist-in-chief and chair of the 
Department of Child and Adolescent Psychiatry and Behavioral Sciences 
(DCAPBS) at Children's Hospital of Philadelphia (CHOP) and the 
Frederick Allen professor of psychiatry at the Perelman School of 
Medicine at the University of Pennsylvania. I also serve as director of 
the Child and Adolescent Mood Program and the Youth Suicide Center at 
CHOP, a multidisciplinary clinical and research program focused on 
depression and suicide among children and adolescents, with an emphasis 
on minority youth. Finally, I am the president-elect of the American 
Academy of Child and Adolescent Psychiatry (AACAP). Thank you for the 
opportunity to testify today about the crisis in the mental, emotional, 
and behavioral health \1\ of our children.
---------------------------------------------------------------------------
    \1\ For brevity, I will refer simply to ``mental health'' in my 
testimony, but the intention is to encompass mental, emotional, and 
behavioral (MEB) health throughout.

    CHOP was founded in 1855 as the Nation's first pediatric hospital. 
Its longstanding commitment to exceptional patient care, training new 
generations of pediatric health-care professionals, and pioneering 
major research initiatives has resulted in many discoveries that have 
benefited children worldwide. Its pediatric research program is among 
the largest in the country, and we conduct research focusing on all 
aspects of mental, emotional, and behavioral health, including 
preventing a child with elevated symptoms from moving into crisis. 
Based on this research and the work of others, we are greatly expanding 
both the type and the reach of our pediatric mental health efforts. 
However, this crisis cannot be addressed without your help.
                                overview
    I wish there were no need for me to appear before you today, but 
young children and adolescents in the U.S. are experiencing mental 
health stress at higher rates and with more dire consequences than ever 
before. Fifty-three percent of adults with children in their household 
are concerned about their children's mental well-being, and they are 
not wrong to have these concerns. In the first half of 2021 alone, 
children's hospitals reported cases of self-injury and suicide in ages 
5-17 at a 45-
percent higher rate than during the same time frame in 2019, and, for 
children under 13, the suicide rate is twice that for Black children 
than for White children.

    I know you've heard many of these statistics before, but I see them 
play out firsthand in my daily work. A few recent examples come to 
mind: a 5-year-old with suicidal ideation and a plan to follow through, 
an adolescent waiting months for a placement with appropriate services 
while occupying a medical bed needed by others, a youth sent several 
States away because finding a placement for children with both physical 
and mental health concerns is nearly impossible, and other stories too 
numerous to mention.

    Clearly, our kids are falling through cracks in the system. While 
these cracks predate the COVID-19 pandemic, the additional traumas and 
challenges for children presented by the pandemic made them both worse 
and more visible. This dire situation led the Children's Hospital 
Association, the American Academy of Pediatrics, and the American 
Academy of Child and Adolescent Psychiatry to declare a national 
emergency in pediatric mental health, and they have joined together in 
an awareness campaign called Sound the Alarm for Kids.\2\
---------------------------------------------------------------------------
    \2\ See list of Sound the Alarm for Kids campaign partner 
organizations in Appendix A, https://www.soundthealarmforkids.org/.

    Already, more than 50 other national groups and 70 children's 
hospitals have joined the campaign, a clear acknowledgement that it is, 
indeed, time to sound the alarm. We have not one but two urgent tasks 
---------------------------------------------------------------------------
before us:

        1.  Addressing the immediate and undeniable crisis facing kids 
        today; and
        2.  Reframing our pediatric mental health system to provide the 
        right care, at the right place, and at the right time.

    This latter point may sound obvious; however, the reality is that 
we commonly only address pediatric mental health after the onset of a 
crisis. Delayed care is costly in many ways, including:

        1.  Emotional burden and social cost to the patient and their 
        family,
        2.  Strain on our child-care and educational systems,
        3.  Excess cost and poor outcomes associated with providing 
        inadequate care,
        4.  Delays in pediatric health care when medical hospital beds 
        are overutilized for boarding children in mental health crisis, 
        and
        5.  Wrongful placement of children in the juvenile justice 
        system.

    The current state of care is unacceptable, and we must pivot to 
proven models of prevention to reduce the number of our children 
entering a period of crisis and assure access to appropriate pediatric 
services both across the entire continuum of care and close to home.
                         shorter-term solutions
    In the immediate-term, this means greater reliance on those on the 
front lines--parents, teachers, general pediatricians, and other 
caregivers. They need whatever proven tools we can give them, and they 
need them as soon as possible. Examples include supplemental training, 
ready access to phone consultations and referrals, pediatric mobile 
crisis units to help children (and their caregivers) manage from home, 
and school-based interventions, including telehealth. While a good 
number of schools have a school psychologist, school counselor and/or 
nurse on hand, they tend to have untenable student ratios. While these 
providers may not have capacity at present, it makes sense to build on 
these existing models of care through evidence-based training and 
supplementing their efforts with telehealth.

    Not only are these front-line workers lacking the support they 
need, in some cases there are financial disincentives to providing 
mental health services. For example, although up to half of all 
pediatric primary care office visits involve a mental health 
concern,\3\ primary care pediatricians who do additional training to 
offer a mental health assessment necessary for appropriate referral, do 
so without receiving compensation for the 1.3 to 2.8 times longer the 
mental health assessment takes, compared to other primary care visits.
---------------------------------------------------------------------------
    \3\ Martini, R., Hilt, R., Marx, L., Chenven, M., Naylor, M., 
Sarvet, B., and Ptakowski, K.K. (2012). Best principles for integration 
of child psychiatry into the pediatric health home, American Academy of 
Child and Adolescent Psychiatry.

    We need more appropriately trained pediatric mobile behavioral 
health crisis units. These provide mobile, short term, face-to-face, 
therapeutic responses to youth experiencing a behavioral health crisis 
and can help reduce psychiatric emergency department visits.\4\ 
Notably, there are effective models to build on in both urban and rural 
settings, and these mobile crisis units can be stood up almost 
immediately.
---------------------------------------------------------------------------
    \4\ Fendrich, M., Ives, M., Kurz, B., Becker, J., Vanderploeg, J., 
Bory, C., Lin, H., and Plant, R. (2019). ``Impact of Mobile Crisis 
Services on Emergency Department Use Among Youths With Behavioral 
Health Service Needs.'' Psychiatric Services: 70 (10) 881-887.

    Twenty-four-hour crisis hotlines, staffed with those trained in 
child and adolescent mental health, can assist with de-escalation and 
assessment. If linked with updated local resource and provider 
information, these crisis lines can also refer to treatment facilities. 
Depending on how they are configured, the crisis lines could be 
utilized by providers, educators, families and even the kids 
themselves. They would work best if connected to a frequently updated 
collection of local resources. For this, it may be possible to build 
out the existing 211 network or expand on the 988 network established 
by the FCC last year to connect people to the National Suicide 
Prevention Lifeline.
                         fixing a broken system
    In the longer term, the whole continuum of care must be addressed 
so that the right types and levels of care are available, e.g., the 
emphasis should not be on inpatient mental health beds (although more 
of those are also needed). If we are doing things right, children will 
be treated more and more outside of a hospital inpatient setting, but 
this will only be possible if intensive outpatient programs (IOPs), 
partial hospitalization programs (PHPs), day programs, a full range of 
additional step-down services, and preventive services are available. 
Today, every one of these services is in short supply. As a result, 
children often go without the services they need, or families find 
themselves seeking services for their child far from home (including 
out of State).

    It is also important to acknowledge that there is a web of systems 
beyond health care that impact the well-being of children and 
adolescents. These include foster care, juvenile justice, childcare, 
education, food programs and more, layering on additional complexities 
to achieving the end goal of doing better by our kids. The many systems 
that touch our kids rarely collaborate, and, when they try to, these 
attempts are too often foiled by bureaucratic barriers or an 
unwillingness to acknowledge the interconnected nature of the services 
offered. Although a daunting prospect, we recommend a thorough 
examination of how various agencies intersect in children's lives and 
policy recommendations aimed at making those intersections synergistic 
rather than counterproductive.
      workforce shortages and pediatric behavioral health boarding
    Not surprisingly, the shortage of pediatric mental health-care 
providers and facilities means many children show up at emergency 
departments (EDs), brought there by distraught caregivers, sent there 
by overwhelmed schools, or taken there by police who see plainly in a 
particular case, that care, not confinement, is what is needed. EDs are 
not the ideal setting for these kids if they do not have medical needs. 
EDs can be stressful environments and starting a mental health journey 
that way often results in delayed care when children are ``boarded'' 
either in the ED itself or admitted to a medical patient bed. Neither 
option satisfies the ``right care, right place, right time'' mantra, 
and both can be detrimental.

    At CHOP, we have up to 50 patients waiting for mental health beds 
on any given day. As we typically operate at (or over) capacity, this 
means that we cannot use that space for a child with more complex 
medical needs. The kids who are boarding are kept physically safe, but 
generally must wait for an appropriate treatment slot to open before 
having their mental health crises fully addressed. Sometimes this wait 
is only a few hours, but weeks of waiting is far too common, months is 
not unheard of, and there are even instances of a child or adolescent 
missing more than a year of their life, removed from school and family, 
while waiting for the services they need to safely return to home and 
school.

    According to the American Psychiatric Association, there are an 
estimated 15 million children nationwide in need of care from mental 
health professionals. However, there are just 8,000 to 9,000 
psychiatrists treating youth in the United States. Even when staffing 
ratios are reasonable, resources are not distributed evenly across the 
country, essentially resulting in pediatric mental health service 
deserts.

    While I can speak most directly to the shortage of child and 
adolescent psychiatrists, there are also severe shortages of 
psychologists, mental health therapists, nurse practitioners, case 
managers, and community mental health workers to support children in 
need.\5\ To increase the number of pediatric mental health providers 
available to care for these children, incentives, including educational 
funding and loan forgiveness programs should be directed at all 
licensed pediatric mental health providers in all settings across the 
continuum of care, including in schools. It is especially important to 
include mental health professionals of all disciplines. While there is 
a severe shortage of new pediatric psychiatrists coming into the 
system, and that must be addressed, increasing the number of clinical 
social workers with pediatric training, mental health therapists, 
psychologists, nurse practitioners, case managers and community mental 
health workers, who are all needed to expand access to mental health 
care, could be done more quickly and in greater numbers.
---------------------------------------------------------------------------
    \5\ National Projection of Supply and Demand for Selected 
Behavioral Health Practitioners: 2013-2025. U.S. Department of Health 
and Human Services. Health Resources and Services Administration. 
Bureau of Health Workforce. Published November 2016, https://
bhw.hrsa.gov/sites/default/files/bureau-health-workforce/data-research/
behavioral-health-2013-2025.pdf.
---------------------------------------------------------------------------
                 the unique needs of military families
    Children in military and veteran families are experiencing mental 
health challenges much like their civilian counterparts, but also face 
some unique challenges due to the nature of their parents' service such 
as frequent moves, prolonged separation resulting from parents' 
deployments, and exposure to returning parents who themselves have been 
affected by the trauma of combat deployment. How these children can be 
connected to the full continuum of care described above must be 
determined and then implemented.
       improved access to integrated care and preventive services
    For an overwhelmed system in which training enough providers will, 
at best, take time, easing pressure on the system now is essential. The 
best way to do this is support for both preventive services as well as 
care that is integrated into settings where youth are likely to be, 
such as the pediatrician's office, school, or other 
community-based centers to help stem the tide of youth entering crisis.

    When care isn't easily accessible (the ideal being true integrated 
care, with a warm hand-off to someone in the same building), too often 
a referral to mental health services ends in no services. When patients 
are referred from primary care to free-standing mental health clinics, 
only 25-50 percent of patients attend an appointment. When behavioral 
health providers are on site, as part of the primary care team, 
treatment initiation is dramatically improved.\6\ The pediatric 
patient-
centered medical home model offers opportunities for family-centered, 
team-based care, and pediatric mental health providers are increasingly 
being recognized as key members of primary care teams.\7\ Insurance 
carve outs for behavioral health care are among the barriers to 
implementation, but targeted incentives related to integrated 
behavioral health could further speed expansion and serve as a pathway 
to mental health parity.
---------------------------------------------------------------------------
    \6\ Blount, A. ``Integrated primary care: Organizing the 
evidence.'' (2003). Families Systems and Health. 21:121-133.
    \7\ Asarnow, J., Kolko, D.J., Miranda, J., and Kazak, A.E. (2017). 
``The pediatric patient-
centered medical home: Innovative models for improving behavioral 
health.'' American Psychologist, 72, 13-27. https://doi.org/10.1037/
a0040411.

    Certified Community Behavioral Health Clinics (CCBHCs) are another 
important access point to mental health care for children and youth, 
particularly for those in underserved communities. In a recent survey, 
79 percent of CCBHCs reported coordinating with hospitals to support 
diversion from emergency departments and inpatient care,\8\ and a 
similar proportion of CCBHCs directly employ child and adolescent 
psychiatrists as part of their care teams. Providing these clinics with 
additional resources could be another way to have more appropriate care 
available closer to home, for kids in need.
---------------------------------------------------------------------------
    \8\ According to a 2021 impact report (https://
www.thenationalcouncil.org/resources/2021-ccbhc-state-impact-report-
transforming-state-behavioral-health-systems/?daf=375atetbd56) that 
surveyed 128 CCBHCs, 79 percent report coordinating with hospitals/
emergency departments to support diversion from emergency departments 
and inpatient care. Additionally, according to a 2020 ASPE 
implementation report (https://www.aspe.hhs.gov/sites/default/files/
migrated_
legacy_files/196051/
CCBHCImpFind.pdf?_ga=2.126261899.727227857.1643912188-731445304.
1625598149), 76 percent of CCBHCs employs child and adolescent 
psychiatrists.

    Ultimately, of course, prevention is the best approach as it both 
serves are children better and it helps to alleviate an over-burdened 
system. Preventive mental health interventions reduce the risk of a 
child suffering a mental health crisis and are cost-
effective,\9\, \10\ but it is not well understood how early 
these interventions can and should start. Remarkably, just by giving 
parents and other caretakers tools to effectively address behaviors and 
emotions as they come up, better trajectories are started as early as 
infancy. Early intervention, services for young children that build 
upon the natural learning opportunities that occur within the daily 
routines of a child and their family, can effectively give children 
tools to overcome delays and manage disabilities.\11\, \12\ 
For older kids, there are several effective depression prevention 
programs, which, if more widely delivered, could prevent 22-38 percent 
of depression episodes.\13\, \14\
---------------------------------------------------------------------------
    \9\ Mihalopoulos, C., Vos, T., Pirkis, J., and Carter, R. (2012). 
``The Population Cost-effectiveness of Interventions Designed to 
Prevent Childhood Depression.'' Pediatrics 129 (3): e723-e730.
    \10\ Bodden, D.H.M., van den Heuvel, M.W.H., Engels, R.C.M.E., and 
Dirksen, C.D. (2021). ``Societal costs of subclinical depressive 
symptoms in Dutch adolescents: A cost-of-illness study.'' Journal of 
Child Psychology and Psychiatry, https://doi.org/10.1111/jcpp.13517.
    \11\ Bailey, D.B., Hebbeler, K., Spiker, D., Scarborough, A., 
Mallik, S., and Nelson, L. (2005). ``36-month outcomes for families of 
children with disabilities participating in early intervention.'' 
Pediatrics, 116, 1346-1352
    \12\ Richard C. Adams, Carl Tapia, and The Council on Children With 
Disabilities. ``Early Intervention, IDEA Part C Services, and the 
Medical Home: Collaboration for Best Practice and Best Outcomes,'' 
Pediatrics, October 2013, 132 (4) e1073-e1088; DOI: https://doi.org/
10.1542/peds.2013-2305.
    \13\ Cuijpers, P., van Straten, A., Smit, F., and Mihalopoulos, C. 
``Preventing the Onset of Depressive Disorders: A Meta-Analytic Review 
of Psychological Interventions.'' (2008). The American Journal of 
Psychiatry; 165, 10; ProQuest Social Sciences Premium Collection pg. 
1272.
    \14\ Cuijpers, P., Munoz, R.F., Clarke, G.N., and Lewinsohn, P.M. 
(2009). ``Psychoeducational treatment and prevention of depression: The 
`coping with depression' course 30 years later.'' Clinical Psychology 
Review 29 449-458.

    Unfortunately, current mental health payment models do little to 
support prevention services. Most billing codes required for use by 
behavioral health clinicians usually necessitate the presence of a 
diagnosed psychiatric condition. This means that a mental health 
concern that could have been resolved relatively quickly can devolve 
into crisis, which is far worse for the child and far more costly, both 
literally and figuratively, for society. Even with early intervention, 
which is inexpensive and effective, there are barriers that can 
---------------------------------------------------------------------------
significantly delay services.

    Although we understand the challenges of fully realizing savings in 
a 10-year legislative budget window, it is nonetheless essential to 
increase funding for and access to preventive services for our 
children. To this end, dedicated grant programs could further enable 
community-based systems of care. Additionally, increasing health-care 
payment flexibility with new billing codes that support preventive 
services without a diagnosed psychiatric condition would better enable 
these services to be embedded into pediatric primary care (where most 
families already visit regularly) and other settings that children and 
families frequent. Also, the Early and Periodic Screening, Diagnostic, 
and Treatment (EPSDT) benefit for youth in Medicaid provides an 
important opportunity to support early identification even before 
diagnosis. The Department of Health and Human Services should be 
instructed to working with States to test innovative strategies and 
sustainable payment models within Medicaid's EPSDT services \15\ to 
allow children at risk of mental health concerns, but without a 
diagnosis to receive preventive services.\16\
---------------------------------------------------------------------------
    \15\ ``Early and Periodic Screening, Diagnostic, and Treatment.'' 
Medicaid.gov (https://www.
medicaid.gov/medicaid/benefits/early-and-periodic-screening-diagnostic-
and-treatment/index.ht
ml#::text=PDF%2C%2068.09%20KB)-
,The%20Early%20and%20Periodic%20Screening%2C%20
Diagnostic%20and%20Treatment%20(EPSDT),who%20are%20enrolled%20in%20Medic
aid.&text=
Treatment%3A%20Control%2C%20correct%20or%20reduce%20health%20problems%20
found).
    \16\ We can look to Massachusetts for innovation in this area. 
Revisiting and realigning health insurer capitated payment rates to 
reflect expanded preventive services would also facilitate earlier 
interventions. Please refer to the relevant MassHealth Bulletin 
(https://www.mass.gov/doc/managed-care-entity-bulletin-65-preventive-
behavioral-health-services-for-members-younger-than-21-0/download).
---------------------------------------------------------------------------
        setting children up for success from the earliest years 
                     and addressing equity concerns
    Early care and education programs, child care, and preschool 
prevention programs have been overlooked and underfunded. As noted 
above, these services have a key role in prevention. When using proven 
techniques, they help young children build social-emotional life 
skills, which can set the child on a pathway to greater resilience and 
prevent mental health crises at later ages.

    Within early education, there is another distinct crisis that 
exists as the result of suspensions and/or expulsions of babies and 
toddlers from childcare and Pre-K settings for behavioral concerns, and 
this problem falls disproportionately on Black boys. If you take a 
moment to imagine being told that nothing can be done for your 2-year-
old's behavior, and he is being expelled from child care--the message 
to both the child and the parents is damaging in the moment 
longitudinally. Promptly investing in basic behavioral health technique 
training for child-care providers and Pre-K teachers will give our 
educators the support they need to teach our youngest the social-
emotional life skills and regulation tools they need to participate in 
these important developmental settings and enter kindergarten ready to 
learn and thrive.

    Care provided in communities offers the opportunity for early 
identification and intervention for children and families with mental 
health challenges at the right level and at the right time. It also 
helps to address longstanding access disparities and overcome stigma. 
Instead of this, our current system relies heavily on private 
facilities which often pick and choose their patients. While they are 
entitled to do so under current law, additional standards could be set 
nationwide both to ensure kids get to open pediatric mental health 
slots in facilities that accept Federal funding and to reduce bias in 
these decisions.

    Of course, inadequate Medicaid reimbursement for mental health 
services disproportionately impacts communities that are already 
medically underserved, in which those services are especially needed. 
Better reimbursement for mental health services in Medicaid would make 
it possible to resource the full continuum of care our children and 
youth need, such as intensive outpatient, partial hospitalization, and 
limited residential treatment facilities--and, importantly, bring that 
care closer to home.
                    how telehealth can enhance care
    Tele-mental health services have been described as an ideal 
application of digital health services, and since the onset of the 
COVID-19 pandemic, behavioral health providers at CHOP have completed 
more appointments via telehealth than any other specialty; nearly 
83,000 across the CHOP Care Network. This is an essential tool for 
addressing the pediatric mental health crisis. To reach the 
underserved, we recommend the inclusion of audio-only services as well 
as coverage across sites of care including a child's home, school, or 
childcare center. Increased reimbursement rates for telehealth services 
supported the rapid expansion of telehealth and should be continued at 
an appropriate level to maintain children's access to tele-behavioral 
health services.

    Telehealth across State lines is also an important way to improve 
access to pediatric mental health services, particularly in States 
where there is a shortage of providers. However, the process is both 
complicated and expensive for providers to become licensed in multiple 
States and/or obtain the credentials (like PsyPact) that allow care 
provision across State lines. There is also no longer a State-by-State 
standard of care, making State-based professional licensure a barrier 
to care that is difficult to justify, especially in federally 
recognized health professional shortage areas (HPSAs) and the dearth of 
providers accepting Medicaid.\17\
---------------------------------------------------------------------------
    \17\ Health Professional Shortage Areas (https://data.hrsa.gov/
topics/health-workforce/shortage-areas).
---------------------------------------------------------------------------
  improving reimbursement through both payment reform and higher rates
    The behavioral health payment system is archaic and convoluted, 
further restricting access to care. As it stands today, arranging for 
care and payments can be confusing and administratively burdensome. 
There is often disagreement as to which payer is responsible and where 
the care can be provided. For boarded children, the result is something 
close to nonpayment, where neither insurer assumes responsibility when 
the services assigned to them are not being provided or not in what 
they consider to be the approved setting. The disfunction is only 
greater when a child or adolescent reports with both a medical and 
mental health issue,\18\ and few settings are equipped to address these 
complex cases.
---------------------------------------------------------------------------
    \18\ We have been able to provide limited relief of this latter 
problem by providing full-time medical staff to a facility that 
otherwise only addresses MEB issues, but this only works when the 
medical issue is relatively easily managed, like diabetes, not for more 
severe comorbidities.

    Many key pieces of the needed continuum of care are simply not 
covered or are reimbursed at such low levels that too few providers 
will offer them. Day programs,\19\ which provide trauma-informed, 
behaviorally based therapeutic services, which teach children how to 
develop safe adaptive behaviors, emotional self-
regulation, and pro-social skills, are an important example. Without a 
significant enough increase in rates for pediatric mental health 
services, we will never be able to provide the full continuum of care 
that our youth need. This is not acceptable, especially when getting 
this right will mean our children receive the care they need at the 
appropriate level, maximizing the likely success of the treatment, 
ensuring that they are not taking a higher acuity spot desperately 
needed by another child, and more wisely spending health-care dollars.
---------------------------------------------------------------------------
    \19\ More information on CHOP's Intensive Emotional and Behavioral 
Services can be accessed here (https://www.chop.edu/centers-programs/
childrens-intensive-emotional-and-behavioral-services).
---------------------------------------------------------------------------
                               conclusion
    Our mental health-care system is not equipped to give our children 
the support they need when they need it. If the right interventions are 
put in place, they would build on our children's remarkable resilience 
and place them on a better trajectory. Our children are in crisis, 
which means we are in crisis as a Nation. Although the pandemic 
deepened the crisis, it has raised awareness on this issue, creating an 
important and rare opportunity to make fundamental changes in the way 
we care for our children.

    Thank you again for the opportunity to provide this testimony. I 
urge you to take this opportunity to act swiftly and decisively to save 
children in crisis and diminish the chances of a repeated emergency of 
this magnitude.

Appendix A: Organizations Participating in the Sound the Alarm for Kids 
Campaign, along with the Children's Hospital Association, American 
Academy of Pediatrics, American Academy of Child and Adolescent 
Psychiatry, and 70+ (https://www.soundthealarmforkids.org/a-national-
emergency/) Children's Hospitals

        AIDS Alliance for Women, Infants, Children, Youth and Families
        American Academy of Family Physicians
        American Foundation for Suicide Prevention
        American Hospital Association
        American Mental Health Counselors Association
        American Muslim Health Professionals (AMHP)
        American Psychiatric Association
        American Psychological Association
        America's Essential Hospitals
        Association of Children's Residential and Community services 
(ACRC)
        Catholic Health Association
        Center for Law and Social Policy (CLASP)
        Child Welfare League of America
        Children and Adults with Attention-Deficit/Hyperactivity 
Disorder (CHADD)
        Children's Defense Fund
        Clinical Social Work Association
        Eating Disorders Coalition for Research, Policy and Action
        Exceptional Families of the Military
        Family Voices
        Federation of American Hospitals
        First Focus on Children
        Global Alliance for Behavioral Health and Social Justice
        International Society of Psychiatric Mental Health Nurses
        Juvenile Protection Association (JPA)
        Mental Health America
        National Alliance on Mental Illness (NAMI)
        National Association for Behavioral Healthcare
        National Association for Children's Behavioral Health
        National Association for Rural Mental Health
        National Association of County Behavioral Health and 
Developmental Disability Directors
        National Association of Pediatric Nurse Practitioners
        National Association of School Psychologists
        National Association of State Mental Health Program Directors
        National Council for Mental Well-being
        National Latinx Psychological Association
        National League for Nursing
        National Military Family Association
        On Our Sleeves--The Movement for Children's Mental Health
        Psychotherapy Action Network (PsiAN)
        REDC Consortium
        RI International, Inc.
        Sandy Hook Promise
        School Social Work Association of America
        School-Based Health Alliance
        Social Current
        Society for the Prevention of Teen Suicide
        Society of Adolescent Health and Medicine
        The Baker Center
        The Barry Robinson Center
        The Jed Foundation
        The Kennedy Forum
        The National Alliance to Advance Adolescent Health
        The Trevor Project
        Tricare for Kids Coalition
        Trust for America's Health
        United Way Worldwide
        WellSpan Health
        Youth Villages

Appendix B: Visual Representation of Recommendations Along the Care 
Continuum and Time to Impact (Now vs. Future) \20\
---------------------------------------------------------------------------
    \20\ Strengthening Kids' Mental Health Now. Children's Hospital 
Association (https://www.
childrenshospitals.org/content/public-policy/policy-position/
strengthen-kids-mental-health-now-bill-would-invest-in-mental-health).

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


                                 .eps__
                                 
       Questions Submitted for the Record to Tami D. Benton, M.D.
            Question Submitted by Hon. Robert P. Casey, Jr.
    Question. On page 6 of your testimony, you note that ``early care 
and education programs, child care, and preschool prevention programs 
have been overlooked and underfunded.'' I strongly agree that we must 
invest in and work through evidence-based early childhood programs to 
equip kids with socio-emotional life skills and increase their 
resilience. When it comes to preventing mental health challenges later 
in life, we should think about what support we can provide every stage 
of a child's life, including their earliest years.

    How can we better integrate infant and early childhood mental 
health into the continuum of care for children?

    Answer. When using proven techniques, services provided to young 
children help them build social-emotional life skills, which can set 
the child on a pathway to greater resilience and prevent mental health 
crises at later ages. Promptly investing in basic behavioral health 
technique training for childcare providers and Pre-K teachers will give 
our educators the support they need to teach our youngest the social-
emotional life skills and regulation tools they need to participate in 
these important developmental settings and enter kindergarten ready to 
learn and thrive. Preventive mental health interventions reduce the 
risk of a child suffering a mental health crisis and are cost-
effective.

    Within early education, there is another distinct crisis that 
exists as the result of suspensions and/or expulsions of babies and 
toddlers from child care and Pre-K settings for behavioral concerns, 
and this problem falls disproportionately on Black boys. If you take a 
moment to imagine being told that nothing can be done for your 2-year-
old's behavior, and he is being expelled from child care--the message 
to both the child and the parents is damaging in the moment and over 
time.

    Remarkably, just by giving parents and other caretakers tools to 
effectively address behaviors and emotions throughout children's 
development, as they occur, will improve developmental outcomes, 
preventing emotional and behavioral problems across the life span. At 
CHOP, we provide behavioral health support to parents, supporting 
healthy social, emotional and behavioral development. One such program 
is the Child Adult Relationship Enhancement in Primary Care (PriCARE) 
program, a 6-session group parent training designed to teach positive 
parenting skills; other programs include the Early Head Start Program 
for at-risk parents. Early intervention, services for young children 
that build upon the natural learning opportunities that occur within 
the daily routines of a child and their family, can effectively give 
children tools to overcome delays and manage disabilities.

                                 ______
                                 
                Question Submitted by Hon. Maggie Hassan
    Question. We know that youth anxiety and depression rates are 
skyrocketing, and that strong social relationships improve a child's 
overall well-being. I worry about children and youth who are 
immunocompromised and might have trouble safely reconnecting with their 
peers during the ongoing pandemic.

    What can parents do to help their immunocompromised children 
socialize with other youth while staying safe?

    Answer. We know that children who are immunocompromised are at 
higher risk of being infected with and suffering complications from 
COVID-19. Parents can make sure kids and family members are vaccinated 
(if eligible) and wear masks when seeing friends, as well as providing 
opportunities for children to socialize with their peers outside where 
the risk of infection is lower. It is also important that school 
personnel be aware of a youth's need for distancing and masking, and 
that there is an opportunity for private space if needed. Communication 
with the school about the child's management at school and daily 
activities and contacts will allow the parents and child to feel 
supported. All will feel better with effective communication.

    Additionally, communities should prioritize in-person learning for 
school-age children. This will require not only ensuring there is 
adequate financial support to safely return to the classroom, but also 
making plans to support the emotional well-being of youth as they 
reacclimate to in-person socialization and catch up on missed 
academics. Expanding the settings in which mental health services are 
delivered to meet families where they are, including in schools as 
students return to classrooms, can help ease this transition.

                                 ______
                                 
                   Submitted by Hon. Sherrod Brown, 
                        a U.S. Senator From Ohio

                       Akron Children's Hospital

                           One Perkins Square

                         Akron, Ohio 44308-1062

                           Phone 330-543-1000

                         www.akronchildrens.org

                   Statement of Steven Jewell, M.D., 
            Director of Pediatric Psychiatry and Psychology

Chairman Wyden, Ranking Member Crapo, members of the United States 
Senate Committee on Finance, thank you for the opportunity to submit 
our statement, which outlines the position and perspective of Akron 
Children's Hospital regarding behavioral health.

Acknowledgement of Surgeon General's Advisory

We appreciate the Surgeon General's recent advisory on ``Protecting 
Youth Mental Health,'' that highlights the long-standing access and 
workforce issues that have plagued the mental health system for 
children and youth across the country for decades, and which have been 
significantly aggravated by the COVID-19 pandemic. In fact, pre-
pandemic in 2019 suicide became the leading cause of death for children 
ages 10-14 in the State of Ohio, and the second leading cause of death 
for those ages 15-34. Reflective of the increasing demand for 
behavioral health services even before the pandemic struck, that same 
year Akron Children's Hospital's behavioral health outpatient volumes 
increased over 45 percent for mental health therapy services and over 
29 percent for psychiatric services.

Within just a few months of the beginning of the pandemic, experts 
began predicting a mental health pandemic that would inevitably follow 
on the heels of the viral pandemic. As the stress and trauma to 
children and families caused by the pandemic persisted, we saw further 
increases in demand for behavioral health services, as well as 
increasing rates of suicide attempts and completed suicides among 
youth, especially girls. By late 2021 (ironically the year that the 
Annapolis Coalition on the Behavioral Health Workforce celebrated 20 
years since it was founded to address the behavioral workforce 
shortage), there was a general recognition that the longstanding 
workforce shortage had also been exacerbated by the pandemic, as it 
became increasingly difficult to recruit mental health professionals 
(especially those with specialized training in serving the needs of 
youth) to address the increasing needs of youth presenting in crisis.

Leaders in the field soon began calling for action. In October 2021 the 
American Academy of Child and Adolescent Psychiatry, the American 
Academy of Pediatrics and the Children's Hospital Association declared 
a ``national state of emergency'' in child and adolescent mental 
health, which they correctly noted required ``urgent government 
action.'' Surgeon General Dr. Vivek Murthy answered that call in 
December 2021 with his advisory, calling for ``a swift and coordinated 
response to this crisis.'' We are grateful for his decision to shine a 
light on this crisis, and his comprehensive set of recommendations that 
all of us can begin to implement with the goal ``to improve the mental 
health of children, adolescents, and young adults.''

Akron Children's Perspective

During the pandemic, Akron Children's Hospital has experienced an 
increase in youth and adolescents presenting in the emergency 
department with suicidal ideation and suicide attempts. The complexity 
and acuity of patients admitted to the inpatient psychiatric unit has 
increased significantly as evidenced by the number of nursing 
specialties required for patient care. In addition, aggressive 
behaviors among the patient population have resulted in more serious 
staff injuries resulting in an increasing number of days absent from 
work. In the ambulatory settings, referral volumes are extremely high. 
In some areas, families seeking services are waiting up to six months 
to be seen by a behavioral health specialist.

Current Efforts

Facing the same challenges to providing behavioral health services to 
children and youth that other organizations do, Akron Children's 
Hospital has embarked on a strategic plan to create a system of care 
that not only capitalizes on our existing resources, but also leverages 
those by partnering with pediatric primary care providers (PCPs) and 
community mental health centers (CMHCs) across our more than 30-county 
service area in northeast Ohio, in an attempt to mitigate existing 
barriers to care. The challenges we are attempting to address include 
the stigma of mental illness, under-identification of children in need 
of services, the above-noted behavioral health workforce shortage, and 
significant gaps in available services in the community (especially for 
youth with more severe mental illness). Our strategy includes the 
following interventions:

    1.  Addressing stigma by embedding masters' level therapists in all 
of our pediatric primary care offices, thereby providing care in a 
natural setting, allowing for ``warm hand-offs,'' and encouraging 
informal consultation between therapists and PCPs;
    2.  Addressing under-identification of youth with mental illness by 
an annual screening process in the primary care offices for all youth 
12 years of age and older, to identify youth in need of services 
earlier in the course of their illness;
    3.  Addressing the behavioral health workforce shortage by 
enhancing PCPs' confidence and competence managing mild to moderate 
mental illness in their office through various supports (including 
telepsychiatry, electronic consults, and telementoring using the 
Project ECHO format), and creating a structured triage process to 
identify and prioritize referral of more severely mentally ill youth 
from primary care to more specialized services; and
    4.  Addressing the gaps in available services in the community by 
bringing up several regional behavioral health centers across our 
geographic footprint, each of which house programming for more severely 
mentally ill youth, tailored to the needs of the local community.

The overall intent of the plan is to create a ``meta-system'' of care 
layered on top of and in collaboration with the existing county-based 
systems of care, but taking care not to compete with existing community 
mental health system resources.

In another effort to address the workforce issues, we are expanding our 
child and adolescent psychiatry and pediatric psychology fellowship 
programs, and are in the process of establishing a fellowship for child 
psychiatric advanced practice nurses. This will include partnering with 
local agencies and universities to create clinical rotations that offer 
a comprehensive learning experience. The goal of these programs is to 
expose fellows to multiple clinical settings and patient populations 
while retaining them within the local community workforce.

For Your Consideration

Finally, as we move forward with this strategic plan we recognize that 
there are interventions that could be beneficial not only in our local 
service area, but also on a national scale in this effort to protect 
youth mental health, and would like to share those with you.

    (1)  Increase availability of behavioral health promotion/
prevention/early intervention services in the community, such as:

        (a)  Enhance suicide prevention activities in communities (many 
have a structure addressing needs of adults, but not youth);

        (b)  Enhance mental health screening of children and youth in 
primary care for the purpose of case-finding, early identification and 
early intervention; and

        (c)  Enhance availability of screening, mental health services, 
and risk assessment capacity in schools.

    (2)  Integration of behavioral health services into primary care:

        (a)  Successful and meaningful integration of behavioral health 
services into primary care on a national level holds the promise of 
resolving many of the most vexing barriers to the effective provision 
of behavioral health services to youth, including (as noted above) 
stigma, workforce shortage, and the need for early identification and 
intervention.

        (b)  However, this requires a number of activities that are not 
billable in a fee-for-service environment. These include, among other 
activities:

              (i)  developing the capacity in the primary care practice 
for regular screening and ongoing monitoring of response to treatment 
using standardized tools;
              (ii)  creation of a roster of patients within the 
practice identified as needing behavioral health services, and 
conducting an ongoing systematic case review of their progress in 
treatment;
             (iii)  embedding a behavioral health-care manager within 
the primary care practice to take responsibility for conducting/
overseeing the above activities; and
             (iv)  providing ongoing psychiatric consultation to the 
PCPs, thereby leveraging the psychiatrist's time to serve a larger 
population than could be served with direct visits alone.

        (c)  The Collaborative Care Model (CoCM)--developed and studied 
by the University of Washington's AIMS Center (http://uwaims.org)--for 
treating common mental disorders in primary care settings is an 
evidence-based strategy recognized as a best practice for improving 
patient outcomes and includes all of the above-described elements. CoCM 
services are currently reimbursable by Medicare, and a few State 
Medicaid programs (e.g., Maryland, New York, North Carolina, and 
Washington, but not on a national level).

       (d)  Thus, authorizing Medicaid (and incentivizing private 
insurers) to reimburse primary care practices for implementation of the 
evidence based CoCM for youth could have a substantial impact on the 
behavioral health needs of the youth across the Nation, and address 
many of the challenges described above.

Thank you for your time and attention to this issue of critical 
importance to the overall health of the children, youth and young 
adults of this Nation. If we can be of any further support or 
assistance to this initiative, please do not hesitate to contact us.

                                 ______
                                 
                Prepared Statement of Hon. Mike Crapo, 
                       a U.S. Senator From Idaho
    Thank you, Mr. Chairman, and thank you to our witnesses for joining 
us today as we discuss ways to respond to mental health challenges 
impacting children and adolescents across the country.

    According to recent reports from the CDC, the number of young 
people dealing with depression, anxiety, and suicidal thoughts has 
unfortunately risen during the pandemic, as social isolation has taken 
its toll on far too many children and adolescents. Although it appears 
the pandemic is subsiding and our return to normalcy may be imminent, 
we cannot ignore the lasting effects of the past 2 years on the social 
and emotional well-being of children.

    We should do all that we can, within our jurisdiction, to increase 
access to high-quality mental health services, and reduce the causes of 
delayed and forgone treatment. While mental health issues affect people 
of all ages, children's needs are often different from those of adults, 
necessitating carefully tailored solutions.

    As this committee works in a bipartisan way to advance the 
conversation on mental health, we must not only identify the complexity 
and scope of the problems at hand, but also explore innovative, 
sustainable, and concrete policy solutions. I look forward to working 
with my colleagues on both sides of the aisle to develop meaningful 
measures to meet some of the Nation's mental health challenges, 
including by expanding access to telehealth services, supporting our 
mental health workforce, and better integrating physical and mental 
health-care services.

    Children can--and often do--benefit from services delivered via 
telehealth. While we often focus our telehealth discussions on 
Medicare, where key access gaps and barriers remain, this committee 
should also prioritize clarifying and expanding care delivery options 
for children covered by Medicaid, regardless of geographic location.

    Additionally, we should work to maintain a strong mental health 
workforce with the capacity to care for all who need services. These 
efforts will prove particularly crucial as health-care professional 
burnout, steep regulatory demands, and other strains jeopardize long-
term provider retention and capacity.

    We have clear opportunities for improvement at every level. I 
regularly hear from front-line providers, as well as State 
policymakers, seeking the flexibility to innovate and craft targeted, 
local solutions to the challenges facing their communities.

    Their ideas and input will play a critical role in this process, 
especially as we look to bridge gaps in care, better integrate physical 
and behavioral health services, and promote value-based payment models 
that put patients first. If structured effectively, these reforms could 
prove game-changing for populations of all ages, including young 
people.

    Finally, no conversation on mental health-care reforms for children 
and young adults would be complete without input from those whom the 
policies intend to empower and support. To that end, Trace, thank you 
for your willingness to join us today to share your perspective.

    We have the opportunity to better support children, their families, 
and their providers, by enhancing mental health outcomes across the 
United States. Moreover, we can--and must--do so while honoring this 
committee's strong tradition of 
member-driven, bipartisan, and fiscally responsible legislative 
solutions.

    Thank you to our witnesses for agreeing to share their expertise 
from across the continuum of care. They have provided invaluable 
services during these unprecedented times, and I look forward to 
hearing their testimonies.

                                 ______
                                 
   Prepared Statement of Sharon Hoover, Ph.D., Professor, Child and 
  Adolescent Psychiatry; and Co-Director, National Center for School 
        Mental Health, University of Maryland School of Medicine
    I want to express my thanks to you, Chairman Wyden, for the 
invitation to speak with the committee today and for your leadership on 
the issue of mental health in our Nation, including the impact on 
youth. Thank you also to ranking member Senator Crapo and to all of the 
committee members for your vision to improve the mental health and 
well-being of our young people and for the opportunity to be here with 
you today to discuss these important issues.

    I am speaking to you from my perspective as a co-director of the 
National Center for School Mental Health, funded by the U.S. Department 
of Health and Human Services, and as a professor of child and 
adolescent psychiatry. I also speak to you through my lens as a parent 
to three teenagers, all of whom had their learning landscape 
significantly altered during COVID, with almost a year of virtual 
education. They, along with most children across the globe, had 
significant disruption to their learning and well-being, though I am 
fortunate that my kids are now in school and doing well.

    But we know that many are suffering. Even before the pandemic, 
youth mental health challenges were rising, with suicide being the 
second leading cause of death for youth ages 10-24.

    As noted by Surgeon General Murthy during last week's hearing, one 
of the most central tenets of creating accessible and equitable systems 
of care is to meet people where they are. For most young people, this 
is in schools.

    I often think back to a story that my dad, who is now 85, told me 
about his first day of school. He grew up in a very small town in rural 
West Texas called Spur. They didn't have pre-K or Kindergarten, so it 
was first grade, and on that first day he recalls that he and his peers 
received toothbrushes from their classroom teacher; It was the first 
toothbrush he ever owned.

    I remember asking him, ``You didn't have toothbrushes?'', to which 
he replied, ``No, my family wouldn't have spent money on toothbrushes 
back then.'' Mind you, my dad went on to a long career in computer 
science where he helped create the coding to put our astronauts on the 
moon. He often credits those teachers in his early years who cared 
about him with setting him on that path. When I consider that moment 
when he received his toothbrush on the first day of school, I think of 
it as a classic example of how our schools are a vital place to promote 
our children's health and well-being.

    We cannot rely on our health-care system alone to support the 
mental health and well-being of young people. We know on average people 
do not get into care for over a decade after their initial onset of 
symptoms and half of mental illnesses begin during the school age 
years.

    Our traditional approach to mental health care has not leveraged 
the natural venues where our young people access support; It is akin to 
waiting for toothaches, cavities, and abscesses until a child gets 
proper dental care. Instead, we should do the equivalent of passing out 
toothbrushes and providing preventive and early dental care, by 
offering every child in every school the social, emotional, and mental 
health supports they need to be successful.

    Increasingly, schools have comprehensive school mental health 
systems, reflecting partnerships between the education and behavioral 
health sectors to support a full continuum of mental health supports 
and services, from promotion to treatment.

    Every child deserves to have this type of mental health support in 
their school. Schools that have these systems in place are doing this 
because they recognize that:

        Poor mental health leads to poor learning; and
        Positive mental health promotes academic and life success.

    When we provide mental health promotion for all students and 
accessible mental health interventions in schools, we take positive 
steps to remedy student inequities in both education and health care. 
When treatment is delivered in the school setting, youth are far more 
likely to be identified early, and to initiate and complete care.

    There are many policy and funding opportunities advance a full 
continuum of mental health supports and services in all schools, and 
Congress has the opportunity to support investment and technical 
assistance to ensure that young people get the mental health support 
they need.

    In my written testimony, I provide detail on several steps that 
Federal and State leaders can take to advance comprehensive school 
mental health systems.

    We have witnessed many States adopt new policies to advance school 
mental health systems. Tomorrow, the Hopeful Futures Campaign, a 
coalition of national organizations committed to ensuring that every 
student has access to effective and supportive school mental health 
care, is releasing the first ever ``America's School Mental Health 
Report Card and Action Center,'' with individual report cards for all 
50 States and DC. These school mental health report cards highlight 
accomplishments and provide important action steps to help address the 
children's mental health crisis in every State. They serve as a great 
starting point for policymakers who want to strengthen school mental 
health supports and policies in their communities. You can find the 
report cards at https://hopefulfutures.us/ starting tomorrow morning.

    Today, Americans across the country are united in their concern 
about the mental health of our young people and the impact it has 
throughout their lives.

    I want to express my gratitude to you all for opening up this 
important discussion on youth mental health, for recognizing schools as 
an essential place to strengthen our children's well-being, and for 
committing to investing now to create hopeful futures for our Nation's 
youth.

    All schools in the United States should have Comprehensive School 
Mental Health Systems that:

    -  Implement organizational and individual strategies to promote 
educator well-being.

    -  Offer mental health literacy for K-12 staff and students 
including knowledge of obtaining and sustaining positive mental health, 
understanding mental illness, and promoting help-seeking.

    -  Integrate social emotional learning into the K-12 curricula to 
promote self-awareness, self-management, responsible decision-making, 
relationship skills, and social awareness.

    -  Assess and engage in continuous improvement toward positive 
school climate.

    -  Conduct regular student well-being check-ins to assess 
subjective well-being, mental health, connectedness, and supports.

    -  Hire, retain, and offer ongoing professional development to a 
full complement of student support professionals, including school 
psychologists, school social workers, and school counselors.

    -  Establish formal partnerships (e.g., memoranda of understanding) 
with community behavioral health providers to offer on-site school 
mental health services and supports and to facilitate referrals and 
coordination of community-based mental health services.

    -  Offer school-based, multi-tiered mental health supports and 
services to promote students' academic, social, and psychological 
development

 Policies to Support Universal Mental Health Promotion and Prevention 
                    Policies

      Require the selection of indicators of student mental health and 
well-being as a core metric of school performance under Federal 
education funding, with provisions to assist schools as they strive to 
perform well on these indicators. Indicators may include school 
climate, student-reported subjective well-being and distress, and 
reports of school connectedness.

      Incentivize teaching education programs to include mental health 
literacy to improve the capacity of the educator workforce to: promote 
mental health of all students in the classroom, including teaching of 
social-emotional learning competencies; identify mental health concerns 
and link students to needed supports and services; reduce stigma 
related to mental illness; and promote student and family help-seeking.

      Establish mental health as a State-required component of K-12 
curricula, with efforts in New York and Virginia as examples. The 
Federal Government could support this State-level effort by passing a 
resolution encouraging States to follow existing State efforts to 
integrate mental health into curricula and by providing direct funding 
for educator training and ongoing professional development.

      Leverage Federal title I and title IV funding to provide 
universal mental health programming for students, including social-
emotional learning programming. Joint guidance by the U.S. Department 
of Education and the U.S. Department of Health and Human Services could 
support States as they navigate these funding mechanisms to support 
universal mental health in schools.

      Expand Federal grants to State and local education and 
behavioral health authorities to increase mental health awareness and 
promotion in schools. This could include the expansion of grant 
programming initiated in recent years by SAMHSA (e.g., Project AWARE) 
and the U.S. Department of Education (School Climate Transformation) 
that require funded States to partner with three local jurisdictions to 
promote student well-being and mental health training and awareness for 
school staff, and then to scale successful efforts statewide.

Policies to Support Early Identification, Intervention, and Treatment 
                    in Schools

      Expand existing Federal workforce development programs (e.g., 
Behavioral Health Workforce Education and Training Program, National 
Health Service Corps, Minority Fellowship Program) to increase the 
school mental health workforce. This strategy can also be applied to 
Federal loan repayment programs by increasing incentives for providers 
who choose schools as a service setting.

      Expand Federal, State, and local funding to ensure adequate 
staffing and professional development for student instructional support 
personnel, including school psychologists, school social workers, 
school counselors and school nurses. Funding expansion could include 
increased investments in title I of the Every Student Succeeds Act 
(ESSA) to provide additional mental health staffing for students living 
in poverty and in title I, title II, and title IV of ESSA and IDEA to 
increase opportunities for professional development. State and local 
investments could include competitive salary and benefits packages to 
recruit and retain school mental health providers and supplementing 
Federal funding for staffing and professional development.

      Require health plans to reimburse for mental health screenings 
conducted in schools. Follow guidance from the American Academy of 
Pediatrics and the American Academy of Child and Adolescent Psychiatry 
to cover universal mental health screening as a mechanism for improving 
mental health and reducing mental illness. Coverage should include 
screening conducted during well-child exams in pediatric primary care, 
and also extended screening conducted in schools.

      Maximize Medicaid, Children's Health Insurance Program (CHIP), 
and private reimbursement for school mental health services, including 
early identification, intervention and treatment. This may include 
better understanding and leveraging existing State Medicaid allowances 
for school mental health or the initiation of State plan amendments to 
improve school mental health coverage. As outlined in the 2019 Joint 
Informational Bulletin from The Centers for Medicaid and Medicare 
Services (CMS) and (SAMHSA), several States already access Medicaid and 
other payers, including private insurers, to cover school and community 
professionals' delivery of mental health services in schools. The 
Centers for Medicaid and Medicare Services (CMS), the U.S. Department 
of Education and the U.S. Department of Health and Human Services could 
offer technical assistance to States seeking to improve Medicaid and 
other payer coverage of school mental health. *

      Expand reimbursement and technical assistance for telemental 
health services in schools. Given the current national shortage of 
mental health specialists, particularly in rural settings, schools will 
benefit from access to telemental health consultation and direct 
service, facilitated by public and private insurance coverage and 
Federal- and State-supported technical assistance.

      Implement accountability mechanisms that require the 
implementation of high-quality, evidence-based practices that align 
with national performance standards for school mental health. Federal, 
State, and local investments should shift their metrics away from 
counting frequency and duration of services to measuring the 
implementation of national best practices for school mental health care 
and impact of school mental health services provision on psychosocial 
and academic outcomes.

    *Additional detail on financing school mental health:

    Successful systems draw from a wide array of sources, including 
(but not limited to) legislative earmarks and Federal block and project 
grants (e.g., Project AWARE State Education Agency Grants), State or 
county funding, fee-for-service revenue from third-party payers 
(including State Children's Health Insurance Programs, Medicaid, and 
commercial insurance), and private individual donors and private 
foundations.

    Of note, Medicaid is the backbone of the school mental health 
system in all 50 States and DC, providing sustainable funding for 
services to students delivered by mental health professionals, 
including school psychologists, school counselors, school social 
workers and more.

    Sixteen States have successfully expanded their school-based 
Medicaid programs to cover services--including mental health--delivered 
in schools to all students. These States have experienced or predict a 
significant increase in Medicaid funding allowing school districts to 
hire more staff and better support the school health and mental health 
professionals in schools.

    Medicaid also allows school districts to set up partnerships with 
community-based mental health providers, like community mental health 
centers. Through these partnerships, schools can increase access to 
services.

    Congress can support student mental health by encouraging all 
States to cover all medically necessary mental health services, 
including prevention services, for all Medicaid enrolled students and 
by ensuring school Medicaid programs have updated guidance, best 
practices, and the technical assistance they need.

                                 ______
                                 
       Questions Submitted for the Record to Sharon Hoover, Ph.D.
               Questions Submitted by Hon. Sherrod Brown
                    school-based mental health care
    Question. In the midst of the pandemic, children and young adults 
have faced unprecedented challenges, ranging from dramatic shifts in 
social interactions and schooling to the tragic loss of family members 
and caregivers, among numerous other struggles. Depressive and anxiety 
symptoms have doubled, with 25 percent of youth experiencing depressive 
symptoms and 20 percent experiencing symptoms of anxiety. In early 
2021, emergency department visits for suspected suicide attempts were 
51 percent higher for adolescent girls and 4 percent higher for 
adolescent boys compared to rates for the same period in 2019. Yet, 
preliminary data show a 32-percent drop in mental health service use 
among children covered by Medicaid and CHIP from March 2020 to February 
2021 compared to the same period in the prior year. Many experts 
attribute this disparity to pandemic-related school closures, which 
limited or suspended access to mental health care through those 
settings.

      1.  As outlined in the 2019 Joint Informational Bulletin from The 
Centers for Medicaid and Medicare Services (CMS) and SAMHSA, several 
States already access Medicaid and other payers, including private 
insurers, to cover school and community professionals' delivery of 
mental health services in schools.

        How can full service community schools \1\ and schools that 
provide comprehensive mental health-care services better coordinate 
with local service providers to meet the needs of students covered by 
Medicaid and CHIP?
---------------------------------------------------------------------------
    \1\ https://oese.ed.gov/offices/office-of-discretionary-grants-
support-services/school-choice-improvement-programs/full-service-
community-schools-program-fscs/.

    Answer. Better coordination between full service community schools 
and schools that provide comprehensive mental health services and local 
services providers is key to meeting the needs of students covered by 
Medicaid and CHIP. Detailed below are best practices States are 
implementing to improve coordination:
Issue Clear Guidance That Encourages Partnerships Between Local Service 
        Providers and School Districts
    Many States do not provide school districts and local service 
providers with guidance to support partnerships. When in place, 
guidance can play a key role in facilitating partnerships and ensuring 
both parties understand the value of collaborating and how to establish 
effective partnerships.

    For example, a key element of Missouri's expansion of their school-
based Medicaid program was the way it encouraged partnerships with 
community-based mental health providers to increase behavioral health 
services in schools.\2\ This leveraged the existing relationships that 
many school districts had with community-based providers, by clarifying 
that these providers can be reimbursed for delivering services in 
schools, as long as they are a qualified Medicaid provider with the 
required licensure and credentials. Partnering with community-based 
providers also offered a route to expanding school-based behavioral 
health services for the many school districts in the State that do not 
participate in the school-based Medicaid program, or had concerns about 
their bandwidth to do additional Medicaid billing.\3\
---------------------------------------------------------------------------
    \2\ Missouri Department of Social Services, Behavioral Health 
Services in a School Setting, https://dss.mo.gov/mhd/providers/pdf/
bulletin40-54_2018apr17.pdf.
    \3\ Healthy Schools Campaign, Expanding School-Based Medicaid in 
Missouri, https://drive.google.com/file/d/
1cWfagNHY_tuxD7PbI_Iqbnk8uAMU7cmn/view.

    The National Center for School Mental Health (NCSMH, 
www.schoolmental
health.org), funded by the U.S. Department of Health and Human 
Services, Health Resources and Services Administration, established 
national performance standards for school-community teaming. The NCSMH 
issued the corresponding School Mental Health Systems Quality Guide: 
Teaming,\4\ providing States and districts guidance and tools for 
establishing effective school-community partnerships that leverage 
multiple funding resources, including Medicaid. As outlined in the 
Guide, a process that has been successful in many communities to foster 
school-community partnerships is the establishment of a request for 
proposals (RFP) issued by school districts to solicit engagement of 
community behavioral health partners with clear expectations for 
school-based service provision, data gathering, target outcomes, and 
funding.
---------------------------------------------------------------------------
    \4\ National Center for School Mental Health, School Mental Health 
Quality Guide: Teaming, https://www.schoolmentalhealth.org/media/SOM/
Microsites/NCSMH/Documents/Quality-Guides/Teaming-7.16.21.pdf.
---------------------------------------------------------------------------
Facilitate Data Sharing Between Local Service Providers and School 
        Districts
    Ensuring data, both aggregated and disaggregated, can be shared 
between local services providers and school districts is needed to 
support care coordination and ensure the children in greatest need of 
services are identified and supported. Multiple States are taking steps 
to facilitate data sharing across child serving agencies to better 
target services and supports.

    For example, the District of Columbia improved coordination and 
service delivery by implementing a data sharing agreement between the 
District of Columbia State Board of Education, District of Columbia 
Department of Health, and the DC Department of Health Care Finance (the 
District of Columbia's Medicaid agency). The agencies collaborated to 
ensure compliance with the Family Educational Rights and Privacy Act 
and used the data to target outreach and resources to schools and 
students with the greatest unmet needs.\5\
---------------------------------------------------------------------------
    \5\ Healthy Schools Campaign, Sharing Data to Meet Student Health 
Needs in Washington, DC, https://healthyschoolscampaign.org/blog/
sharing-data-meet-student-health-needs-washington-d-c/.

    The State of Connecticut partnered with a purveyor organization, 
the Child Health and Development Institute (CHDI, www.chdi.org), to 
establish a statewide electronic platform, the EBP Tracker, to collect 
data on evidence-based interventions being delivered in schools and 
other community settings. Results from their analyses show that the use 
of EBPs delivered in schools resulted in improved psychosocial and 
educational outcomes and reduced or eliminated disparities for children 
of color compared to usual care.\6\
---------------------------------------------------------------------------
    \6\ Child Health and Development Institute, EBP Tracker, https://
www.chdi.org/our-work/mental-health/evidence-based-practices/ebp-
tracker/.

    Additional examples and best practices for data sharing between 
community providers and school districts are available in Data Sharing 
Across Child-Serving Sectors: Key Lessons and Resources, a report by 
Nemours Children's Health System and Mental Health America.\7\
---------------------------------------------------------------------------
    \7\ Data Sharing Across Child-Serving Sectors: Key Lessons and 
Resources, Nemours Children's Health System and Mental Health America, 
https://www.movinghealthcareupstream.org/wp-content/uploads/2020/01/
data-sharing-brief.pdf.
---------------------------------------------------------------------------
Leverage Telehealth to Connect School Districts With Local Service 
        Providers
    Across the country, telehealth is increasingly being used to 
connect students to local service providers to ensure they receive 
necessary school health services. The partnerships require coordination 
between all parties and create an important opportunity to amplify the 
impact of available providers.

    For example, in 2016, South Carolina's Governor signed S.B. 1035 
into law to increase access to telehealth, including in schools. As of 
2019, the State's telehealth program has expanded to over 80 schools, 
focusing on schools with students who experience the greatest health 
disparities. The South Carolina Department of Education and South 
Carolina Medicaid were key in expanding telehealth services. Through 
the telehealth program, school nurses are linked with community 
providers to coordinate acute and chronic disease management services 
as well as mental health services.\8\
---------------------------------------------------------------------------
    \8\ Building a School-Based Telehealth Program in South Carolina, 
Healthy Schools Campaign, https://healthystudentspromisingfutures.org/
wp-content/uploads/2019/07/SouthCarolinaTele
healthCaseStudy.pdf.

    Question. In your testimony, one of the policies you recommend to 
better support early identification, intervention, and treatment in 
schools is to ``maximize Medicaid, CHIP, and private reimbursement for 
---------------------------------------------------------------------------
school mental health services.''

    Can you please elaborate on this recommendation?

    Answer. Sustainable funding streams are critical to better 
supporting early identification, intervention and treatment in schools. 
Currently, school districts fund the delivery and implementation of 
these services and programs through a patchwork of funding, often 
including one-time grant funds that are not sustainable and time-bound. 
Supporting States and school districts in leveraging health-care 
funding to deliver this work is necessary to fully leverage the role 
schools can play in meeting the mental health needs of children and 
youth.

    Currently, many school districts access Medicaid and CHIP funding 
to support the delivery of school health services but very few are able 
to access private insurance since private insurers rarely recognize 
schools as eligible sites of service delivery. When it comes to 
Medicaid and CHIP funding, only 16 States allow school districts to 
bill Medicaid for services delivered outside of an Individualized 
Education Program (IEP). Since early identification and intervention 
services are rarely included in a students' IEP, there is a need to 
ensure the remaining 34 States and the District of Columbia expand 
their school Medicaid programs to allow school districts to bill for 
all medically necessary services delivered to all Medicaid enrolled 
students.

    Community-based and community-linked providers, including school-
based health centers, also bill Medicaid and CHIP for eligible services 
and are better positioned to seek reimbursement from private insurers. 
However, there is still a need to support these providers in maximizing 
funding for services delivered in schools since providers may not 
understand they can bill insurance for school health services, 
understand how to bill, or understand how to establish partnerships to 
deliver these services. Ensuring community-based and community-linked 
providers understand the opportunities for reimbursement is critical to 
supporting partnerships between school districts and outside providers 
and meeting student mental health needs.

    Question. Would you suggest the Centers for Medicaid and Medicare 
Services (CMS) and the U.S. Department of Education provide best 
practices to States seeking to improve Medicaid and other payer 
coverage of school mental health, in addition to offering technical 
assistance?

    Answer. Yes, there is a tremendous need for best practices to 
support States and school districts in leveraging Medicaid and other 
payer coverage and for additional technical assistance. In our work and 
the work of partners with States and school districts across the 
country, the need for best practices and technical assistance continue 
to emerge as top requests of CMS and the U.S. Department of Education.

    A best practices document that highlights the different ways States 
and school districts are leveraging Medicaid funding and funding from 
other payers to expand access to school mental health services and 
programs can help break down siloes that exist between Medicaid and 
education and ensure States and school districts understand the menu of 
options for structuring their school Medicaid programs.

    Question. As you state in your testimony, Medicaid is the backbone 
of the school mental health system, and helps school districts 
establish partnerships with other community-based mental health 
providers which help increase access to services for students and the 
broader community.

    Can you please elaborate on the 16 States that have successfully 
expanded their programs to cover services in schools? What are their 
best practices for using Medicaid to build out services, hire 
additional staff, and meet children where they are?

    Answer. There are now 17 States that have successfully expanded 
their school Medicaid programs: Arkansas, Arizona, California, 
Colorado, Connecticut, Florida, Georgia, Kentucky, Louisiana, Maine, 
Michigan, Minnesota, Missouri, North Carolina, New Hampshire, Nevada, 
and South Carolina.\9\ In addition, Illinois, Indiana, New Mexico, 
Oregon, and Virginia are in the process of expanding their school 
Medicaid programs. All 50 States and the District of Columbia have 
school Medicaid programs that allow school districts to seek Medicaid 
reimbursement for Medicaid eligible services included in a student's 
Individualized Education Program (IEP) or Individualized Family Service 
Plan (IFSP). The 17 States that have expanded their programs allow 
school districts to bill for additional services not included in a 
student's IEP or IFSP. In the majority of these States, this means 
allowing school districts to bill Medicaid for all medically necessary 
services delivered to all Medicaid enrolled students. Expanding school 
Medicaid programs to include services delivered outside of students' 
IEPs or IFSPs presents a significant opportunity to increase access to 
and resources for school mental health services.
---------------------------------------------------------------------------
    \9\ State Efforts to Expand School Medicaid Through the Free Care 
Policy Reversal, Healthy Schools Campaign, http://bit.ly/
freecareupdate.

    The majority of the 17 States that have expanded their school 
Medicaid programs did so in the last 3 years. As a result, 
implementation and documentation of the impact of this policy change 
was impacted by COVID-19 and the resulting school building closures. 
For many States, the 2021-2022 school year was the first full year of 
program implementation. As a result, data is still being collected on 
the overall impact. With that being said, initial data and projections 
are promising and indicate a significant increase in Medicaid revenue 
generated by the program and, in many cases, an increase in school 
health providers. For example, Michigan is one of the 16 States that 
has expanded their program. The State has been able to use the increase 
in Medicaid funding, coupled with an investment from the State, to go 
from 1,738 school-based behavioral health providers statewide to 2,975 
school-based behavioral health providers statewide and increased school 
nursing staff from 253 to 307.\10\
---------------------------------------------------------------------------
    \10\ U.S. Department of Education, Supporting Child and Student 
Social, Emotional, Behavioral, and Mental Health Needs, https://
www2.ed.gov/documents/students/supporting-child-student-social-
emotional-behavioral-mental-health.pdf.

    Best practices for using Medicaid to build out services, hire 
additional staff, and meet children where they are include the 
---------------------------------------------------------------------------
following:

        Align State education and State Medicaid qualifications for 
school health providers. Many States are working to align their State 
education and State Medicaid standards to ensure all qualified school 
health providers are recognized as Medicaid eligible. This is a key 
strategy to ensure that school districts are able to maximize Medicaid 
reimbursement for the school Medicaid program and to incentivize school 
districts to hire qualified school mental health professionals. For 
example, States are increasingly adding marriage and family therapists, 
behavior health analysts, registered behavior technicians and alcohol 
and drug counselors as Medicaid eligible in the school-based setting. 
Recognizing all qualified mental and behavioral health providers as 
Medicaid eligible in the school-based setting is a key strategy to 
ensuring schools are able to maximize the available mental health 
workforce and receive sustainable funding to support access to these 
providers in the long run.
        Invest in State infrastructure to support implementation. 
States with strong State infrastructure to support implementation of 
the school Medicaid program are able to better leverage Medicaid funds 
to expand access to school health services. This infrastructure 
includes training for school districts on program implementation, a 
designated website to house all program related materials, ongoing 
technical assistance for school districts including regular trainings 
and help desks and technology platforms, including those that support 
the use of telehealth and electronic health records.
        Build cross-agency collaboration. Dedicated school Medicaid 
staff in both the State education agency and State Medicaid agency 
level who can collaborate to implement a State's school Medicaid 
program is critical. The States that have the strongest school Medicaid 
programs are those with dedicated school Medicaid staff in both the 
State education agency and State Medicaid agency who can coordinate 
program implementation, oversee training and technical assistance and 
collaborate to develop program resources. For example, Louisiana was 
the first State to expand their school Medicaid program and has used 
the additional Medicaid revenue, in addition to COVID relief funding, 
to hire dedicated staff in both the State education and State Medicaid 
agencies to oversee the program. In addition, the State agencies have 
worked together to build out a school Medicaid resource library to 
support school district implementation.\11\
---------------------------------------------------------------------------
    \11\ Louisiana Department of Education, School-Based Medicaid 
Resources, https://www.louisianabelieves.com/schools/public-schools/
school-based-medicaid-services.
---------------------------------------------------------------------------
        Reinvest school Medicaid revenue in school health and wellness 
programs: In many States, revenue generated by the school Medicaid 
program goes to school districts' general revenue fund and is not 
required to be reinvested in school health and wellness programs and 
services. A few States, including California, Colorado, and Louisiana, 
require revenue generated by the school Medicaid program be reinvested 
in school health and wellness activities. This is a key strategy to 
ensure additional Medicaid revenue ultimately supports school health 
and wellness and is used to strengthen and expand the delivery of 
school health services.

    Question. What can the other 34 States learn from what these 16 
States are doing well?

    Answer. In addition to the best practice highlighted above, the 
States that have not expanded their programs to date can learn the 
following from those that have:

        States should expand their programs to cover all medically 
necessary services delivered in the school-based setting. States are 
amending their State Medicaid plans to allow school districts to bill 
Medicaid for services delivered to Medicaid enrolled students that are 
included in an IEP, IFSP, 504 plan, other individualized health or 
behavioral health plan, or where medical necessity has been otherwise 
established. This is important because it allows States and school 
districts the flexibility to cover all the services a student may need 
that can be provided in a school-setting by a qualified provider. 
Further, it signals that the school is simply the site of service at 
which a Medicaid enrolled student can get care--rather than as a unique 
benefit. CMS has been highly supportive of States making this change.
        States should include the school Medicaid program under the 
Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) 
benefit. Under the advice of CMS, States are recognizing their school 
Medicaid programs as a part of their EPSDT benefit. This is an 
important change that enables school districts to bill for any EPSDT 
service delivered by any Medicaid enrolled provider recognized under 
EPSDT.
        Cross-agency coordination is key to successful expansion and 
implementation. As States move forward with expanding their school 
Medicaid program it is critical that one agency does not lead this work 
alone. While the Medicaid State plan amendment must ultimately be 
submitted by the State Medicaid agency, States are best setup for 
success when the State Medicaid agency collaborates with the State 
education agency to make policy decisions and ideally collects input 
from school districts as well. It is also critical that the State 
education agency plays an active role in implementation of the expanded 
program, including supporting school district training and 
communicating with school districts about the programmatic changes.

    Question. How can Congress support and encourage more States to 
expand their school-based Medicaid programs to cover more services, 
including mental health services?

    Answer. Congress can support school Medicaid by working with CMS to 
modernize the existing school guidance and promoting best practices in 
school Medicaid, including in prevention and mental health services. 
CMS' school Medicaid guides were last updated in 2003 and 1997. Updated 
guidance is key to ensuring States and school districts understand how 
to implement the school Medicaid program without exposing themselves to 
risk of audit. A number of States are hesitant to move forward with 
expanding their school Medicaid programs because the current guides 
from 1997 and 2003 explicitly state that schools cannot bill Medicaid 
for services delivered outside of an IEP or IFSP. While this position 
was clearly changed with a 2014 State Medicaid directors letter, States 
are hesitate to move forward until guidance is updated to reflect this 
policy change.\12\
---------------------------------------------------------------------------
    \12\ Centers for Medicare and Medicaid Services, Medicaid Payment 
for Services Provided Without Charge (Free Care), https://
www.medicaid.gov/federal-policy-guidance/downloads/smd-medicaid-
payment-for-services-provided-without-charge-free-care.pdf.

    Additional ways in which Congress can support and encourage States 
---------------------------------------------------------------------------
to expand their school-based Medicaid programs include the following:

        Provide funding to CMS for the establishment of a technical 
assistance center to support States and school districts who want to 
improve the delivery of Medicaid mental health services in schools.
        Provide funds to States to work with small and rural school 
districts to do planning and technological improvements to participate 
in school Medicaid.
        Provide an increased FMAP for any mental health service 
delivered in a school-based setting by a district-employed provider or 
a community-based provider.

                                 ______
                                 
Prepared Statement of Jodie L. Lubarsky, M.A., LCMHC, Vice President of 
Clinical Operations, Youth and Family Services, Seacoast Mental Health 
                              Center, Inc.
    Chairman Wyden, Ranking Member Crapo, Senator Hassan, and members 
of the U.S. Senate Committee on Finance, I want to thank you for the 
opportunity to testify and submit a written statement regarding 
pediatric mental health.

    In March of 2020, life as we once knew it changed for all of us. As 
adults, we made many quick pivots to respond and adapt to the COVID-19 
pandemic. As we made many adaptations in both our personal and 
professional lives, we had our past experiences to reflect upon. When 
faced with the new and often unpredictable challenges the pandemic 
created, we pulled from our toolbox of coping strategies. We knew who 
we could turn to for the extra support we might have needed as we 
navigated those challenges. But, for most of the youth in our country, 
they were left feeling paralyzed, stymied, hopeless, and scared. For 
many youth, this was their first experience with grief, trauma, 
depression, or anxiety. Life for them had completely changed and their 
worlds were turned upside down. The uncertainty, social isolation, and 
stressors related to the pandemic, have left many kids unable to cope 
or understand the breadth and depth of this experience. For some youth, 
there is no trusted adult to support them during this critical 
developmental period. Many lack a social support network. Many remain 
isolated from peers and other trusted adults. And, for too many youth, 
their only means of symptom relief is contemplating death.

    We are learning that teenage girls have begun to demonstrate an 
increase in the acuity of their symptom presentation. Data from the 
Centers for Disease Control and Prevention indicates a 51 percent 
increase in suicide attempts by teenage girls ages 12 to 17. LGBTQ+ 
youth continue to have higher rates of suicide than their heterosexual 
peers. And, according to a Wisconsin NPR piece in March 2021, data from 
2020 demonstrated that ``the percentage of emergency department visits 
for mental health emergencies rose by 24 percent for children between 
the ages of 5 and 11 and 31 percent for those 12 to 17, compared with 
2019.'' Youth mental health has become the secondary pandemic to the 
COVID-19 pandemic.

    As mental health needs rose for pediatric patients, the 
availability of services continues to become more scarce. Youth are 
presenting to hospital emergency rooms in a state of psychiatric 
crisis. Many who are assessed and meet the criteria for psychiatric 
inpatient level of care will be faced with boarding in an emergency 
room for days, weeks and sometimes months until a bed becomes 
available. Emergency room boarding often creates more distress, 
decompensation in psychiatric symptoms, and increased traumatic 
exposure, while receiving no mental health care until the inpatient bed 
becomes available. Staffing shortages in both outpatient and inpatient 
settings due to an exhausted, depleted, and underpaid mental health 
workforce has only prolonged access to care for pediatric patients. 
Without adequate funding and reimbursement structures from both 
Medicaid and private payers, mental health providers are left with the 
difficult decision to leave the nonprofit world and enter the for-
profit world in order to make a livable wage. During the pandemic, 
there were two 3-percent increases to Medicaid rates.

    And while that is appreciated, prior to those two increases there 
had not been meaningful increases in Medicaid rates in over 20 years. 
Without a realistic reimbursement structure based on current cost of 
living, centers are losing staff who can no longer afford to work in 
mental health settings. Some mental health centers are reporting a 40-
percent turnover in staffing, during the pandemic, leaving no workforce 
available to attend to the critical and fragile needs of pediatric 
patients. And for the mental health workforce that remains, they are 
often left supporting higher caseloads than their private practice 
peers, with limited time while attending to significant administrative 
tasks that private mental health providers are not expected to 
complete.

    While we can discuss an ideal service array, evidence-based 
practices, and the ideal care setting, none of this can be provided 
without a robust, well-trained, adequately compensated, and sustainable 
mental health workforce from all professional disciplines and degree 
levels. Simply put, we need to be able to adequately compensate the 
mental health workforce in order to have a sustainable and robust 
mental health workforce to provide high-quality, timely, adequate care 
to our pediatric population.

    Mental health care needs to be both accessible and realistic. A 
continuum of care must include prevention, intervention, and education. 
As schools return to in-person learning environments, teachers, 
paraprofessionals, guidance counselors, and building administrators are 
witnessing the exacerbated mental health needs of the students entering 
school buildings every day. Faced with the added pressures of testing 
students and overwhelming them with missed academic instruction, 
teachers report feeling professionally stretched and uncertain of how 
to support the social and emotional health needs of students. Teachers 
are not provided training on pediatric mental illness. Teachers do not 
know how to intervene. A component of prevention should be affording 
schools the professional development time needed to better understand 
pediatric mental health and for educators to become certified in Youth 
Mental Health First Aid. Youth Mental Health First Aid would provide 
educators with a foundational understanding of the signs and symptoms 
of an emerging mental health need, how to offer timely support, and 
bridging a student to the appropriate mental health professional and 
level of care to attend to the student's mental health needs.

    There is no one-size-fits-all option for mental health care. The 
pandemic created the opportunity to reduce barriers to accessing care 
with the expansion of telehealth services. In addition to telehealth, 
mental health care provided in the office, home, community, and school 
settings needs to be supported and adequately reimbursed for by both 
Medicaid and private payers. Different levels of care need to exist 
within the intervention continuum. Traditional office-based therapy 
does not meet all mental health needs and not all pediatric mental 
health patients will require an inpatient level of care. Intensive 
outpatient or partial hospitalization programs need to be established 
and adequately funded to be sustained in the mental health treatment 
continuum. Mental health providers should be adequately reimbursed by 
all payers to sustain a variety of treatment and programming options. 
And, evidenced-based practices should be reimbursed at enhanced rates 
to account for the required clinical consultation, professional 
development, and time to complete required fidelity implementation 
reviews.

    A bipartisan spirit to adequately fund pediatric mental health 
services is one of many ways to address the growing pediatric mental 
health surge. Care must be affordable, available, and mental health 
providers must be adequately reimbursed to sustain a mental health-care 
workforce. Telehealth and telephonic services must remain an option 
within the service array to reduce barriers to accessing care, but not 
be the primary option for care delivery. But we must erase the stigma 
associated with mental illness to make a meaningful impact! The stigma 
and shame that continues to persist for individuals struggling with 
mental illness continues to be a significant barrier to recognizing the 
need for and accessing mental health care. Respect, compassion, and 
patience must be afforded to every person struggling with their mental 
health. We must all act as ambassadors for reducing the stigma 
associated with having a mental illness and accessing appropriate care. 
One in five individuals will struggle with a serious mental illness, 
yet most individuals will delay accessing care for 10 years after the 
onset of symptoms. Fifty percent of all lifetime mental illness begins 
by age 14 and 75 percent by age 24. We have an obligation to provide 
prevention and early intervention and to offer hope and recovery for 
all children and adolescents struggling with their mental health. We 
know that suicide is the second leading cause of death among people age 
10-34, yet we continue to stigmatize those who seek care. We continue 
to shame those with struggle. Until we can acknowledge, treat, and 
offer respect to all individuals with mental illnesses and offer mental 
health patients the same respect we would provide any individual 
receiving care for a physical health issue, we will never be able to 
make a meaningful difference. We all need to challenge the stigma that 
persists. We all need to advocate on behalf of those who are struggling 
with their mental health because at any moment, they could be us, our 
child, or a loved one.

                                 ______
                                 
  Questions Submitted for the Record to Jodie L. Lubarsky, M.A., LCMHC
               Questions Submitted by Hon. Sherrod Brown
                    school-based mental health care
    Question. In the midst of the pandemic, children and young adults 
have faced unprecedented challenges, ranging from dramatic shifts in 
social interactions and schooling to the tragic loss of family members 
and caregivers, among numerous other struggles. Depressive and anxiety 
symptoms have doubled, with 25 percent of youth experiencing depressive 
symptoms and 20 percent experiencing symptoms of anxiety. In early 
2021, emergency department visits for suspected suicide attempts were 
51-percent higher for adolescent girls and 4-percent higher for 
adolescent boys compared to rates for the same period in 2019. Yet, 
preliminary data show a 32-percent drop in mental health service use 
among children covered by Medicaid and CHIP from March 2020 to February 
2021 compared to the same period in the prior year. Many experts 
attribute this disparity to pandemic-related school closures, which 
limited or suspended access to mental health care through those 
settings.

    Teachers, staff, and faculty are often the first line of defense 
when identifying signs of mental distress in a student.

    What structural supports can schools adopt so that educators are 
better equipped to conduct regular student well-being check-ins and 
identify and support students exhibiting signs of mental distress or 
trauma, including signs of Adverse Childhood Events (ACEs)?

    Answer. As a mental health provider within a community mental 
health center, we have been able to partner with schools in our region 
to deliver mental health services to students during their academic 
day. It has offered insight into both the needs of the students and 
what the education staff encounter when providing instruction.

    When considering the structural supports that a school may need to 
adopt in order to better equip themselves to support student well-
being, we must begin with better education to community members, school 
boards, administrative leaders, and parents about pediatric mental 
health. There seems to be a large cohort of individuals who do not 
understand that one in five children will be diagnosed with a mental 
health condition or that 40 percent of all mental health needs arise 
during childhood and adolescence. These community members have failed 
to recognize the importance of early intervention as a tool for 
preventing long-term mental health decompensation in children. Simply 
stated, the sooner we intervene the greater opportunity for recovery. 
As a result, schools in our State report having to change their consent 
to provide mental health care in schools from using language that says, 
``mental health'' to ``behavioral health'' due to community protests. 
Rather than utilizing an opt-in process for participation, schools are 
shifting to opt-out language in consent for participation forms. When 
community members create barriers to providing care in school settings, 
it seems to leave very few options for interventions. In an ideal 
world, all guardians of children enrolled in public and private school 
settings would be required to participate in social emotional programs 
to provide them with a foundational understanding of pediatric mental 
health, signs and symptoms, and treatment options for pediatric 
patients. Programs would be targeted at erasing the stigma, so schools 
and mental health providers can deliver care without barriers or 
interruption. Utilizing evidenced-based universal screeners like the 
PHQ-9 or Brief Columbia Suicide Severity Rating Scale will allow for 
early identification of a student's needs and an opportunity to bridge 
the student to mental health supports outside of the school setting in 
an informed manner. This early identification would provide early 
assessment of adverse childhood experiences and an opportunity to 
provide clinical and social supports to pediatric patients. When 
schools adopt the usage of screeners used by pediatricians and mental 
health-care providers, it allows them to speak a common language with 
those professional in order to support pediatric mental health needs 
and refer patients to the most appropriate level of care.

    Question. What tools, resources, and guidance are necessary to 
ensure schools meet current student needs and adopt a model of 
prevention moving forward?

    Answer. I must acknowledge that my background is not one of 
academics but of community mental health. As someone who has worked 
with schools in my current role for over 15 years and more specifically 
reflecting upon the last 2 years, it appears schools could use more 
support on the implementation of social emotional programs in academic 
settings. Educators in our community have reflected on the significant 
pressure they are facing to catch students up on the academics that 
they may have been lost during the pandemic. They report pressure from 
school boards, administrators, and caregivers to force an accelerated 
style of learning in order to cover missed material and increase test 
scores. Many educators report having no background or knowledge about 
pediatric mental health care, yet they see the mental health needs of 
their students walk into their classrooms every day. They report a 
frequent dilemma of trying to support unique emotional needs without 
foundational mental health training and the stress of administrating 
assessment exams while trying to complete their classroom instruction.

    A clearinghouse for educators similar to Substance Abuse and Mental 
Health Services Administration that mental health-care providers use 
that recommends 
evidence-based social emotional programs for schools that are 
culturally and linguistically considerate of the unique pediatric 
emotional and developmental needs will allow districts to select 
programming that can be braided into academic curriculums without 
directly disrupting academics. Schools should be viewed as a component 
of the prevention spectrum. Schools should consider their role to 
identify pediatric mental health needs in students as an opportunity to 
bridge a student over to structured mental health-care supports. 
Programs like Project AWARE that utilize multi-tiered systems of 
identification and support in collaboration with mental health-care 
providers allows schools to play a role in pediatric mental health care 
without having to deliver all the mental health supports that a student 
might need, especially since many educators and guidance counselors do 
not have the same training can mental health-care providers to diagnose 
and treat mental illness.

    Training all educators, paraprofessionals, auxiliary staff, and 
building administrators in Youth Mental Health First Aid is another 
component of prevention spectrum. YMHFA trains adults to recognize 
signs and symptoms, strategies for offering support, and bridging a 
youth and their family to appropriate mental health services when the 
need arises. It provides the foundational understanding that many 
educators lack and would offer much needed training and resources to 
those adults who might be the first point of contact for a student 
experiencing a mental health crisis in the classroom, on the 
playground, in the cafeteria, or at after school activities.

    Question. What resources, technical assistance, or other supports 
can Congress provide to attract and retain high-quality, certified 
mental health providers in schools, particularly in low-income areas?

    Answer. As Congress considers more resources, technical assistance, 
or other supports to attract and retain high quality certified mental 
health providers, Congress should continue to support and expand loan 
forgiveness programs. While the Student Loan Repayment Program (SLRP) 
has been helpful, access by professionals has been limited. With a 
limited number of eligible spots and funding, not every professional 
who could be eligible is able to access the program when the funding 
has been exhausted. Increased funding to SLRP and creating more 
eligibility opportunities for staff employed in settings than serve 
disadvantaged populations would attract and retain more staff based on 
the forgiveness expectations of the SLRP. Many staff view the 
forgiveness of their student loans as a benefit when considering 
employment in non-profit settings. For many staff, after completing 
their forgiveness expectation, they continue to remain employed at the 
organization and take advantage of additional educational or 
professional development opportunities.

    Creating a deliberate crosswalk between higher education settings 
and mental health centers that offer accessible and affordable 
education at both the bachelor's and master's level would assist in 
attracting and retaining staff. For full-time employees who need to 
continue working while attending school, being able to access their 
academics in their work environments promotes and supports professional 
development. This concept of offering class work on-site at 
organizations also creates a direct funnel of internship candidates who 
then can become employed at those organizations. Two goals are 
achieved: (1) The employee achieves a higher education degree without 
financial or occupational disruption, and (2) the employer has access 
to a pool of mental health-care candidates for the mental health 
workforce. When considering educational opportunities for mental 
health-care professionals, a structure needs to be created to offer 
paid internships. Most bachelor's and master's level interns are not 
compensated for their internship experiences. They are often faced with 
going to school full-time and engaging in a meaningful internship, 
while potentially maintaining part- or full-time employment to meet 
their basic needs.

    The opportunity to pay interns is impacted by funding and 
reimbursement rates. Although there were two 3-percent increases to 
Medicaid rates in the past 2 years, there had not been meaningful rate 
increases in over 20 years. Mental health services should be reimbursed 
at rates that are competitive with a private practice market to allow 
employers to offer competitive wages to the mental health-care 
workforce if the workforce is to be sustained. A colleague reported 
that at her center, staff at the bachelor's level can make more working 
in the retail market than they can delivering behavioral supports to 
pediatric patients. Over the past 2 years, Centers report a rolling 
turnover rate in staffing of 40 percent. Staff often cite poor wages, 
stress, and administrative burdens associated with mental health-care 
documentation as reasons for seeking other employment, often outside of 
the mental health-care field.

    Increasing reimbursement rates and compensating providers for non-
billable events related to the implementation of Evidence-Based 
Practices (EBPs) are two considerations for sustaining the workforce. 
While EBPs are highly beneficial, they are expensive in relation to 
nonbillable activities involved with implementation and ongoing 
utilization. True implementation of an EBP is more than providing a 
staff person with a manual and setting them off to their office to 
provide the work if we want to guarantee that it is done correctly and 
to fidelity. For most EBPs, in order to practice to fidelity, there 
should be weekly consultation with a trained expert, on-going review of 
the materials that are used for the EBP during and outside of 
consultation, preparation time by the practitioner for sessions, data 
collection, and a lengthy fidelity review process with expert trainers. 
None of these activities are eligible for reimbursement and often 
create drift from EBP utilization.

                                 ______
                                 
        Prepared Statement of Trace Terrell, Lead Intervention 
                   and Outreach Specialist, YouthLine
    Thank you, Chairman Wyden, Ranking Member Crapo, and the other 
members of the committee, for the opportunity to represent the youth 
perspective as it pertains to mental health.

    My name is Trace Terrell, I use he/him pronouns, and I am a 17-
year-old from Oregon. Before I share more about myself, I would first 
like to tell you some things I have heard from teens across the 
country: 4:07 p.m.: I just need someone to talk to; 4:37 p.m.: my dad 
hit me but you can't call the cops; 9:45 p.m.: I'm afraid I might be 
pregnant; 5:23 p.m.: I need therapy but my family can't afford it; 6:28 
p.m.: I just failed my math test; 8:07 p.m.: I just lost my dad and I 
can't stop crying; 6:42 p.m.: I want to kill myself.

    These are just some examples of the many conversations that I 
respond to as a volunteer with YouthLine, a free, confidential, teen-
to-teen crisis help support hotline located in Oregon. Whether helping 
someone navigate complicated feelings about their sexuality or working 
with others to develop comprehensive safety plans, I spend 3\1/2\ hours 
every week responding to a variety of mental health challenges 
experienced by teens across the country, with an emphasis on the fact 
that no problem is ever too big or too small.

    I became involved with YouthLine during my freshman year of high 
school. As someone who struggled with depression, suicidal ideation, 
eating disorder behavior, and anxiety throughout middle and early high 
school, I, for the longest time, believed that no one could relate to 
my experiences. However, as I became more involved with YouthLine, I 
began to see my challenges reflected in those who contacted the line. 
Whether it was the shared experience of wishing to wake up straight or 
the common struggle of access to care, I realized that my challenges 
were a microcosm of public health issues that affected hundreds of 
thousands of teens across the country.

    As more and more teens start to have conversations about mental 
health and engage in help-seeking behaviors, the need for expansive and 
intersectional mental health efforts has never been so needed. Since 
YouthLine's inception, we have experienced an annual increase in 
contact volume of about 15 percent annually, with an additional 
increase of 3 percent-5 percent since the COVID-19 pandemic started 2 
years ago.

    So, what can we do to address the youth mental health crisis?

    1. We must centralize our efforts in schools.

    From my experience and many of my peers, mental health efforts in 
schools are lacking. Day after day, I hear my friends and those on the 
line voice about how inaccessible school counselors are due to being 
overworked and overloaded. This is an especially difficult challenge 
for the many teens who rely on school mental health professionals for 
crisis care. We must either provide funding for more mental health 
professionals or funding for additional staff who can assume some of 
the overwhelming workload placed on counselors.

    We must also create a streamlined approach to free mental health 
screenings and referrals. At my school, four out of every five 
referrals to external resources are not carried out. Let that sink in: 
80 percent of referrals go nowhere. Someone who needs help, should 
receive help. We need funding for schools to develop meaningful and 
sustainable partnerships with School-Based Health Centers, CCBHCs, 
county and State governments, community organizations, and primary care 
facilities.

    Last, we need to provide funding and technical support for State 
mental health education standards. In ninth grade, my health class 
spent less than a week on our mental health curriculum that only 
addressed the symptoms of mental illnesses. Students should learn about 
engaging in real-world help-seeking behaviors, developing systems of 
self-care, and supporting our friends with mental health struggles, 
because statistics show we turn to each other before anyone else. That 
can only be done with a comprehensive and evidence-based mental health 
curriculum that invites the active participation of school, community, 
and youth leaders.

    2. We need to address the pressing challenges that young people 
continue to face in accessing mental health care.

    While I'm no expert in policy solutions, I am someone with lived 
experience. I know what it's like to be a teen--today--struggling with 
mental health. And I know what it's like to offer support to teens in 
crisis.

    On and off the lines, the most common struggles I see expressed by 
my peers in regard to accessing mental health care are: (1) financial, 
transportation, and broadband barriers; (2) the urban/rural divide in 
mental health care; (3) the lack of mental health professionals and 
adequate follow-through care; and (4) the stigma around mental health.

    These issues are incredibly real.

    When I sought help from a mental health professional, my options 
were limited. In my rural community, there is only one State-funded 
behavioral health clinic. While I was able to attend virtual 
appointments, I'm not sure I would have been able to get the help I 
needed without Telehealth. For someone who lives on the outskirts of 
town like I do, coordinating safe transportation would have been a 
challenge.

    Sadly, my experience isn't isolated. My friends have struggled to 
receive professional mental health services because it's too expensive 
for their families, not covered entirely by their insurance, too far 
away to be accessed, or inaccessible because of unreliable Internet 
access. Financial, transportation, and broadband barriers are even more 
prevalent and intensified in rural areas, which is why we need funding 
for isolated communities to develop robust mental health 
infrastructure. Most importantly, we need to bring care to where people 
are--and for teens, that's in schools or at home. We must fund 
accessibility before we fund new initiatives.

    In addition, the lack of mental health professionals and adequate 
follow-through care prevents teens from receiving the help they need. 
On the lines, we often have people who reach out more than once, 
whether that's between therapy appointments or simply because there is 
no one in their lives they can go to for support. Although YouthLine is 
a crisis service and not meant for long-term care, we're often some 
teens' first step in accessing professional mental health services.

    We know from a study of the National Suicide Prevention Lifeline 
that about 18 percent of the 2 million people who call every year are 
under 25 years of age, which means there are about 360,000 young people 
reaching out for help. We also know that teens are more likely to talk 
to teens. One of the ways we could approach the lack of mental health 
professionals is by funding a national YouthLine. What youth need is to 
be able to call the National Suicide Prevention Line, press a number, 
and have the opportunity to connected with another trained teen. Think 
of it as an off-ramp like the Veterans Crisis Line.

    Finally, addressing the stigma around mental health means building 
on our existing efforts and encouraging people with lived experience to 
share their stories. I share my story to ensure others in similar 
situations know that they're not alone. However, too often our lived 
experiences are overlooked in legislative work. We must make every 
effort to invite and incorporate personal storytelling in this work.

    3. We must invite youth to the table and value their insights as 
natural partners in this work.

    I am just one of 165 YouthLine volunteers.

    What does that tell you?

    Youth aren't afraid to talk about mental health--if anything, 
adults are.

    Across the country, young people are mobilizing and advocating for 
mental health like never before. Beyond YouthLine, I have been involved 
with organizations like Active Minds, through whom I and millions of my 
peers help to change the narrative for how we talk about, value, and 
seek care for our mental health. I have also been able to serve as part 
of the National Mental Health Advisory Board, facilitated by Well Being 
Trust, Young Invincibles, and Active Minds. During my time, I helped to 
guide the development of a digital mental health advocacy toolset to 
empower future youth mental health leaders in enacting change on a 
local, State, and national level. In all of this, I have seen my peers 
speak at school board meetings about the importance of mental health 
excused absences, foster upstream suicide prevention in elementary and 
middle schools, and meet with local and State legislators.

    We believe in the power of peer-to-peer mental health support.

    We believe in the power of robust, youth-led mental health 
coalitions.

    We believe in the power of our generation to create meaningful and 
sustainable change.

    But most of all, we believe that we deserve a seat at the table.

    We need to recognize youth as stakeholders in this work. We can do 
this by funding the countless youth-led mental health coalitions across 
the country; by funding new opportunities for youth to be involved in 
legislative work on the local, State, and national level; and by 
funding organizations that can make sure the voices and sentiments of 
youth are captured and shared.

    If there's anything I want to leave with you today, it's this: 
teens are talking--and we need you to listen.

    At YouthLine, we know that what we do makes a difference in the 
lives of young people across the country. And we know that because of 
what we hear from teens after--after we've connected them to help, 
after we've talked about self-care, and after we've helped them find a 
path forward.

        6:26 p.m.: I feel so much better talking.
        7:34 p.m.: there's no one else in my life I could have talked 
        to.
        8:34 p.m.: if it weren't for this conversation, I wouldn't be 
        here today.

    Thank you.

                                 ______
                                 
                 Prepared Statement of Hon. Ron Wyden, 
                       a U.S. Senator From Oregon
    During this morning's hearing on the youth mental health epidemic, 
the committee has an opportunity to build on last week's excellent 
discussion with Surgeon General Dr. Murthy. Last Tuesday, Dr. Murthy 
told us that mental health problems often show up first when people are 
young, but the average delay between the onset of mental health 
symptoms and the beginning of treatment is 11 years. Those are, in his 
words, ``11 long, confusing, isolating, and painful years.''

    That is a figure worth a thousand words, but more than anything, it 
says that our approach to mental health care is severely out of whack, 
and it's failing our young people from the very beginning.

    First, mental health care must start much earlier. Earlier 
screenings. Earlier interventions. Earlier discussions with primary 
care doctors. There's also a big need to step up our mental health 
efforts in schools and in the community.

    Those are also places where trained professionals can spot symptoms 
right from the outset and refer young people to a psychiatrist when 
necessary. The challenge is, school counselors are overwhelmed, 
community-based programs are too few, and referrals are inconsistent. 
Mental health care simply isn't starting early enough, and it's not 
reaching young people where they are, particularly kids in rural areas.

    Number two, the country must have better crisis care. The 11-year 
treatment gap is a sign that young people are struggling, going without 
the treatment they need, and heading down a path toward crisis. The 
fact is, the system too often fails them when they're in crisis too.

    The pandemic has driven a shocking increase in self-harm among 
young people. Suicide attempts among teen girls resulting in 
hospitalizations recently jumped more than 50 percent. Far too many of 
these young people in distress are spending days or weeks boarded in 
emergency departments. For the bulk of that time, they're probably 
alone. Imagine feeling a sense of extreme isolation clashing with the 
chaos and commotion of the emergency department buzzing outside your 
door.

    Just yesterday I spoke with a group of Oregon health-care providers 
and physicians who are concerned that in many of these situations, 
young people who wind up in emergency rooms aren't even seeing 
practitioners with the right training in mental health. The emergency 
room is no place for a kid in crisis to spend day after day after day, 
but it's all too common. Young people deserve better.

    Third, solving these challenges is going to require creativity from 
the public and private sectors. The Children's Health Insurance Program 
and Medicaid, which is the largest single payer of mental health care 
for young people, can help spark new solutions. These efforts will be 
essential to make sure mental health is treated with the same 
consistency and focus given to physical health.

    Bottom line, you cannot have mental health business as usual, 
because business as usual is failing too many young people at every 
point--from the first sign of symptoms to the most critical moments of 
crisis. There's a lot for the committee to discuss today on these 
issues.

    We're fortunate to be joined by an excellent panel, whom I'll 
introduce shortly. Again, I want to thank Senators Carper and Cassidy 
for heading up our efforts on youth mental health. Next, I'll turn to 
Senator Crapo for his opening remarks.

                                 ______
                                 

                             Communications

                              ----------                              


                     American Hospital Association

                          800 10th Street, NW

                       Two CityCenter, Suite 400

                       Washington, DC 20001-4956

                             (202) 638-1100

On behalf of our nearly 5,000 member hospitals, health systems and 
other health care organizations, our clinician partners--including more 
than 270,000 affiliated physicians, 2 million nurses and other 
caregivers--and the 43,000 health care leaders who belong to our 
professional membership groups, the American Hospital Association (AHA) 
appreciates the opportunity to submit this statement for the record as 
the Committee on Finance examines ways to protect the mental health of 
our nation's youth. We applaud you for your leadership in this area, 
and we look forward to continuing to work with you to advance the 
health of the communities we serve.

As America enters the third year of the COVID-19 pandemic, health care 
providers are confronting a landscape deeply altered by its effects, 
including the emergence of behavioral health care as an even greater 
challenge than in previous years.

While behavioral health care has long been underfunded, 
underappreciated and stigmatized, the pandemic has intensified the 
unmet need for services and has led to heightened difficulties for 
individuals with behavioral health conditions in accessing care.

In freestanding psychiatric hospitals, behavioral health units of acute 
care hospitals, emergency departments and hospital outpatient 
departments across the nation, our member hospitals are facing 
increasing demand for services to help patients deal with anxiety, 
depression, substance use disorder and other behavioral health 
conditions. Reported increases in domestic violence and child abuse 
cases, financial stress, and a lack of community resources have set the 
stage for an exacerbated behavioral health crisis. For children and 
adolescents who have faced disrupted daily routines or who see parents 
dealing with job loss and other stressors, the consequences of the 
COVID-19 pandemic on their behavioral health are even more pronounced, 
as is their inability to access needed services on a timely basis.

To amplify the call to address these urgent issues, the AHA has joined 
the Sound the Alarm for Kids initiative, which comprises more than 50 
organizations united to raise awareness and urge immediate action to 
support the mental health of children, adolescents and their families. 
We are proud to work alongside these many organizations in this effort.

Over the past two years, Congress has enacted several significant laws 
aimed at providing relief from the social and economic impacts of the 
pandemic. Several provisions contained in these laws are designed to 
address the behavioral health care crisis, but some gaps remain. To 
further address the issues brought about or intensified by the 
pandemic, the AHA supports additional approaches to help ensure 
improved access to needed comprehensive, affordable and quality 
behavioral health services for youth.

PSYCHIATRIC BED SHORTAGES

As behavioral health needs are increasing across the nation, we see an 
alarming trend of decreasing behavioral health services in many 
communities, leading to severe challenges in providing inpatient 
psychiatric care to children and adolescents. Bed shortages lead to 
``boarding'' in acute-care hospital emergency departments (EDs) and in 
non-psychiatric units as patients await available inpatient psychiatric 
beds. Although little data is available regarding boarding times for 
children and adolescents, our hospital members report untenable 
crowding in their EDs, with some describing a crisis in their 
communities.

Many young patients are presenting in the ED with suicidal ideation or 
after having attempted suicide, but our members report that the 
patients frequently must wait days or even weeks to be admitted to a 
psychiatric hospital or unit for treatment. According to the Centers 
for Disease Control and Prevention (CDC), over the past decade, suicide 
rates in the United States have increased dramatically. Suicide now 
ranks as the tenth leading cause of death for all Americans and the 
second leading cause of death for Americans between the ages of 10 and 
34.

The demand for mental health treatment after suicide attempts has 
increased during the pandemic; as reported by the CDC, the number of ED 
visits by adolescent girls following suicide attempts was more than 50% 
higher in 2021 than in 2019. However, at the same time the number of 
beds has decreased, as some hospitals have had to reduce bed capacity 
due to COVID-19 concerns, as well close units temporarily to 
accommodate COVID-19 patients.

PROVIDER SHORTAGES

As with psychiatric beds, the demand for child and adolescent 
psychiatrists far outstrips the supply. Prior to the COVID-19 pandemic, 
in 2019, the Academy of Child and Adolescent Psychiatry estimated the 
number of practicing child and adolescent psychiatrists in the U.S. at 
8,300 and the number of youths in need of their services at more than 
15 million. That figure fell far short of the U.S. Bureau of Health 
Professions' projection that in the year 2020, more than 12,000 child 
and adolescent psychiatrists would be necessary just to maintain the 
level of services that had been provided in 2000. Lack of access to 
providers is even more acute in rural areas, according to the Health 
Resources and Services Administration, which reports that 61% of areas 
with a mental health professional shortage are rural or partially 
rural.

Because the number of Medicare-funded residency slots for all 
physicians, including psychiatrists, has only increased by 1,000 since 
1996, Congress needs to act to increase the number of slots available. 
The AHA supports legislation that would lift the caps on residency 
positions, thereby helping to alleviate physician shortages that 
threaten access to care.

Additionally the AHA urges Congress to establish scholarships, bolster 
loan forgiveness programs and provide additional financial supports 
that will encourage providers to specialize in children's behavioral 
health care. Congress also should examine payment rates to ensure that 
reimbursement structures pay providers fairly for the services they 
render.

The AHA also supports robust funding for the Health Resources and 
Services Administration's Title VII and Title VIII programs, including 
the National Health Service Corps and the nursing workforce development 
program. To support diversity in the behavioral health workforce, we 
support increasing funding for Centers of Excellence and the Health 
Careers Opportunity Programs, which bolster recruiting and retaining 
underrepresented groups in the health care workforce.

THE CHILD SUICIDE PREVENTION AND LETHAL MEANS SAFETY ACT

In working to care for survivors of suicide and implement preventive 
services for those who may be at risk, hospitals recognize the 
importance of identifying and mitigating suicide risk factors, such as 
ready access to lethal means. However, millions of Americans live in 
areas with severe shortages of mental health professionals, and these 
shortages are especially acute in rural and low-income urban 
communities.

To help remedy this situation, the AHA has endorsed the Child Suicide 
Prevention and Lethal Means Safety Act (S. 2982/H.R. 5035), legislation 
that would fund training programs to help health care workers identify 
those at high risk for suicide or self-harm. The bill also would 
promote expertise among the emerging health care workforce by providing 
grants to facilitate suicide prevention training at health professions 
schools.

 MITIGATING THE IMPACT OF VIOLENCE ON CHILDREN AND ADOLESCENTS

Every day, hospitals and health systems provide critical, lifesaving 
care to victims of violence. However, when violence occurs, the victims 
are not limited to those killed or physically injured; the impact on 
families and the surrounding community can affect the health of the 
entire community. Numerous studies have documented the behavioral and 
physical health effects on children and adolescents who have been 
exposed to violence.

Through the AHA's Hospitals Against Violence (HAV) initiative, our 
members share information about their efforts to help combat community 
violence using Hospital-based Violence Intervention Programs (HVIPs). 
HVIPs work to reduce retaliation and recidivism by engaging patients in 
the hospital during their recovery. This valuable and effective work 
continues after patients are discharged, providing an important network 
of support during their outpatient care.

To reinforce the work of these important programs, the AHA supports the 
Preventing and Addressing Trauma with Health Services (PATHS) Act (S. 
2873), a bill that would provide grants for high-quality, culturally 
competent trauma support and mental health services for individuals in 
communities affected by violence. The funds authorized by this bill 
would assist hospitals and health systems in advancing the work of 
HVIPs and their goal of fostering safer communities.

INTEGRATING BEHAVIORAL HEALTH AND PHYSICAL HEALTH

Behavioral health disorders have significant impact on the physical 
health of children and adolescents. Many of our member hospitals and 
health systems are working to create one system of care with multiple 
entry points for patients with multiple conditions and to integrate 
behavioral health services into every patient's experience. This 
approach enables providers to effectively treat the whole patient--both 
their physical and behavioral health care needs.

As providers work to integrate behavioral health care for children, 
major factors to consider are developmental challenges and delays, 
including issues related to autism, speech and sexual reaction. These 
factors influence how behavioral conditions present and are best 
treated, as well as which non-medical services children might need to 
realize improvement, such as speech-language pathology and case 
management involving a child's family and support system.

Another major consideration is the influence of, and interaction with, 
other entities, including the child's family members, school and the 
judicial system. For children, any treatment or screening procedures 
will almost certainly overlap with other institutional protocols.

AT-RISK CHILDREN AND ADOLESCENTS

The needs of at-risk children and adolescents deserve special 
attention. First and foremost, focusing sufficient resources on their 
needs, such as eligibility for and access to early screening for 
behavioral health conditions, will help reduce the likelihood of their 
involvement in the child welfare or juvenile justice systems. The input 
of parents, foster parents, the foster care system and schools are 
essential in ensuring optimal, culturally sensitive behavioral health 
care for these youth. In addition, close coordination is necessary with 
programs that support their social needs and provide meaningful health 
care coverage upon transition out of the child welfare or juvenile 
justice system. This includes partnerships with crisis intervention 
organizations that can respond to school-based issues.

 ENFORCEMENT OF MENTAL HEALTH AND SUBSTANCE USE DISORDER PARITY LAWS

In addition to needing access to behavioral health care services, 
children, adolescents and their families need the behavioral health 
care benefits that our laws mandate. The Paul Wellstone and Pete 
Domenici Mental Health Parity and Addiction Equity Act, enacted in 
2008, requires insurance coverage for mental health conditions, 
including substance use disorders, to be no more restrictive than 
insurance coverage for other medical conditions. Most insurers and 
health plans comply with the more straightforward aspects of the law 
that relate to cost sharing and numerical limits on treatment, such as 
annual inpatient day limits--known as Quantitative Treatment Limits.

Unfortunately, health plans and insurers generally are not yet meeting 
the requirements of the law that govern how they design and apply their 
managed care rules, called Non-Quantitative Treatment Limits, or NQTLs, 
to these services. NQTLs are related to benefit plan design, such as 
requiring preauthorization before services are rendered, or imposing 
extra review processes for medical necessity or medical 
appropriateness. To save money, some plans limit coverage for medicines 
prescribed to treat behavioral health conditions by requiring patients 
to try less expensive drugs first before ``stepping up'' to the more 
costly drug actually ordered by the provider. This approach is called 
step therapy protocol, and its use can delay needed treatment with 
often catastrophic consequences for patients.

However, the federal entities charged with enforcing mental health and 
substance abuse parity laws have not done a thorough job, and insurers 
have taken advantage of that. To resolve the issue of insurance 
companies' noncompliance, we need greater transparency, accountability 
and enforcement of current laws. In the 116th Congress, the AHA 
supported the Mental Health Parity Compliance Act introduced by 
Senators Chris Murphy (D-CT) and Bill Cassidy (R-LA), legislation whose 
provisions were incorporated into the Consolidated Appropriations Act, 
2021 \1\ (CAA). Those provisions require health plans and issuers that 
cover mental health and substance use disorder services as well as 
medical and surgical benefits to create a comparative analysis of any 
NQTLs that apply, and to provide such analyses whenever requested by 
federal agencies. The CAA also requires the Departments of Labor, 
Treasury and Health and Human Services to report to Congress annually 
and issue additional guidance on NQTLs.
---------------------------------------------------------------------------
    \1\ https://www.congress.gov/116/bills/hr133/BILLS-116hr133enr.pdf.

Unfortunately, the 2022 report found that none of the comparative 
analyses reviewed by the federal departments were in full compliance 
with the law, and none contained required information. The AHA urges 
Congress to exercise vigorous oversight of the federal agencies 
responsible for ensuring that health plans comply with the MHPEA and 
all its reporting requirements. Further, we support an increase in 
federal penalties for noncompliance to help ensure that patients can 
receive the behavioral health care benefits they are entitled to under 
the law.

BATTLING STIGMA

Finally, the AHA continues to fight the stigma associated with seeking 
behavioral health care. Children and adolescents may not seek the help 
they need due to the stigmatization of mental health care. Often 
parents may avoid seeking care for their children due to apprehension 
that a mental health diagnosis will unfairly label them for the rest of 
their lives. AHA member hospitals and health systems work to dispel 
misperceptions about mental health disorders and treatment, and we have 
launched the People Matter/Words Matter poster series to help health 
care workers adopt patient-centered, respectful language around 
behavioral health.

CONCLUSION

As a nation, we are just beginning to fully comprehend the effects of 
the COVID-19 pandemic on the emotional well-being of the nation's 
youth. America's hospitals and health systems recognize that our 
collective efforts today to protect the mental health of children and 
adolescents can have a lasting impact on their lives and the overall 
health of our communities well into the future. We appreciate the 
Committee's efforts to examine this issue and look forward to working 
with you to advance policies to that end.

                                 ______
                                 
                   American Psychological Association

                          750 First Street, NE

                       Washington, DC 20002-4242

                              202-336-5800

                            202-336-6123 TDD

                          https://www.apa.org/

   Statement of Arthur C. Evans, Jr., Ph.D., Chief Executive Officer

On behalf of the American Psychological Association (APA), please 
accept our organization's written comments for the consideration of the 
Senate Finance Committee for its hearing on ``Protecting Youth Mental 
Health: Part II--Identifying and Addressing Barriers to Care.'' APA is 
the nation's largest scientific and professional organization 
representing the discipline and profession of psychology, with more 
than 133,000 members and affiliates who are clinicians, researchers, 
educators, consultants, and students in the field of psychology. 
Through the application of psychological science and practice, our 
association's mission is to have a positive impact on critical societal 
issues.

To respond to the children's mental health crisis, APA urges policy 
initiatives in the following key areas. While not all the policies and 
programs referenced in this document are directly within the 
jurisdiction of the Finance Committee, we raise them in keeping with 
the committee's comprehensive consideration of policies affecting youth 
mental health:

      Strengthen the behavioral health workforce;

      Improve Medicaid coverage policies and payment rates;

      Increase access to school-based behavioral health services;

      Promote integration of pediatric primary care and behavioral 
health; and

      Maintain and extend access to behavioral health services 
provided via telehealth.

The COVID pandemic is particularly harming the mental health of 
children and youth. During the first three-quarters of 2021, children's 
hospitals reported a 14% increase in mental health-related emergencies 
and a 42% increase in cases of self-injury and suicide, compared with 
the same period in 2019.\1\ In recent months, children's hospitals 
experienced their highest number of children ``boarding'' in hospital 
emergency departments awaiting treatment.\2\ Surveys of households with 
young children found high levels of childhood hunger, emotional 
distress among parents, and frequent disruptions in child-care 
services.\3\ Nearly 10% of U.S. children lived with someone who was 
mentally ill or severely depressed,\4\ and since the start of the 
pandemic over 167,000 children have lost a parent or caregiver to the 
virus,\5\ further contributing to anxiety, depression, trauma, and 
stress-related conditions in children. Aggressive action is needed to 
address the adverse long-term impacts of the pandemic on the mental 
health and well-being of children and adolescents.
---------------------------------------------------------------------------
    \1\ Children's Hospital Association. (2021). COVID-19 and 
Children's Mental Health. Retrieved from: https://
www.childrenshospitals.org/-/media/Files/CHA/Main/Issues_and_Advocacy/
Key
_Issues/Mental-Health/2021/
covid_and_childrens_mental_health_factsheet_091721.pdf?la=en&
hash=F201013848F9B9C97FAE16A89B01A38547C7C5C7.
    \2\ Children's Hospital Association. (n.d.). Emergency Room 
Boarding of Kids in Mental Health Crisis. Retrieved from: https://
www.childrenshospitals.org/-/media/Files/CHA/Main/Issues_
and_Advocacy/Key_Issues/Mental%20Health/2021/
Boarding_fact_sheet_121421.pdf.
    \3\ Center for Translational Neuroscience. (2021). RAPID-EC Fact 
Sheet: Still in Uncertain Times; Still Facing Hunger. University of 
Oregon. Retrieved from: https://www.uorapid
response.com/our-research/still-in-uncertain-times-still-facing-hunger; 
Center for Translational Neuroscience. (2021). RAPID-EC Fact Sheet: 
Emotional Distress On the Rise for Parents . . . Again. University of 
Oregon. Retrieved from: https://www.uorapidresponse.com/emotional-
distress-on-rise-
again?utm_medium=email&utm_source=email_link&utm_content=baby_monitor_11

042021&utm_campaign=Q1_2022_Policy+Center_Resources.
    \4\ Ullmann, H., Weeks, J.D., Madans, J.H. (2021). Disparities in 
stressful life events among children aged 5-17 years. National Center 
for Health Statistics, https://dx.doi.org/10.15620/cdc:109052.
    \5\ Treglia, D., Cutuli, J.J., Arasteh, K., J. Bridgeland, J.M., 
Edson, G., Phillips, S., and Balakrishna, A. (2021). Hidden Pain: 
Children Who Lost a Parent or Caregiver to COVID-19 and What the Nation 
Can Do to Help Them. COVID Collaborative.

It is important to note that people of color remain at 
disproportionately higher risk of infection, hospitalization, and death 
from the virus.\6\ The pandemic has also exacerbated the impact of 
historic disparities in access to behavioral health care among 
communities of color, which has further harmed their mental well-being 
since the start of this crisis.\7\ Rates of suicide, which have 
traditionally been high predominantly among White and Native American 
children, have risen sharply among Black youth.\8\ Black and Hispanic 
children lost a parent or a caregiver at more than two times the rate 
of White children, while American Indian, Alaska Native, Native 
Hawaiian, and Pacific Islander children lost caregivers at nearly four 
times that rate.\9\ Additionally, young people within other 
marginalized populations, including those who identify as LGBTQ+ and 
children with developmental and physical disabilities, have been 
disproportionately impacted as well.\10\
---------------------------------------------------------------------------
    \6\ Centers for Disease Control and Prevention. (2021). Risk for 
COVID-19 Infection, Hospitalization, and Death By Race/Ethnicity. 
Retrieved from: https://www.cdc.gov/coronavirus/2019-ncov/covid-data/
investigations-discovery/hospitalization-death-by-race-ethnicity.html.
    \7\ McKnight-Eily, L.R., Okoro, C.A., Strine, T.W., et al. (2021). 
Racial and Ethnic Disparities in the Prevalence of Stress and Worry, 
Mental Health Conditions, and Increased Substance Use Among Adults 
During the COVID-19 Pandemic--United States, April and May 2020. 
Morbidity and Mortality Weekly Report, 70(5), 162-166, http://
dx.doi.org/10.15585/mmwr.mm7005a3.
    \8\ Sheftall, A.H., Vakil, F., Ruch, D.A., Boyd, R.C., Lindsey, 
M.A., and Bridge, J.A. (2021). Black Youth Suicide: Investigation of 
Current Trends and Precipitating Circumstances. Journal of the American 
Academy of Child and Adolescent Psychiatry, https://doi.org/10.1016/
j.jaac.2021.08.021.
    \9\ Treglia, D., Cutuli, J.J., Arasteh, K., J. Bridgeland, J.M., 
Edson, G., Phillips, S., and Balakrishna, A. (2021). Hidden Pain: 
Children Who Lost a Parent or Caregiver to COVID-19 and What the Nation 
Can Do to Help Them. COVID Collaborative.
    \10\ Morning Consult and the Trevor Project. (2021). Issues 
Impacting LGBTQ Youth. Retrieved from: https://
www.thetrevorproject.org/wp-content/uploads/2021/12/
TrevorProject_Public_
Final-1.pdf.

The need for greater investment in behavioral health care existed long 
before COVID-19. Establishing a robust and effective mental health and 
substance use disorder treatment system capable of delivering the 
mental health resources our children and young people need will require 
action across multiple fronts, ranging from improving access to the 
full spectrum of high-quality treatment to addressing social 
determinants of health. We must use the current crisis as an 
opportunity to make major structural improvements and new, sustained 
investments.

Strengthen the Behavioral Health Workforce

A strong behavioral health workforce is critical to combating the long-
term impact of the pandemic and remedying longstanding access gaps. 
Even before COVID-19, the U.S. lacked an adequate supply of behavioral 
health providers, including psychologists, with shortages expected to 
worsen significantly by 2030.\11\, \12\, \13\ 
Rural communities, in particular, face major challenges in recruiting 
licensed behavioral health care professionals.\14\ The rising 
behavioral health needs associated with COVID-19 will make an already 
bad situation worse.
---------------------------------------------------------------------------
    \11\ Bureau of Health Workforce. (2019). Designated Health 
Professional Shortage Area Statistics. Health Resources and Services 
Administration; U.S. Department of Health and Human Services. Retrieved 
from https://data.hrsa.gov/hdw/Tools/MapToolQuick.aspx?mapName=HP
SAMH. Health Resources and Services Administration. (n.d.). Behavioral 
Health Workforce Projections, 2016-2030: Clinical, Counseling, and 
School Psychologists. Retrieved from: https://bhw.hrsa.gov/sites/
default/files/bureau-health-workforce/data-research/psychologists-
2018.pdf.
    \12\ Health Resources and Services Administration. (n.d.). 
Behavioral Health Workforce Projections, 2016-2030: Clinical, 
Counseling, and School Psychologists. Retrieved from: https://
bhw.hrsa.gov/sites/default/files/bureau-health-workforce/data-research/
psychologists-2018.pdf.
    \13\ Bureau of Labor Statistics. Occupational Outlook Handbook, 
Psychologists. U.S. Department of Labor. Retrieved from: https://
www.bls.gov/ooh/life-physical-and-social-science/psychologists.htm.
    \14\ Rural Health Information Hub. (2021). Rural Mental Health. 
RHIhub, https://www.ruralhealthinfo.org/topics/mental-health.

Congress can strengthen the behavioral health workforce by providing 
support for psychologist training programs in a manner similar to the 
support it provides to medical professional training programs. Unlike 
physicians, doctoral-level psychologists are not eligible for Medicare-
funded residency programs, which provide billions of dollars to support 
the expansion of the physician workforce through Graduate Medical 
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Education (GME).

The lack of support for psychology trainees under the nation's single 
largest health insurance program makes it difficult to support training 
programs. We urge Congress to establish Medicare coverage of behavioral 
health services provided by psychology interns and postdoctoral fellows 
(``trainees'') by directing the Centers for Medicare and Medicaid 
Services (CMS) to develop a Medicare modifier--like the GE modifier 
used for billing for services provided by medical residents--to allow 
psychology trainees to bill for behavioral health-care services 
provided under the supervision of a licensed psychologist. 
Simultaneously, Congress should establish an add-on code to compensate 
behavioral health clinicians for the non-clinical time they devote to 
working with trainees, so that time spent teaching does not have to be 
effectively donated by the clinician and carried out at the expense of 
providing billable services.

Although some state Medicaid programs are already covering services 
provided by psychology trainees, encouraging and incentivizing such 
coverage in all state Medicaid programs would support training programs 
and their growth. Both Congress and CMS previously endorsed providing 
payments for clinical psychology training programs.

In addition to Medicare and Medicaid policy changes, reauthorization 
and funding for programs administered by the Health Resources and 
Services Administration (HRSA) and Substance Abuse and Mental Health 
Services Administration (SAMHSA) is needed to strengthen the behavioral 
health workforce.

To incentivize qualified providers to pursue careers delivering care to 
underserved populations, APA encourages passage of the bipartisan 
Mental Health Professionals Workforce Shortage Loan Repayment Act (S. 
1578), which would authorize a new student loan repayment program for 
mental health care professionals who commit to working in an area 
lacking accessible care.

Because of the high level of training required, the cost of attending 
graduate school is a significant barrier for entering the field of 
psychology. Most psychology graduate students finance their education 
by taking on substantial student debt, and graduate with an average 
debt load of between $95,000 and $160,000. Close to half of doctoral-
level psychologists rely on loans to pay for graduate school, which 
takes on average 5-6 years to complete.\15\ Data show that psychology 
graduate students worry about the affordability of completing their 
training requirements, experience difficulties focusing on their 
studies as a result of trying to make ends meet, and struggle to afford 
health care.\16\ At the same time, the imposition of higher interest 
rates and multiple loan origination fees, as well as the elimination of 
subsidized federal loans for graduate students, further increased the 
cost of financing graduate education.\17\
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    \15\ Doran, J.M., Kraha, A., Marks, L.R., Ameen, E.J., and El-
Ghoroury, N.H. (2016). Graduate Debt in Psychology: A Quantitative 
Analysis. Training and Education in Professional Psychology, 10(1), 3-
13.
    \16\ Lantz, M.M. (2013). Uncovering the graduate student economic 
landscape: A difficult but necessary dialogue. Society of Counseling 
Psychology Newsletter, 34, 22-23. Retrieved from: http://www.div17.org/
wp-content/uploads/SCP17-2013-9.pdf.
    \17\ U.S. Department of Education. (n.d.). Federal Interest Rates 
and Fees. Federal Student Aid. Retrieved from: https://studentaid.gov/
understand-aid/types/loans/interest-rates.

High levels of student loan debt impede workforce diversity in mental 
health care fields, where demand for representative, culturally 
competent providers is high.\18\ Due to a variety of factors, such as 
lack of generational wealth, many students--including first-generation 
students, those from communities of color, and those with a lower 
socioeconomic background--working toward doctoral psychology degrees 
disproportionately rely on student loans.\19\ The prospect of adding 
further debt often disincentivizes the pursuit of advanced degrees, and 
research shows that debt also impacts career choice by reducing the 
probability that qualified professionals will enter public service 
careers.\20\
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    \18\ Sullivan, L., Meschede, T., Shapiro, T., and Escobar, F. 
(September 2019). Stalling Dreams: How Student Debt is Disrupting Life 
Chances and Widening the Racial Wealth Gap. Institute on Assets and 
Social Policy, Heller School for Social Policy and Management at 
Brandeis University. Retrieved from: https://heller.brandeis.edu/iere/
pdfs/racial-wealth-equity/racial-wealth-gap/stallingdreams-how-student-
debt-is-disrupting-lifechances.pdf.
    \19\ Wilcox, M.M., Barbaro-Kukade, L., Pietrantonio, K.R., Franks, 
D.N., and Davis, B.L. (2021). It takes money to make money: Inequity in 
psychology graduate student borrowing and financial stressors. Training 
and Education in Professional Psychology, 15(1), 2-17, https://doi.org/
10.1037/tep0000294.
    \20\ Choi, Y. (2014). Debt and college students' life transitions: 
The effect of educational debt on career choice in America. Journal of 
Student Financial Aid, 44(1), 3. Retrieved from: https://
ir.library.louisville.edu/cgi/
viewcontent.cgi?article=1050&context=jsfa.

Accordingly, APA calls for the expeditious reauthorization of the 
following programs, which are set to expire at the end of Fiscal Year 
---------------------------------------------------------------------------
(FY) 2022:

The Graduate Psychology Education Program (GPE) is the nation's primary 
federal program dedicated solely to the education and training of 
doctoral-level psychologists. GPE provides grants to accredited 
psychology doctoral, internship, and postdoctoral training programs to 
support the interprofessional training of psychology graduate students 
while also providing behavioral health services to underserved 
populations in rural and urban communities. APA urges reauthorization 
of this vitally important program at $50 million per year.

The Minority Fellowship Program (MFP) serves a dual purpose: to both 
increase the number of mental health professionals of color and 
increase access to mental health services in underserved areas. Decades 
of psychological research has shown that youth of color report less use 
of behavioral health services than non-Hispanic white youth,\21\ in 
part due to the lack of bilingual and culturally competent providers. 
MFP provides funding for the training, career development, and 
mentoring of behavioral health professionals--including trainees in 
psychology, nursing, social work, psychiatry, addiction counseling, 
professional counseling, and marriage and family therapy--to work in 
ethnically diverse communities and provide culturally and 
linguistically competent services to meet the needs of individuals in 
underserved areas.
---------------------------------------------------------------------------
    \21\ Marrast, L., Himmelstein, D.U., and Woolhandler, S. (2016). 
Racial and ethnic disparities in mental health care for children and 
young adults: A national study. International Journal of Health 
Services, 46(4), 810-824.

The Behavioral Health Workforce Education and Training (BHWET) Program 
supports pre-degree clinical internships and field placements for a 
broad array of behavioral health professionals, including doctoral-
level psychology students, master's-level social workers, school social 
workers, professional and school counselors, psychiatric mental health 
nurse practitioners, marriage and family therapists, and occupational 
therapists. The program is also a key source of support for other 
behavioral health training programs and substance use disorder 
prevention efforts. Preserving this program is key to reaching 
underserved populations, as well as meeting the needs of patients 
wherever they are on the spectrum of mental health needs, from early 
screening and prevention services for those who may be experiencing 
symptoms of a behavioral health disorder to mobile crisis services for 
---------------------------------------------------------------------------
those in need of immediate intervention.

The Integrated Substance Use Disorder Training Program (ISTP) expands 
the number of nurse practitioners, physician assistants, health service 
psychologists, and/or social workers trained to provide mental health 
and substance use disorder (SUD) services, including opioid use 
disorder (OUD) services, in underserved community-based settings that 
integrate primary care, mental health, and SUD services.

Improve Medicaid Coverage Policies and Payment Rates

Medicaid is the largest payer of behavioral health services in the 
U.S., and yet many patients cannot access quality, affordable care in 
their communities, instead seeking care in emergency rooms or facing 
interminable wait lists for services. Despite their status as 
``essential health benefits'' that many private plans must cover under 
the Affordable Care Act, mental health and substance use services are 
not mandatory benefits under state Medicaid programs. Accordingly, APA 
urges enactment of Senator Smith's Medicaid Bump Act (S. 1727), which 
incentivizes state Medicaid programs to increase their coverage of 
mental and behavioral health services. Without access to crisis 
services, patients often find themselves languishing in emergency rooms 
or seeking treatment in other inappropriate settings. We strongly 
support the inclusion of Chairman Wyden's CAHOOTS Act (S. 764) to 
incentivize state Medicaid coverage of services provided by round-the-
clock mobile crisis teams.

Research consistently demonstrates connections between low Medicaid 
reimbursement rates and low rates of provider participation in the 
program.\22\, \23\, \24\, \25\ 
Psychologists and other providers often accept Medicaid patients as a 
public service, but low reimbursement rates can be a barrier to 
participation. In surveys we have conducted, psychologists who have 
chosen not to participate in Medicare cite the program's low 
reimbursement rates as the primary reason for their decision. 
Similarly, a recent report issued at the request of the Oregon 
Legislature documented behavioral health providers' significant concern 
over low Medicaid reimbursement rates, and the authors' conclusion that 
``wage increases are a necessary but insufficient component to 
improving behavioral health workforce shortages'' (p. 5).\26\
---------------------------------------------------------------------------
    \22\ Holgash, K., and Heberlein, M. (2019). Physician acceptance of 
new Medicaid patients. Medicaid and CHIP Payment and Access Commission, 
January, 24.
    \23\ Candon, M., Zuckerman, S., Wissoker, D., Saloner, B., Kenney, 
G.M., Rhodes, K., and Polsky, D. (2018). Declining Medicaid fees and 
primary care appointment availability for new Medicaid patients. JAMA 
Internal Medicine, 178(1), 145-146.
    \24\ Chatterji, P., Decker, S.L., and Huh, J. (2021). Medicaid 
physician fees and access to care among children with special health 
care needs. Review of Economics of the Household, 1-33.
    \25\ Alexander, D., and Schnell, M. (2019). The impacts of 
physician payments on patient access, use, and health (No. w26095). 
National Bureau of Economic Research.
    \26\ Zhu, J.M., Howington, D., Hallett, E., Simeon, E., Amba, V., 
Deshmukh, A., and McConnell, K.J. (2022). Behavioral Health Workforce 
Report to the Oregon Health Authority and State Legislature.

Medicaid provider payment rates remain substantially below Medicare 
reimbursement rates.\27\ Given the dire need to increase access to 
behavioral health services for children and youth, we urge Congress to 
consider assisting states in raising Medicaid reimbursement rates to 
match Medicare reimbursement rates for behavioral health services for 
this population.
---------------------------------------------------------------------------
    \27\ Zuckerman, S., Skopec, L., and Aarons, J. (2021). Medicaid 
Physician Fees Remained Substantially Below Fees Paid by Medicare in 
2019: Study compares Medicaid physicians fees to Medicare physician 
fees. Health Affairs, 40(2), 343-348.
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Increase Access to School-based Behavioral Health Services

Meeting the need for behavioral health services for children and youth 
will only be possible if all available venues are utilized effectively 
for reaching those in need of help, so that there is ``no wrong door'' 
for obtaining care. Schools are an essential component of such an 
approach. In fact, in many communities, they are an essential--and 
often the only--source of meeting the physical and mental health needs 
of students and families. While some school districts leverage Medicaid 
funds to stretch scarce resources and create school-based behavioral 
health programs, shortages of school-based behavioral health 
professionals continue to persist.\28\
---------------------------------------------------------------------------
    \28\ National Association of School Psychologists. (2017). 
Shortages in school psychology: Challenges to meeting the growing needs 
of U.S. students and schools. Retrieved from: https://www.
nasponline.org/resources-and-publications/resources-and-podcasts/
school-psychology/shortages-in-school-psychology-resource-guide.

Improving the behavioral health and emotional well-being of all 
students, including by instituting evidence-based comprehensive 
behavioral health systems in schools, can help mitigate the impacts of 
pandemic-related learning loss,\29\ and reduce the frequency and 
severity of mental health and substance use disorders.\30\ Such a 
holistic approach provides a full complement of supports and services 
that establish multi-tier interventions and promotes positive school 
environments. They are built on collaborations between students, 
parents, families, community health partners, school districts, and 
school professionals, such as administrators, educators, and 
specialized instructional support personnel, including school 
psychologists.
---------------------------------------------------------------------------
    \29\ Dorn, E., Hancock, B., Sarakatsannis, J., and Viruleg, E. 
(2020, December 8). COVID-19 and learning loss--Disparities grow and 
students need help. McKinsey and Company, https://www.mckinsey.com/
industries/public-and-social-sector/our-insights/covid-19-and-learning-
loss-disparities-grow-and-students-need-help.
    \30\ American Psychological Association. (2020). APA's Guide to 
Schooling and Distance Learning During COVID-19. Retrieved from: 
https://www.apa.org/ed/schools/teaching-learning/recommendations-
starting-school-covid-19.pdf.

As the third-largest stream of federal funding for school-based health 
care services, Medicaid remains a critical mechanism for meeting many 
of these needs among our most vulnerable students by broadening access 
to physical and mental health care available through school-based 
health centers. School districts can use Medicaid reimbursement to fund 
health professionals and specialized instructional support personnel, 
including school psychologists,\31\ purchase and update specialized 
equipment and connect eligible students with providers outside of 
school settings. Medicaid can also be used to pay for services 
described in a Medicaid-enrolled student's individual education plan 
(IEP) under the Individuals with Disabilities in Education Act.
---------------------------------------------------------------------------
    \31\ Pudelski, S. (2017). Cutting Medicaid: A Prescription to Hurt 
the Neediest Kids. AASA, The School Superintendent's Association, 
https://www.aasa.org/uploadedFiles/Policy_and_Advocacy
/Resources/CuttingMedicaid2018Addendum.pdf.

To meet the growing need for child and adolescent behavioral health 
care and increase access to school-based behavioral health services, 
APA urges the Committee to strengthen Medicaid-funded services in 
schools by directing CMS to update its guidelines on Medicaid in 
schools to ensure that Medicaid reimbursement can be utilized for 
school-based physical and behavioral health care. CMS must also 
periodically review Medicaid's early and periodic screening, 
diagnostic, and treatment (EPSDT) requirements to determine whether 
they are being implemented successfully in support of access to 
prevention, early intervention, and developmentally appropriate 
---------------------------------------------------------------------------
services.

Additionally, we strongly oppose restrictions on Medicaid payments to 
schools for necessary services, as well as the implementation of per-
capita caps or block grant funding for Medicaid programs. Finally, we 
urge the Committee to support a permanent extension of the Children's 
Health Insurance Program (CHIP) as a stable source of coverage for low-
income children.

Further, we urge Congress to pass legislation that increases access to 
behavioral health services in schools and addresses disparities in 
behavioral health care among Black youth, including:

      The Mental Health Services for Students Act (S. 1841), to build 
partnerships among local educational agencies, tribal schools, and 
community-based organizations;

      The Comprehensive Mental Health in Schools Pilot Program Act (S. 
2730), to provide resources for low-income schools to develop a 
holistic approach to student well-being;

      The Increasing Access to Mental Health in Schools Act (S. 1811), 
to expand the school-based mental health professional workforce; and

      The Pursuing Equity in Mental Health Act (S.1795), to authorize 
funding for research on Black youth suicide and improve the pipeline of 
culturally competent providers.

Promote Integration of Pediatric Primary Care and Behavioral Health

Increasing implementation of evidence-based integrated pediatric 
primary and behavioral healthcare could significantly increase access 
to care, improve treatment outcomes, promote healthy development, and 
aid in addressing social determinants of health.\32\ A substantial 
percentage of patients visiting primary care practices are experiencing 
behavioral health issues affecting their well-being, including both 
mental health and substance use disorders or difficulties, and 
behavioral factors associated with physical conditions or chronic 
disease management.\33\
---------------------------------------------------------------------------
    \32\ McCabe, M.A., Leslie, L., Counts, N., and Tynan, W.D. (2020). 
Pediatric integrated primary care as the foundation for healthy 
development across the lifespan. Clinical Practice in Pediatric 
Psychology, 8(3), 278.
    \33\ Crowley, R.A., Kirschner, N., and Health and Public Policy 
Committee of the American College of Physicians. (2015). The 
integration of care for mental health, substance abuse, and other 
behavioral health conditions into primary care: Executive summary of an 
American College of Physicians position paper. Annals of Internal 
Medicine, 163(4), 298-299.

More than a decade of research has documented the effectiveness of 
programs implementing the primary care behavioral health (PCBH) model, 
the collaborative care model (CoCM), and blended models of integrated 
care. One of the leading models of integrated care is the Primary Care 
Behavioral Health Model (PCBH), in which primary care providers, 
behavioral health consultants (BHCs), and care managers work as a team, 
sharing the same health record systems, administrative support staff, 
and waiting areas, and collaborate in monitoring and managing patient 
progress in order to improve the management of behavioral health 
problems and conditions. In the PCBH model, the behavioral health 
consultant role is often, but not always, filled by a clinical 
---------------------------------------------------------------------------
psychologist.

The PCBH model is a truly population-based approach to integrated care, 
in which the goal is to improve both mental and physical health 
outcomes for the clinic's patients of every age and condition by 
managing behavioral health problems and bio-psychosocially influenced 
health conditions.\34\ Generally, the BHC strives to see patients on 
the same day the primary care provider (PCP) requests help, ideally 
through a ``warm hand-off,'' and works with the PCP to implement 
clinical pathways for treatment. An integrated care psychologist's day 
may include meeting with a parent of a child exhibiting behavioral 
difficulties or hyperactivity, seeing a new mother experiencing 
symptoms of depression, helping another patient manage chronic pain or 
diabetes, and working with another patient who has recently 
discontinued using psychotropic medication. Both patients and providers 
have reported high levels of satisfaction with PCBH model 
services.\35\, \36\ From the patient's perspective, 
behavioral health services are seamlessly interwoven with medical care, 
mitigating the stigma often associated with behavioral health services.
---------------------------------------------------------------------------
    \34\ Reiter, J.T., Dobmeyer, A.C., and Hunter, C.L. (2018). The 
primary care behavioral health (PCBH) model: An overview and 
operational definition. Journal of Clinical Psychology in Medical 
Settings, 25(2), 109-126.
    \35\ Petts, R.A., Lewis, R.K., Brooks, K., McGill, S., Lovelady, 
T., Galvez, M., and Davis, E. (2021). Examining patient and provider 
experiences with integrated care at a community health clinic. The 
Journal of Behavioral Health Services and Research, 1-18.
    \36\ Angantyr, K., Rimner, A., Norden, T., and Norlander, T. 
(2015). Primary care behavioral health model: Perspectives of outcome, 
client satisfaction, and gender. Social Behavior and Personality: An 
International Journal, 43(2), 287-301.

The PCBH model is particularly well-suited for use in pediatric care. 
Interventions and supports to promote children's physical, behavioral, 
and emotional health can positively influence the long-term trajectory 
of their health and well-being into adulthood. Almost all children are 
seen in primary care, and it is estimated that one in four pediatric 
primary care office visits involves behavioral health problems. 
Psychologists can be especially helpful in pediatric care because 
assessing behavioral and emotional issues in children is generally more 
difficult than in adults, and pediatric education traditionally focuses 
on children's physical health. In addition to improving treatment in 
this area, early childhood behavioral health services can help mitigate 
the effect of adverse social determinants of health. Ideally, 
integrated pediatric primary care includes a whole-family approach to 
services that encompasses screening and services for perinatal and 
maternal depression, domestic violence, and adverse childhood 
---------------------------------------------------------------------------
experiences.

Investing in evidence-based integrated primary and behavioral health 
care across multiple delivery models would help us meet the current 
crisis, as more than a decade of research has shown that programs 
implementing the PCBH model, the collaborative care model (CoCM), and 
blended models of integrated care can increase access to care and 
achieve the health care triple aim of improving patient outcomes, 
increasing satisfaction with care, and reducing overall treatment 
costs.

Adoption of PCBH and other integrated care models is often challenging 
for primary care providers, as they face barriers related to physical 
office space, the need for improved information technology systems, 
management procedures, clinical staffing and policies, health records 
and data tracking practices, and provider education and training.

APA supports the provision of federal financial and technical 
assistance to aid in the expansion of integrated care, whether provided 
through partnerships (including state agencies) or through direct aid 
to primary care providers. Initiatives and incentives to promote 
integrated care should support implementation of not just PCBH 
programs, but all evidence-based models of integrated care. Because of 
differences in providers' patient populations and access to behavioral 
health providers, there is no ``one-size-fits-all'' approach to 
effective integrated primary care. APA urges Congress to continue 
giving primary care practices the flexibility to choose the model of 
integrated care that works best for their community.

 Maintain and Extend Access to Behavioral Health Services Provided via 
                    Telehealth

The decisions by Congress and CMS to expand access to tele-mental 
health services represented a rare positive outcome of the COVID-19 
pandemic, as it extended evidence-based mental behavioral health care 
to many individuals in areas and communities that traditionally lacked 
access to these services and made access to care easier and/or safer 
for many others. There is ample evidence demonstrating that mental and 
behavioral health services delivered via telehealth can be at least 
equally effective as services delivered in person.\37\ Audio-only 
telehealth is an especially important treatment modality for those 
residing in areas lacking accessible or affordable broadband Internet 
services, as well as individuals who lack the technological familiarity 
with video conferencing platforms. Telehealth will remain in use long 
after the pandemic ends; According to a recent survey of practicing 
psychologists, 93% of respondents said that they intend to continue 
offering telehealth as an option in their practice after the 
pandemic.\38\
---------------------------------------------------------------------------
    \37\ See, e.g., Turgoose, D., et al., (2018) Journal of 
Telemedicine and Telecare, Vol. 24, No. 9, https://doi.org/10.1177/
1357633X17730443; Varker, T., et al. (2019), Psychological Services, 
Vol. 16, No. 4, https://doi.org/10.1037/ser0000239; Slone, N.C., et al. 
(2012) Psychological Services, Vol. 9, No. 3, https://doi.org/10.1037/
a0027607.
    \38\ American Psychological Association (October 19, 2021), 
Worsening Mental Health Crisis Pressures Psychologist Workforce: 2021 
COVID-19 Practitioner Survey, https://www.apa.org/pubs/reports/
practitioner/covid-19-2021.

APA urges enactment of the bipartisan Telehealth Improvement for Kids' 
Essential Services (TIKES) Act (S. 1798) introduced by Senator Carper 
and Senator Cornyn to provide guidance to states on increasing coverage 
of telehealth services through state Medicaid and CHIP programs. APA 
also supports several other bills before Congress to cement the gains 
in access achieved under recent improvements in telehealth and audio-
only services coverage, including the Telemental Health Care Access Act 
(S. 2061), introduced by Senators Cassidy, Smith, Cardin, and Thune, 
which would eliminate a new Medicare telehealth coverage requirement 
---------------------------------------------------------------------------
that unnecessarily requires patients to be periodically seen in person.

To incentivize providers to continue offering telehealth services, 
coverage of and reimbursement for telehealth services should be 
equivalent to their in-person counterparts. Reimbursing at a lower rate 
and requiring coverage on more stringent terms would drive providers to 
offer more in-person services, making it more difficult for the many 
patients who rely on services delivered via telehealth to access care. 
APA recommends that Congress enact the Telehealth Coverage and Payment 
Parity Act (H.R. 4480), which requires private insurance plans to cover 
telehealth services on equal terms and equal rates as their in-person 
counterparts.

APA is heartened by the focus on mental health in Congress, and eager 
to work with this Committee and its members to develop legislation to 
carry out these and other initiatives. We urge Congress to regard the 
COVID-19 pandemic as an opportunity to address the longstanding 
shortcomings of our behavioral health treatment system.

                                  1____
                                 
              American Therapeutic Recreation Association

                      25 Century Blvd., Suite 505

                          Nashville, TN 37214

                           D: +1.703-234-4140

                           F: +1.781-623-8103

                      https://www.atra-online.com/

U.S. Senate
Committee on Finance

RE: COVID-19, Mental Health Care in Adolescents and Young People, and 
the Role of Recreational Therapists

Dear Chairman Wyden, Ranking Member Crapo, and Members of the Senate 
Finance Committee,

On behalf of the American Therapeutic Recreation Association (ATRA), we 
appreciate the opportunity to submit this statement for the record 
regarding the Committee's hearing on ``Protecting Youth Mental Health: 
Part II--Identifying and Addressing Barriers to Care.'' The hearing 
highlights the pressing issues facing today's youth and the gaps in 
mental health treatment in our current healthcare system. We look 
forward to working with you to develop solutions to address America's 
mental health crisis.

ATRA is committed to advancing access to recreational therapy and 
ensuring that individuals, in particular adolescents, are able to 
receive care that suits their interests and needs and supports the 
development of functional skills for daily living and stress release. 
ATRA is the largest professional association representing recreational 
therapy. Recreational therapists are nationally certified, and where 
applicable, state-licensed to provide evidence-based treatment services 
for individuals with a range of disabling conditions across the 
lifespan. Recreational therapy is active treatment, medically 
necessary, and can be prescribed by a physician as part of a client's 
plan of care.\1\

ATRA has watched with interest and concern as new data has highlighted 
the significant impact COVID-19 has had on adolescents and young 
people's mental health outcomes. As recreational therapists, we are 
trained to use a variety of interventions to help clients address 
mental health challenges, as well as other areas like physical health 
and emotional/social well-being. Therefore, we recognize the critical 
need to ensure that resources are in place following the public health 
emergency to ensure that young people are able to successfully manage 
the stress and anxiety associated with COVID-19.

In mental health care, recreational therapists support clients with 
cognitive, social, leisure, and physical interventions, as well as 
stress management techniques, to improve a client's overall health. 
Recreation therapy (RT) for mental health incorporates activities 
including music, sports, dance, art, and outdoor activities to help a 
client find strategies that work for them to manage stress and ensure 
they have a healthy outcome for managing their mental health. RT also 
uses meaningful engagement in life activities or leisure as a means to 
increase coping and therefore reduce depression and anxiety. This type 
of therapy can be particularly helpful and attractive to individuals, 
including adolescents, as an alternative, non-pharmacological outlet.

As illustrated during the hearing, the impact of the COVID-19 pandemic 
highlights the next public health emergency: stress, depression, and 
anxiety among young people and adolescents. To respond to this, serious 
steps must be taken to support young people as they cope and adjust to 
different normalcy with resiliency. The use of interdisciplinary health 
teams that include recreational therapy is required to ensure that 
young people have the necessary skills and resources to improve their 
mental health. We urge Congress to include recreational therapists in 
any legislation addressing youth mental health.

The Important Role that Recreational Therapists Play

Recreational Therapy (RT) embraces a definition of ``health'' which 
includes not only the absence of ``illness,'' but extends to the 
enhancement of physical, cognitive, emotional, social, and leisure 
development so individuals may participate fully and independently in 
chosen life pursuits. Recreational therapists address assessed client 
needs related to behavior, cognition, function, pain management, 
physical activity level, socialization, recreation, and leisure.\2\ 
Recreational therapists have the competencies to assess and implement 
interventions necessary to promote improved mental health, quality of 
life, and prevent secondary conditions \3\, \4\ by reducing 
depression, stress, and anxiety in their clients and helping build 
confidence to socialize in their community. Recreational therapists 
work in a variety of settings that promote youth and adolescent mental 
health including community mental health centers, public and 
alternative schools, co-occurring disorder programs, day hospitals for 
outpatient treatment, inpatient psychiatric hospitals, inclusive 
recreation programs, residential living facilities, nature-based 
recreation programs, and addiction recovery centers.

In the United States, recreational therapists at a minimum must have a 
bachelor's degree in recreational therapy (or therapeutic recreation) 
or a related field.\5\ Anatomy and physiology, assessment, salient 
characteristics of illness and disabilities, medical terminology, the 
therapeutic process, and 560 hours of fieldwork are required 
courses.\6\ The Certified Therapeutic Recreation Specialist (CTRS) is 
the required certification for recreational therapists by NCTRC and 
shows that the recreational therapist has passed an all-encompassing 
national certification exam demonstrating extensive knowledge and 
skill-based training in core therapy skills (assessment, planning, 
implementation, documentation, and evaluation), a team-oriented 
approach to care delivery, and training in group processes.\5\ The CTRS 
credential is required for practice as a recreational therapist in 
Veterans Affairs \7\ and designated as the accepted certification for 
recreational therapists by the Centers for Medicare and Medicaid 
Services federal guidelines for skilled nursing facilities. Ethical 
conduct is mandated by the professional organization, the American 
Therapeutic Recreation Association (ATRA)'s code of ethics, and quality 
indicators of RT practice are supported by the ATRA Standards of 
Practice.\1\

Research has shown the effectiveness of recreational therapy services 
for young people's mental health outcomes. Through recreational therapy 
interventions, youth with mental health challenges saw increases in 
health-related quality of life,\8\ positive changes in their perceived 
self-esteem,\9\ and decreases in feelings of social isolation and 
loneliness.\10\ Through outdoor adventure interventions, recreational 
therapists also helped some young people with substance abuse disorder 
and post-
traumatic stress disorder to learn effective strategies for their 
personal recovery.\11\

To better explain the role of RT, we have provided some examples of 
recreational therapy services specific to adolescents with mental 
health conditions:

      A recreational therapist in Virginia works at a residential 
treatment center for adolescents with mental health diagnoses. 
Utilizing stress management interventions like guided imagery, 
progressive muscle relaxation, Tai Chi, and yoga, recreational therapy 
services help adolescents reach goals like decreasing symptoms of 
depression and anxiety while increasing self-confidence and personal 
grounding.
      Another recreational therapist works in a school in New Mexico 
with high school students with intellectual and developmental 
disabilities (IDD) who are experiencing increased anxiety during COVID-
19. Recreational therapy services help the students cope with feelings 
of fear, worry, and hopelessness through after-school, group therapy 
sessions for teaching emotional identification, coping skills, and 
adjustment strategies to navigate their ever-changing daily schedules.
      Lastly, a recreation therapist in Colorado utilizes nature-
based, adventure therapy interventions for adolescents with mental 
health diagnoses. Goals of improving adolescents' self-confidence, 
problem-solving skills, and sense of community are achieved through 
outcomes-based, recreational therapy modalities that include kayaking, 
rock climbing, high and low ropes courses, and wilderness hiking.

Conclusion

As Congress considers new legislative efforts to improve youth mental 
health, we ask that recreational therapy services be considered 
essential to addressing the mental health crisis for youth and 
adolescents as a result of the COVID-19 pandemic. Specifically, we urge 
Congress to include recreational therapists in any legislative language 
dedicated to reducing stress, anxiety, and depression among youth and 
adolescents. We welcome the opportunity to speak with you more about 
what RT is, and how it can help in responding to the mental health 
emergency as a result of COVID-19. Please do not hesitate to reach out 
to the American Therapeutic Recreation Association (ATRA) directly, 
please contact Brent Wolfe, ATRA Executive Director, at brent@atra-
online.com or by phone at (703) 234-4140.

Sincerely,

Brent Wolfe

End Notes

[1] Kemeny B, Fawber H, Finegan J, Marcinko D. Recreational therapy: 
            Implications for life care planning. J Life Care Plan. 
            2020;18(4):35-58.
[2] Commission on Accreditation of Rehabilitation Facilities. 2020 
            Medical Rehabilitation Standards Manual. 2020.
[3] Hawkins B, Kemeny B, Porter H. Recreational therapy competencies, 
            Part 2: Findings from the ATRA competencies study. Ther 
            Recreation J. 2020;54(4). doi:10.18666/trj-2020-v54-i4-
            10238.
[4] Kinney J. Analysis of services performed by recreational 
            therapists. Ther Recreation J. 2020;54(3):227-243. 
            doi:10.18666/trj-2020-v54-i3-10248.
[5] National Council for Therapeutic Recreation Certification. The CTRS 
            is the qualified provider of Recreational Therapy Services. 
            2020.
[6] Bureau of Labor Statistics U.S. Department of Labor. Occupational 
            Outlook Handbook, Recreational Therapists. 2020.
[7] U.S. Department of Veterans Affairs. VA Handbook 5005, Part II, 
            Appendix G60. The Recreation and Creative Arts Therapist.
[8] Bennett JR, Negley SK, Wells MS, Connolly P. Addressing well-being 
            in early and middle childhood: Recreation therapy 
            interventions aimed to develop skills that create a healthy 
            life. Spec Issue Strengths-based Pract--Part 1. 2016;50(1): 
            unpaginated. http://js.sagamorepub.com/trj/article/view/
            6782.
[9] Concepcion H. Video game therapy as an intervention for children 
            With disabilities. Ther Recreation J. 2017;(3):221-228.
[10] Luchies LB, Barbour AL, Anderson SR. Children's Healing Center 
            involvement reduces social isolation and loneliness among 
            immunocompromised children and their family members. Am J 
            Recreat Ther. 2019;18(3):37-47.
[11] Leighton J, Lopez KJ, Johnson CW. ``There is Always Progress to Be 
            Made'': Reflective Narratives on Outdoor Therapeutic 
            Recreation for Mental Health Support. Ther Recreation J. 
            2021;55(2):185-203.

                                 ______
                                 
                 Letter Submitted by Stephanie Barrett

U.S. Senate
Committee on Finance

To the honorable members of the Senate Finance Committee:

I've worked on the social service delivery and government sides of the 
system of care for youth with mental health challenges over the last 27 
years, in direct service to teens facing adversity, sexual assault 
services (including child sexual abuse), and child protective field 
work before moving to the bureaucratic role. There are numerous 
challenges in accessing effective mental health services for children 
and youth.

Most recently, the Private Equity Stakeholder Project released a report 
on the rising impact of private equity in children's mental health 
services. This is a concerning trend, as equity has turned an eye to 
extracting profits from an industry with slim margins. Whatever 
approaches to this problem are taken must account for the vultures, 
circling what is an apparent cash cow in the birthing, as attention 
(and as it follows, money) is turned toward this vital sector. See 
report: ``The Kids Are Not Alright: How Private Equity Profits Off of 
Behavioral Health Services for Vulnerable and At-Risk Youth,'' Eileen 
O'Grady, February 2022, https://pestakeholder.org/wp-content/uploads/
2022/02/PESP_Youth_BH_Report_2022.pdf.

Having been elbows deep in treatment programs for the last 14 years, I 
can share some essential observations regarding factors that affect 
quality services to children and youth:

    -  Bureaucratic focus on Evidence-Based Practices (EBPs): I have 
repeatedly seen EBPs embraced, at considerable expense, then delivered 
to those outside the basis of the evidence. There are good EBPs and 
there are bad EBPs. At the end of the day, no EBP will be effective if 
safety, both physical and emotional in a way the nervous system can 
perceive it, is not established.

    -  The longest-running, most well-established factor (evidence 
base) that predicts success of treatment is the quality of the 
relationship with the clinician.

    -  Mental health treatment for children and youth is delivered, 
broadly, by the least qualified and capable clinicians in the field, 
typically the new grads and those with ``conditional'' licenses.

    -  Children's program clinicians experience low wages for the field 
and poor supervision.

    -  As conditional clinicians gain any skill and experience, and 
their full licensure, they often move on to work outside of residential 
programs and beyond, to private practice.

    -  With the turnover in children's clinicians, it's difficult to 
establish a trustworthy relationship. Oftentimes, the broken 
relationships just reinforce the relational trauma of those in 
services.

My suggestions for improvement include:

      Wage standards, identified in rate, to increase starting pay for 
clinicians in children's treatment settings with the aim of attracting 
and retaining high-quality, capable clinicians.

      Enforceable standards for quality clinical supervision of 
conditional licensees, and accounted for within the rates.

      Enforceable standards for clinical quality--I have read 
terrible, terrible work, over and over, with few to no teeth to force a 
change.

      Standards for providers that emphasize safety at all levels, and 
freedom from intrusive behavioral interventions. The Qualified 
Residential Provider language under FFPSA takes a huge stride in the 
right direction.

      Statute that obligates investigation of ANY allegation of sexual 
abuse or impropriety by a clinician or residential program staff 
against any child or youth receiving services.

      Enforceability. Not just through cost recovery, but through 
public information and a clearly delineated quality and corrections 
process that is uniform regardless of the state or entity providing 
oversight and that is impervious to swings in policy that is common at 
the state level with changes in administration.

This last suggestion will also give bones and hope to dedicated public 
servants who are trying to fulfill their duties in the public trust. I 
have stories I can tell about how administrations can quickly dismantle 
oversight structures and how hard it is to recover. Meanwhile, children 
and youths suffer with their struggles and poor quality services. 
Meanwhile, the child welfare system has a role to play as well. I once 
evaluated a number of youth suicides occurring in our state and nearly 
all had or should have had effective child welfare involvement. Those 
youths (age 8-17) were living in dangerous homes and several had taken 
their own lives after yet again meeting a child welfare worker who 
unsubstantiated the allegations of abuse. When the worker walked out 
the door, that kid had no hope that anyone would be able to help them. 
Meanwhile, the 8-year-old's family didn't have a CPS record, but should 
have. Sadly, the most challenging cases I handled as a CPS worker were 
intergenerational trauma and when I knocked on the door, with the tools 
I had, I was failing the fourth generation.

I'm happy to provide any additional info or context as requested. With 
respect,

Stephanie Barrett
Quality Assurance and Training Manager
Disability and Brain Injury Services
Office of Aging and Disability Services
41 Anthony Avenue, SHS 11
Augusta, ME 04333
Desk: (207) 287-7048

To access the CDS Amin and Trainers list self-service, please use this 
link: https://forms.office.com/g/TDA1A8p9zU.

DirectCourse ON-DEMAND ADMINISTRATOR TRAINING:
Select ``Resource Center'' from bottom of DirectCourse landing page. 
Then select ``DirectCourse'' from second page and ``Training'' from top 
of final landing page.

                                 ______
                                 
                   California Youth Connection et al.

March 1, 2022

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

Dear Chairman Wyden, Ranking Member Crapo, and members of the Senate 
Finance Committee:

Thank you for your interest and focus on improving access to mental 
health services and supports for children and youth. The testimony 
provided at the hearings on February 8th and February 15th was 
insightful, sobering, and provided many helpful recommendations on how 
to address the mental health crisis that children, youth and families 
are confronting across the country. We write to add our voice and the 
voices of young people with experience in foster care for your 
consideration as you begin to develop solutions that will improve 
access to and the quality of mental health care for children, youth, 
and families.

Young people in and leaving foster care are at the center of the mental 
health crisis. The removal and separation of children from their 
families in and of itself can be a traumatic experience requiring 
mental health treatment. Many young people have entered the child 
welfare system because of unmet mental health needs. Their family 
members may also be experiencing mental health challenges as well. Once 
in the foster care system, young people often experience additional 
trauma and mental health challenges which frequently last long beyond 
their time in care. Failing to address the needs of these young people 
has dire consequences for their health and well-being as youth and as 
adults, yet large numbers of youth report that their needs are not met 
and that their healing is not a priority in the child welfare and 
mental health systems. We hope that designing a better approach to 
providing mental health services, addressing the impact of trauma, and 
centering healing will be a priority for both mental health and child 
welfare reform and improvements.

We agree with Trace Terrell from Youth Line in Oregon who testified on 
February 15th; it is critical to hear from young people and families 
who are impacted by the mental health system. We're grateful to the 
members of the Senate Finance Committee and the Committee's commitment 
to listening to young people and families. With this in mind, our 
recommendations were developed in collaboration with young people with 
experience in foster care and the organizations that serve them.

Young people who have been in foster care have consistently called for 
mental and behavioral health reforms that are youth-driven, supportive, 
gender-affirming, and culturally responsive. Our suggested reforms 
follow their lead because the first step in healing is establishing an 
environment where young people feel safe to develop trusting 
relationships with those who are helping them on their journey. 
Services and treatment must be trauma-informed, constructive, and 
healing. Even more importantly, we have to base our reforms in an anti-
racist framework. Healing is thwarted when the behavioral health care 
system ignores the historical harms, present realities, unique needs, 
and cultural strengths of young people of color. Changes to the 
behavioral health care system must work against the pathologizing of 
non-white cultural practices, values, and familial norms. Reforms must 
be sensitive to the systemic oppressions that have harmed the mental 
and behavioral health of youth who have experienced foster care and 
actively remove barriers to equity at the intrapersonal, interpersonal, 
community, and system levels.

We have submitted detailed recommendations in response to the 
Committee's Request for Information in the Fall of 2021, which are 
attached. Below we summarize our key recommendations.

RECOMMENDATION 1:

Connect young people with behavioral and mental health care providers 
in their communities and ensure that healing is at the center of case 
planning and service delivery in the child welfare system.

RECOMMENDATION 2:

Ensure that young people have education, agency, and access to 
available behavioral and mental health services in their communities.

RECOMMENDATION 3:

End systemic racism and all forms of oppression in mental health 
systems by requiring training, ensuring and enforcing anti-
discrimination provisions, requiring affirming practices, and 
supporting the provisions of services in the communities of youth and 
their families.

RECOMMENDATION 4:

Radically reduce the use of psychotropic medications and enhance 
federal and state oversight of their use for youth in the foster care 
system.

RECOMMENDATION 5:

Ensure that young people in and leaving foster care have access to--and 
that Medicaid can fund--holistic and alternative treatment other than 
medication and talk therapy, including specialized treatments and 
enrichment activities.

RECOMMENDATION 6:

Ensure that young people in and leaving foster care have access to the 
effective intervention of peer support as a part of the behavioral 
health array of services in every state.

RECOMMENDATION 7:

Ensure that behavioral health providers serving youth with experience 
in foster care have a caseload, the training, and expertise that allows 
them to provide excellent and age-appropriate services.

RECOMMENDATION 8:

Ensure and enhance the EPSDT guarantee to better promote the health and 
well-being of young people in and leaving foster care by (1) providing 
presumptive eligibility for Medicaid to all youth in foster care for 
all available mental health services that a youth elects to receive, 
(2) improving and enhancing planning and support for mental health care 
and Medicaid coverage when youth leave the child welfare system due to 
permanency or age, and (3) incentivizing specialized care coordination 
through the development of a national foster care enhanced case 
management definition that is Medicaid reimbursable.

Submitted by:

California Youth Connection

Children's Law Center of California

Children's Rights

First Focus Campaign for Children

FosterClub

Juvenile Law Center

National Foster Youth Institute

Think of Us

Youth Law Center

Youth Villages

                                 ______
                                 
November 1, 2021

RE: Request for Proposals to Address Unmet Mental Health Needs

Dear Chairman Wyden, Ranking Member Crapo, and members of the Senate 
Finance Committee:

The undersigned organizations are writing to submit a joint response to 
the Committee's September 21, 2021 request for proposals from the 
public about how Congress can make data-driven policy to improve 
health-care access for ``Americans with mental health and substance use 
disorders.'' We comprise the Mental and Behavioral Health Subgroup of 
the Federal Older Youth Coalition, which advocates for services and 
support for older and former youth in foster care. We have collaborated 
with young people with experience in foster care and the organizations 
that serve them to identify federal legislative and administrative 
reforms.

Young people who have been in foster care have consistently called for 
behavioral health reforms that are youth-driven, supportive, gender-
affirming, and culturally responsive. Our suggested reforms follow 
their lead because the first step in healing is establishing an 
environment where young people feel safe to develop trusting 
relationships with those who are helping them on their journey. Through 
policy papers, presentations and reports, young people with foster care 
experience have told us what they need from the behavioral health 
system and so we are proposing reforms that facilitate youth's 
connection to services and treatment that are trauma-informed, 
constructive and healing.

Comprehensive reform in the area of behavioral health care is needed to 
ensure that young people with experience in foster care receive the 
services and support they need to heal and thrive. ``Comprehensive 
reform'' means we need to change what services and supports are offered 
and the frequency and timing that they are offered. Even more 
importantly, we have to base our reforms in an anti-racist framework. 
Changes to the behavioral health-care system must work against the 
pathologizing of non-white cultural practices, values, and familial 
norms. Healing is thwarted when the behavioral health-care system 
ignores the historical harms, present realities, unique needs, and 
cultural strengths of young people of color. Therefore, these reforms 
have to be driven by an anti-racist approach that is sensitive to the 
systemic oppressions that have harmed the mental and behavioral health 
of youth who have experienced foster care and that actively removes 
barriers to equity at the intrapersonal, interpersonal, community and 
system levels.

We believe that comprehensive reform, which is detailed in our 
recommendations below, must achieve the following:

      Educate young people about the impact of trauma and the range of 
treatment, supports, and activities that are available to them to help 
them cope and heal;
      Make improvements to screening and assessment that are informed 
by knowledge of the impact of trauma on behavior, acknowledges the 
trauma of removal from family, and does not result in anthologizing and 
labeling expected reactions to trauma;
      Provide timely connection to treatment;
      Provide timely connection with the supports that young people 
identify, including alternatives to traditional forms of clinical care, 
supports, and activities that center healing and the development of 
well-being; and
      Make high quality, effective treatment, supports, and 
interventions available at multiple intervals.

Under each of our recommendations, we have highlighted their overlap 
with the five areas referenced in the Request for Information: (1) 
Strengthening the workforce; (2) Increasing integration, coordination 
and access to care; (3) Ensuring parity between behavioral and physical 
health care; (4) Expanding the use of telehealth; (5) Improving access 
to behavioral health care for children and young people.\1\ We have 
also addressed Funding, Cultural Humility, Racial Equity, and Research 
within several of our recommendations. We urge the Committee to ensure 
that all reforms advance racial equity and to elevate policies aiming 
to eliminate racism in the mental and behavioral health arena.
---------------------------------------------------------------------------
    \1\ While some of our recommendations may fall into a few of the 
categories in area (5), we noted the category that seemed most 
relevant.
---------------------------------------------------------------------------

RECOMMENDATION 1:

Congress should take the following actions to connect young people with 
behavioral and mental health-care providers authentically and ensure 
that healing is at the center of case planning and service delivery.

Strengthening the Workforce

      Provide funding for grants and technical assistance to build 
state and local agencies' psychosocial services capacity to ensure that 
transition-age youth and their parents or caregivers have access to 
mental health screenings and comprehensive, trauma-informed, evidence-
based psychosocial services.

Increasing Integration, Coordination, and Access to Care

      Develop a plan to improve coordination among maternal and child, 
youth, and family programs (HRSA, ACF, etc.) and plans to integrate 
trauma-informed and resilience training and programming on a systematic 
basis.
      Develop standards of practice and highlight models of service 
delivery that are most effective for expectant and parenting youth.

Calls for Research

      Establish a demonstration program within the Centers on Medicaid 
and Medicare Services (CMS) that: Reviews research and makes 
recommendations on the use of non medical interventions for the 
treatment of trauma, the current availability of those treatments, and 
how they are funded.

RECOMMENDATION 2:

Congress should take the following action to ensure that young people 
have education, agency, and access to available behavioral and mental 
health services in their communities.

Strengthening the Workforce

      Adjust reimbursement rates to better compensate and attract 
mental and behavioral health-care providers.

Increasing Integration, Coordination, and Access to Care

      Congress should require coordination between HHS and CMS to 
improve the availability of trauma-informed, evidence-based 
psychosocial services to 
transition-age youth via additional grants and technical assistance. 
This should include additional funding for wrap-around services to 
facilitate access to and receipt of behavioral health services for 
transition-age youth, including transportation costs, child care costs, 
and reimbursement for lost wages.
      Congress should ensure the availability of and accessibility to 
comprehensive preventative health-care services guaranteed in federal 
law through EPSDT for children younger than 21.

Improving Access for Children and Young People

      Congress should amend Title IV-B, Subpart 2 to include more 
explicit requirements around post permanency supports, including 
additional funding for post-adoption, guardianship and reunification 
services that are available until the age of 26.
      Congress should take action to allow youth exiting Adoption 
Assistance to apply early for SSI as an adult so that their Medicaid 
coverage continues during the determination period.

Calls for Research

      Congress should authorize a study on transition-age youth access 
to mental health services and outstanding providers that work with 
transition age youth that show positive outcomes on mental health 
services. The study should also include how youth are provided the 
following: information about the terms of their health insurance 
coverage, coverage for behavioral health services, information about 
how to renew their coverage, and a listing of available health-care 
providers in their area who will accept their coverage prior to their 
discharge from care.

RECOMMENDATION 3:

Congress should take the following action to end systemic racism and 
all forms of oppression in mental health systems.

Strengthening the Workforce by Promoting an Anti-Racist Approach

      Require that providers of behavioral health services participate 
in pre-service and ongoing anti-racism and trauma-informed training and 
collect data on the receipt of training.
      As a condition of receiving federal funds, require that all 
service providers follow non-discrimination policies and provide 
services that are culturally competent and developmentally appropriate.
      Require child welfare agencies contract with medical and 
behavioral health providers in sufficient numbers to reflect the racial 
and cultural diversity of children and youth in care, and with medical 
and behavioral health providers that can support transgender and gender 
nonconforming children and their caregivers.

Funding Reforms and Cultural Humility

      Fund research on culturally responsive evidence based mental 
health prevention and treatment services for children and families of 
color. Allow for the cultural adaptation of existing evidence based 
mental health service models to address the disparities and inequities 
for children and families of color, especially those who are Indigenous 
and Alaska Native, LGBTQ+ or Two-Spirit, and those that are 
intersectional.

RECOMMENDATION 4:

Congress should take the following actions to radically reduce the use 
of psychotropic medications and enhance federal and state oversight of 
their use for youth in the foster care system.

Increasing Integration, Coordination, and Access to Care

      Congress should increase federal oversight of states' 
prescription and use of psychotropic medications among children and 
young people in foster care and require that states' health-care 
coordination and oversight plans are included in a state's Title IV-E 
plan. States should have the following in place:
          Policies to ensure meaningful informed consent 
and assent to psychotropic medication are obtained for each new or 
continuing psychotropic medication prescription, including 
documentation that the youth has been offered other evidence-based 
interventions besides psychotropic medication;
          Clear guidance to caseworkers, prescribers, 
caregivers, biological parents, and youth on which individuals are 
responsible for the informed consent and assent decisions, including: 
the role(s) of a protective adult and pre-TPR biological parent in a 
informed consent; youth-friendly process(es) for refusal, complaints, 
and grievances by the youth; and process(es) to be heard by a neutral 
decision-maker in the event of conflict;
          Best practices around metabolic baseline 
screening and monitoring prior to psychotropic medication authorization 
and continuance;
          Access to a secondary medical review by a 
licensed child and/or adolescent psychiatrist for outlier or off-label 
prescriptions with known risks, such as those above the maximum adult 
dosage, prescription of multiple medications in the same class and 
across classes, prescription of psychotropics to children under the age 
of 6, and others;
          An oversight process to routinely assess the 
safety of prescribed psychotropic medications, including an analysis of 
appropriate dosages, strength, necessity, generics and substitutions, 
and contraindications of combined medications;
          A red flag or independent second opinion system 
with a licensed child psychiatrist;
          An up-to-date medical passport containing 
essential information on the child, including health history, 
diagnoses, medications, dosages, potential side effects, and observed 
side effects, is delivered with the child upon placement and moves with 
the child from placement to placement;
          Details regarding how the state will provide 
first-line psychosocial services, reducing over-reliance on 
psychotropic medications, and how it will help young people that may 
develop an addiction.

      Congress should also:

          Ensure that states are incorporating professional 
practice guidelines and that the prescription of and monitoring of 
psychotropic medications is done in compliance with professional 
practice guidelines for the state;
          Ensure that states provide an opportunity for 
young people to voice their wishes on whether they are prescribed 
psychotropic medication.

RECOMMENDATION 5:

Congress should take the following actions to ensure that young people 
have access to holistic and alternative treatment other than medication 
and talk therapy, including specialized treatments that are currently 
not billable to Medicaid.

Increasing Access for Children and Young People

      Develop a national peer certification protocol that will enable 
the expansion of peer support programs.
      Ensure that holistic and alternative treatments can be funded 
through Medicaid and other federal funding streams.

Funding Proposals

      Establish a demonstration program within the Centers on Medicaid 
and Medicare Services (CMS) that reviews research and makes 
recommendations on the use of non- medical interventions for the 
treatment of trauma, the current availability of those treatments and 
how they are funded.

RECOMMENDATION 6:

Congress should take the following actions to ensure that young people 
have access to the effective intervention of peer support as a part of 
the behavioral health array of services in every state.

Increasing Access for Children and Young People

      Develop a national peer certification protocol that will enable 
the expansion of peer support programs.
      Ensure that Medicaid and other funding streams support the 
delivery of outreach, treatment and ancillary support services that 
improve mental health and well-being by individuals with lived 
experience, including federal protocols for peer certification that 
streamline the process in the states.

RECOMMENDATION 7:

Congress should take action to ensure that behavioral health providers 
serving youth with experience in foster care have a caseload, the 
training, and expertise that allows them to provide excellent and age-
appropriate services.

Funding Reforms

      Increase funding for statewide family networks currently 
administered through SAMHSA discretionary funds and set aside for child 
welfare and juvenile justice involved children.
      Increase the Medicaid reimbursement rate for behavioral health 
providers that are effectively able to respond to the treatment needs 
of young people in foster care by delivering treatments that have been 
identified as effective through research, are trauma sensitive, 
informed by a racial equity approach, and informed by the feedback of 
young people.

RECOMMENDATION 8:

Congress should take the following actions to preserve and enforce the 
EPSDT guarantee to better promote the health and well-being of young 
people.

Increasing Integration, Coordination, and Access to Care

      Provide presumptive eligibility for Medicaid to all youth in 
foster care for all available behavioral health services that a youth 
elects to receive.
      Congress should require all states to provide a final needs 
assessment if a youth wishes, to assess the mental and emotional well-
being of all youth achieving permanency and/or when their case closes 
and ensure an adequate plan for services, including for young people 
who are transitioning to adulthood. In the assessment, youth should be 
evaluated for their mental and emotional well being to determine a plan 
of recommended service(s) to ensure a successful healing and growth 
process for youth beyond placement. States will also benefit from this 
assessment, as it will be a tool to address the gap in services 
specific to their population.
      For young people who are transitioning out of foster care to 
adulthood, amend the transition planning requirement of the Social 
Security Act to ensure that there is documentation of the following:
          That the young person's Medicaid eligibility as a 
former foster youth has been established, that eligibility under 
another category has been established, or other health insurance 
coverage if the young person is not eligible for Medicaid;
          The transition plan includes a list of behavioral 
health or mental health treatment providers if the young person wanted 
continued treatment and services.
          That the young person with a disability or 
special need has been assisted in applying for any federal and state 
benefits that will support their care and well-being, including, but 
not limited to SSI, SSDI, and Home and Community Based Waivers.

Increasing Access for Children and Young People

      Develop a national foster care enhanced case management 
definition that is Medicaid reimbursable so that children and youth in 
foster care can receive improved care coordination. Conduct a study on 
evidence-based case management services (i.e., Motivational 
Interviewing, Solution-Based) and provide Medicaid reimbursement.
      Mandate Medicaid coverage for all children and youth in foster 
care regardless of their in-state or out of state status,\2\ receipt of 
a foster care maintenance payment or their immigration status.
---------------------------------------------------------------------------
    \2\ Effective January 2023, The Substance Use-Disorder Prevention 
that Promotes Opioid Recovery and Treatment for Patients and 
Communities Act (Pub. L. 115-271) will expand Medicaid coverage for 
former foster youth so that all states will cover youth regardless of 
the state in which they were in foster care. We propose that the 
effective date of this vital reform be moved up to 2022.
---------------------------------------------------------------------------

Strengthen the Workforce

      Increase the Federal Match Assistance Percentage (FMAP) to 90% 
for all children's mental health and supportive services provided under 
the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) 
entitlement, covering all children under the age of 21 in all states 
and territories.
      Apply the 90% FMAP to Medicaid Administrative Activities (MAA) 
related to youth behavioral health including workforce training, 
technical assistance, outreach and education. Gradually reduce the 90% 
FMAP over a 5-year period to 80%.

Submitted by:

California Youth Connection

Children's Rights

First Focus Campaign for Children

FosterClub

Juvenile Law Center

National Foster Care Institute

Think of Us

Youth Law Center

Youth Villages

For more information, please contact:

        Aubrey Edwards-Luce, First Focus Campaign for Children, 
        aubreyel@firstfocus.
        org Tony Parsons, Youth Villages, 
        [email protected].

                                 ______
                                 
                    Children Now (California) et al.

                                                        Elissa Hyne
             On behalf of the undersigned organizational members of
                the State Policy Advocacy and Reform Center (SPARC)
                             c/o Partnership for America's Children
                                 5335 Wisconsin Ave., NW, Suite 440
                                              Washington, DC, 20015

March 14, 2022

Chairman Ron Wyden
U.S. Senate
221 Dirksen Senate Office Building
Washington, DC 20510

Ranking Member Mike Crapo
239 Dirksen Senate Office Building
Washington, DC 20510

RE: Testimony regarding the mental health of children and youth in the 
foster care system for the ``Protecting Youth Mental Health: Part II--
Identifying and Addressing Barriers to Care'' hearing held on Tuesday, 
February 15, 2022

Dear Chairman Wyden and Ranking Member Crapo:

The undersigned organizations are members of the State Policy Advocacy 
and Reform Center (SPARC), a network of state multi-issue child 
advocacy organizations, legal advocates, and organizations focused on 
children and families involved with the child welfare system. We submit 
testimony to the Senate Committee on Finance regarding the hearing that 
took place on February 15, 2022, entitled ``Protecting Youth Mental 
Health: Part II--Identifying and Addressing Barriers to Care.'' SPARC 
commends the Committee for its continued attention to the mental health 
needs of children and youth. Children and youth involved with the child 
welfare system are a particularly vulnerable population and the systems 
and processes meant to address their mental health needs require 
special consideration and improvement.

On any given day there are over 400,000 children in foster care in the 
United States, and an estimated 80 percent of those children have 
significant mental health issues.\1\ That is four times the incidence 
found in the general population (approximately 18 to 22 percent).\2\ In 
fact, children in foster care and those who have aged out of foster 
care experience Post-Traumatic Stress Disorder (PTSD) at a rate that is 
double that of war veterans.\3\ Children in foster care have a history 
of complex trauma, have experienced frequent home and life changes, 
have suffered the loss of family relationships, and have had 
inconsistent and inadequate access to mental health services. The very 
act of the child welfare agency removing a child from their family and 
home and placing them in foster care is a traumatizing experience. 
Given the prevalence of mental health issues in the foster care 
population, providing quality mental health services and care 
coordination is essential.
---------------------------------------------------------------------------
    \1\ Dore, M. (2005). ``Child and adolescent mental health.'' In G. 
Mallon and P. Hess (eds.), Child Welfare for the Twenty-first Century: 
A Handbook of Practices, Policies and Programs (148-172). New York: 
Columbia University Press.
    \2\ Dore, M. (2005). ``Child and adolescent mental health.'' In G. 
Mallon and P. Hess (eds.), Child Welfare for the Twenty-first Century: 
A Handbook of Practices, Policies and Programs (148-172). New York: 
Columbia University Press.
    \3\ Casey Family Programs, Assessing the Effects of Foster Care: 
Mental Health Outcomes from the Casey National Alumni Study. Retrieved 
March 4, 2022 from: http://www.casey.org/media/
AlumniStudy_US_Report_MentalHealth.pdf.

Despite the prevalence of mental health issues among the child welfare 
population, there is an overall lack of adequate access to mental 
health services. In fact, the American Academy of Pediatrics has 
identified mental and behavioral health as the ``greatest unmet health 
need for children and teens in foster care.'' Without appropriate 
mental health care, children in foster care are prescribed psychotropic 
medications at a much higher rate than children in the general 
population. Some studies have found that children in foster care are 
prescribed psychotropic medications at a rate 3 times that of other 
children enrolled in Medicaid and have higher rates of polypharmacy.\4\ 
Not only is this practice incredibly harmful to the children 
themselves, it costs states millions each year.
---------------------------------------------------------------------------
    \4\ Zito, J.M., Safer, D.J., Said, D., et al. (2008). 
``Psychotropic medication patterns among youth in foster care.'' 
Pediatrics, 121 (1). Available at: www.pediatrics.org/cgi/content/full/
121/1/e157[PubMed].

Notwithstanding the clear and compelling evidence that children and 
youth in foster care experience a wide array of mental health issues, 
the processes and systems created to meet those needs are falling 
short. There are multiple barriers to providing adequate and 
appropriate mental health care to children in foster care: incomplete 
or unavailable health information, difficulty identifying who has the 
authority to consent for health care on behalf of the child, deficient 
care coordination between agencies, and inadequate resources for 
evaluation and treatment. For example, although most children in foster 
care are eligible for Medicaid, many pediatric mental health care 
providers are unwilling to accept Medicaid patients--only approximately 
one third of psychiatrists accepted new Medicaid patients.\5\
---------------------------------------------------------------------------
    \5\ Holgash, K., and Heberlein, M. (2019). ``Physician acceptance 
of new Medicaid patients: What matters and what doesn't.'' Retrieved 
March 4, 2022 from https://www.healthaffairs.org/do/10.1377/
forefront.20190401.678690/full/.

The situation for children and youth in foster care has only worsened 
during the COVID-19 pandemic as providers have witnessed an alarming 
number of children and adolescents with severe mental health issues. 
During the hearing held on February 15, Senator Wyden stated that 
America's children are ``on a path to crisis.'' In fact, children and 
youth in the foster care system are already experiencing that mental 
---------------------------------------------------------------------------
health crisis.

There is general acceptance that there needs to be cross-system 
collaboration and care coordination to ensure that behavioral health 
care is coordinated between Medicaid and other child-serving systems, 
including the child welfare system. There must be more effective 
psychotropic medication management for children in the foster care 
system, including red-flag systems and consent processes. Children in 
foster care need more access to appropriate and effective mental health 
services for children and youth up to age 26, including using Medicaid 
to support intensive care coordination, wraparound services, family and 
youth peer support, in-home services, treatment foster care, and other 
home and community-based services and supports. Child welfare systems 
must provide the required, but not always administered, periodic 
thorough mental health assessments and screenings for all children and 
youth in their care. And there must be systems in place to ensure 
continuity of mental health care at all points throughout the child's 
life: at entry into care, between placements while in care, and at exit 
from care (whether that be reunification, adoption, or aging out).

We commend the Senate Committee on Finance's willingness to focus on 
this mental health crisis for children and youth in foster care and we 
thank you for your consideration of our views. If you have any 
questions, please feel free to contact SPARC's Senior Child Welfare 
Policy Manager, Elissa Hyne at (203) 561-7212 or ehyne@
foramericaschildren.org.

Sincerely,

Children Now (California)           Michigan's Children
Children's Action Alliance 
(Arizona)                           Nebraska Appleseed
Children's Trust of South Carolina  Our Children Oregon
Florida's Children First            Partners for Our Children 
                                    (Washington)
Foster Success (Indiana)            Pennsylvania Partnerships for 
                                    Children
FosterAdopt Connect (Missouri and 
Kansas)                             Rhode Island KIDS COUNT
Hawai'i Children's Action Network   Tennessee Voices for Children
Juvenile Law Center (Pennsylvania)  TexProtects (Texas)
Kansas Appleseed                    Texans Care for Children
Kentucky Youth Advocates            Voices for Utah Children
Maine Children's Alliance           Voices for Vermont's Children
Marion County Commission on Youth 
(MCCOY) (Indiana)                   Voices for Virginia's Children

                                 ______
                                 
                           Children's Health

                      1935 Medical District Drive

                          Dallas, Texas 75235

                              214-456-7000

                           www.childrens.com

            Statement of Jeanne Nightingale, MS, BSN, R.N., 
                Senior Director for Psychiatry Services

Chairman Wyden, Ranking Member Crapo, and members of the committee, 
thank you for convening two hearings on youth mental health and for the 
opportunity to submit a statement for the record.

As Senior Director for Psychiatry Services at Children's Health in 
Dallas, Texas, I oversee clinical operations related to pediatric 
psychiatry programs at Children's Health--including inpatient services, 
partial hospitalization, intensive outpatient, outpatient, consultative 
and research services--as well as the embedded psychological services 
for patients who are being treated throughout the hospital for a 
chronic or acute medical diagnosis. Children's Health has seen 
firsthand the growing crisis in pediatric mental health, which has only 
been compounded by COVID-19.

The pandemic has taken a toll on children, whose lives were disrupted 
at a critical time in their development. Children and families--
especially those in underserved communities disproportionately impacted 
by the virus--have experienced significant social isolation, economic 
stress, fear and grief. These challenges have contributed to a sharp 
increase in the number of children with mental health concerns, 
including depression, anxiety, suicidal ideation, disordered eating, 
anger and substance use. As a result, more children and families in 
crisis are presenting to pediatric emergency departments without 
anywhere else to turn.

The Pediatric Mental Health Crisis at Children's Health

Since the start of the pandemic, Children's Health has seen a larger 
percentage of children in the emergency department (ED) with mental 
health needs than ever before. In 2021, more than 5,400 children 
presented to our Dallas and Plano EDs in need of mental health 
evaluations and services. This is a 43% increase from 2020 and a 273% 
increase in the past five years. Often, these children are presenting 
with acute mental and behavioral health needs--including aggression, 
intentional self-harm and suicidal ideation--that require significant 
resources to keep patients and staff physically safe.

In addition to the increasing number and acuity of behavioral health 
patients, we are also seeing these children stay in the ED longer due 
limited alternative placement options such as available inpatient 
psychiatric hospitalization and outpatient psychiatric treatment 
programs. North Texas lacks sufficient pediatric inpatient psychiatric 
beds and facilities to meet the growing need in our community. In 2021, 
49% of children (1,787) seen for mental health concerns at Children's 
Medical Center Dallas waited in the ED for more than 8 hours, and 16% 
of children (583) waited for more than 24 hours. Inpatient psychiatric 
beds are increasingly hard to find and wait times for outpatient 
psychiatric programs can be weeks or months long. These children have 
no better option but to board in our ED for extended periods of time 
while they wait for space to become available in an appropriate 
pediatric mental health care setting. Not only does ED boarding delay 
appropriate treatment and recovery for the child, but it also drains 
staff and resources.

Psychiatry Programs at Children's Health

Despite this broken system and limited resources, Children's Health is 
implementing strategies to mitigate ED volumes and ensure more children 
can access appropriate mental health care. Last year we launched a 
multifaceted response that included integrating an electronic bed 
search tool for inpatient placement to psychiatric facilities, as well 
as the launch of a mental health coordinator program to increase 
efficiencies in transferring patients from direct patient care to 
inpatient psychiatric care. Together, these initiatives decreased ED 
throughput times for patients with mental health chief complaints by 
29% from January 2021 to year end and reduced the percentage of 
patients in the ED for more than 24 hours from 24% in April 2021 to 12% 
by year end.

Children's Health has also developed and grown unique programs and 
strategies to address pediatric mental health needs, including:

      Suicide Prevention and Resilience at Children's Health (SPARC), 
an innovative, nationally renowned teen suicide prevention program that 
aims to help teens manage intense emotions and reduce risk for self-
harm and suicidal behaviors. Suicide is the second leading cause of 
death in adolescents. The SPARC program was developed to help 
adolescents who have had a recent suicidal event and need intensive 
care and support. It is the only program in Texas that uses a 
combination of teen skills group therapy, multifamily therapy, 
individual therapy and family therapy and is specifically designed to 
target the risk and protective factors associated with suicidality.

      The Center for Pediatric Eating Disorders at Children's Health, 
the nation's only pediatric program that has earned the Joint 
Commission's Disease-Specific Certification for eating disorders 
treatment. The program is a part of the Psychiatry Department, and our 
highly trained psychologists and psychiatrists have decades of 
experience treating eating disorders and other mental health issues 
that may play a role in a child's overall well-being. The program 
includes an inpatient program as well as a partial hospitalization and 
intensive outpatient program, designed to support the child and family 
throughout their journey towards recovery.

      The Teen Recovery Program, the only program in North Texas 
offering intensive outpatient care--designed just for teens--to address 
substance use and mental health conditions at the same time.

      The Center for Autism and Developmental Disabilities, which 
brings together experts in different specialties to provide care to 
children living with autism and developmental disabilities. This 
includes psychiatry services that help children cope with anxiety, 
aggression and other emotional or behavioral disorders.

      The Children's Health School-Based Tele-Behavioral Health 
Program, which connects students with licensed behavioral health 
specialists via telemedicine and is currently available to students in 
more than 250 schools across North Texas. The program expands access to 
behavioral health services for students experiencing common behavioral 
health issues such as depression, anxiety and self-esteem. Last year, 
Children's Health launched a new virtual reality technology that is 
being successfully used with students to treat their anxiety and 
depression in telehealth visits. Virtually reality can help teach 
positive coping skills and self-management techniques, such as muscle 
relaxation and deep breathing, to manage behavioral health issues.

      Strengthening our relationship with community behavioral health 
providers. Improving access to pediatric behavioral health requires 
hospitals and community providers work together. In 2021, Children's 
Health established an agreement with a community-based behavioral 
health care provider to reserve 40 beds for Children's Health patients. 
Ten of these beds are intensive beds for children who require more 
oversight, which is especially important as these children are often 
the hardest to find community placements and treatment for. Since 
September 1, 59% of behavioral health patients in our ED requiring 
inpatient psychiatric treatment have been admitted to this community 
provider, allowing more children to access care in an appropriate 
mental health setting.

 Request for Robust Support to Enhance Access to Pediatric Mental 
                    Health Care

While our current programs help us meet the needs of community, 
Congress must act to bolster the pediatric mental health care 
infrastructure. Simply put, the behavioral health needs of our children 
will not go away, and we must invest in services and supports that 
promote access to pediatric mental health care. The solution must have 
two parts:

    1.  Address the immediate need for more beds and acute care 
services by investing in pediatric mental health infrastructure to 
build capacity, and

    2.  Strengthen the continuum of care by increasing access to 
community-based services and intermediate levels of care, such as 
partial hospitalization, intensive outpatient and residential treatment 
programs.

Specifically, Children's Health encourages Congress to consider 
bipartisan policy solutions like the Children's Mental Health 
Infrastructure Act (H.R. 4943, https://www.congress.gov/117/bills/
hr4943/BILLS-117hr4943ih.pdf), which would establish a grant program 
for children's hospitals to expand mental health capacity, ranging from 
construction or modernization of facilities to other additional 
pediatric behavioral health services. This investment would help 
regions like North Texas reallocate existing resources and create new 
capacity to accommodate more pediatric behavioral health patients. 
Further, resources would be leveraged in a way that allows communities 
to come up with localized, flexible solutions to address shortages of 
beds and acute care services.

Children's Health also supports the Helping Kids Cope Act (H.R. 4944, 
https://www.congress.gov/117/bills/hr4944/BILLS-117hr4944ih.pdf), which 
would provide flexible funding to support a range of community-based 
activities including community health navigators, pediatric practice 
integration, telehealth, crisis response services, school-based 
partnerships, and workforce development. More community resources will 
go a long way to decompress emergency departments, address gaps in 
``in-between'' care, and ensure children and families receive support 
beyond the hospital. With earlier support and improved resources, 
children can better avoid, navigate and recover from mental health 
crises.

Children's Health sincerely appreciates the committee's attention to 
this pressing issue. The impact of the COVID-19 pandemic on children's 
mental health will be felt for years to come, and it is imperative that 
we make the right investments now to ensure the right level of care is 
available for children with immediate and future behavioral health 
needs. This includes providing more resources for early identification 
and preventative care, a full continuum of acute care and stepdown 
services, and long-term care services with improved care coordination 
for our most seriously ill children. Building capacity and addressing 
profound gaps in the care continuum will take collaboration, and 
children's hospitals are ready to be a part of the solution.

About Children's Health

Children's Health is the leading pediatric health care system in North 
Texas and one of the largest pediatric health care providers in the 
nation. A private, not-for-profit organization, Children's Health is 
anchored by two full-service hospitals and one specialty hospital. The 
system includes an extensive network offering specialty, urgent, 
primary, virtual care and more to the children of North Texas and 
beyond. In addition, Children's Health is affiliated with UT 
Southwestern as the official pediatric teaching hospital for the 
medical school. This provides families with access to a world-renowned 
medical faculty and transformative biomedical research. For more 
information about Children's Health, visit www.childrens.com.

For more information, contact Matt Moore, Senior Vice President, 
Government and Community Relations, Children's Health at 214-456-1971 
or Matt.Moore@
childrens.com.

                                 ______
                                 
                    Children's Hospital Association

                      600 13th St., NW, Suite 500

                          Washington, DC 20005

                              202-753-5500

                  https://www.childrenshospitals.org/

The Children's Hospital Association (CHA), representing over 220 
children's hospitals, thanks the Senate Finance Committee for holding 
this hearing, ``Protecting Youth Mental Health: Part II--Identifying 
and Addressing Barriers to Care,'' focused on this critical issue for 
children, families, the pediatric health care workforce and our entire 
nation. We call on this committee to join us in recognizing the 
magnitude of the situation and advancing meaningful and 
transformational solutions to address it.

Children's hospitals serve as a vital safety net for all children 
across the country, regardless of insurance status, including those 
that are uninsured, underinsured and enrolled in Medicaid. Medicaid is 
the single largest health insurer for children in the U.S. and serves 
as the backbone of children's health coverage. Children account for 
over 40% of Medicaid enrollees, and a large portion of children served 
by children's hospitals are covered by the program.

The challenges facing children's mental, emotional and behavioral 
health are so dire that we joined the American Academy of Pediatrics 
and American Academy of Child and Adolescent Psychiatry in declaring a 
national emergency (https://www.aap.
org/en/advocacy/child-and-adolescent-healthy-mental-development/aap-
aacap-cha-declaration-of-a-national-emergency-in-child-and-adolescent-
mental-health/) in child and adolescent mental health last fall. On the 
same day that we declared a national emergency, we launched the Sound 
the Alarm for Kids initiative (https://www.soundthealarmforkids.org/) 
to raise the visibility of the children's mental health crisis and 
build momentum for action. The emergency for our children is broadly 
recognized--now we need to work together on immediate action.

We strongly encourage the committee to put forward tailored and 
dedicated policies and support for children to better address their 
emotional, mental and behavioral health needs. The current mental 
health system for children has been under-resourced for years and now 
requires significant attention by this committee. It is an historic 
opportunity to make a national impact for children and prevent larger 
and more costly problems in the long term. As the single largest payer 
for children, Medicaid investment, through better support for services, 
integrated care and consistent implementation of the Early and Periodic 
Screening, Diagnostic and Treatment (EPSDT) benefit, is critical to 
supporting children's mental health needs across the continuum and 
before diagnosis to prevent future and more serious problems. We ask 
the committee to remember that broader supports and those provided 
through Medicare do not reach children. There is a need in your work 
for focus on children's unique needs and the major programs, like 
Medicaid, that support much of the pediatric mental health services 
provided in our country.

The statistics illustrate an alarming picture for our children. Prior 
to the pandemic, almost half of children with mental health disorders 
did not receive care they needed.\1\ This is not limited to one state 
or one community--children in states across the country face the same 
challenges accessing the necessary mental health care to address their 
needs.\2\ Children's mental health conditions are common. One in five 
children and adolescents experience a mental health disorder in a given 
year,\3\ and 50% of all mental illness begins before age 14.\4\ For 
children needing treatment, it takes 11 years on average after the 
first symptoms appear before getting that treatment.\5\ Significant 
investments are needed now to better support and sustain the full 
continuum of care needed for children's mental health. These 
investments will significantly impact our children and our country for 
the better as we avoid more serious and costly outcomes later--such as 
suicidal ideation and death by suicide.
---------------------------------------------------------------------------
    \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.

---------------------------------------------------------------------------
As reported from children's hospitals:

      Between March and October of 2020, the percentage of emergency 
department visits for children with mental health emergencies rose by 
24% for children ages 5-11 and 31% for children ages 12-17.\6\
---------------------------------------------------------------------------
    \6\ CDC, ``Mental Health-Related Emergency Department Visits Among 
Children Aged <18 Years During the COVID-19 Pandemic--United States, 
January 1-October 17, 2020,'' https://www.cdc.gov/mmwr/volumes/69/wr/
mm6945a3.htm, November 13, 2020 .
---------------------------------------------------------------------------
      In 2021, children's hospitals reported emergency room visits for 
self-injury and suicide attempts or ideation in children ages 5-18 at a 
44% higher rate than during 2019.\7\
---------------------------------------------------------------------------
    \7\ Children's Hospital Association (CHA), analysis of CHA PHIS 
database, n=38 children's hospitals.
---------------------------------------------------------------------------
      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\
---------------------------------------------------------------------------
    \8\ CDC, ``Emergency Department Visits for Suspected Suicide 
Attempts Among Persons Aged 12-25 Years Before and During the COVID-19 
Pandemic--United States, January 2019-May 2021,'' https://www.cdc.gov/
mmwr/volumes/70/wr/mm7024e1.htm, June 18, 2021.

Demand is outstripping supply causing kids in crisis to wait in 
children's hospital EDs for long periods of time, otherwise known as 
boarding. Medicaid investments in the full spectrum of pediatric mental 
health services are critical in making immediate strides to address the 
crisis end of the continuum, which is overstretched right now, and 
---------------------------------------------------------------------------
prevent emergencies in the future.

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

Military and veteran families are also affected. Military and veteran 
families face additional challenges with separation from parents and 
caregivers, frequent moves and caregivers or parents with their own 
---------------------------------------------------------------------------
trauma and mental health pressures.

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

      Increase Medicaid investments in pediatric mental health 
services to address the current crisis and better support coordination 
and integration of care. Medicaid is the largest payer for behavioral 
health services, but there continue to be access issues. In 2018, only 
54% of non-institutionalized children on Medicaid and CHIP who 
experienced a major depressive episode received mental health 
treatment.\10\ According to MACPAC, ``Just 35 percent of psychiatrists 
accepted new patients enrolled in Medicaid in 2014-2015, in contrast 
with 62 percent accepting new patients covered by Medicare and private 
insurance (Heberlein and Holgash 2019).''\11\ We believe creating 
equity between what Medicaid and Medicare pay for similar services will 
improve access for the millions of children who rely on this program 
for care. Low payment rates weaken provider engagement and 
participation in the Medicaid program and directly relate to the mental 
health workforce shortages and access challenges for children. The 
primary care payment bump passed in 2010 was found to increase access 
to these services and to support continued engagement of primary care 
physicians.\12\
---------------------------------------------------------------------------
    \10\ MACPAC, Response to Senate Finance RFI on behavioral health, 
November 15, 2021, https://www.macpac.gov/wp-content/uploads/2021/11/
MACPAC-response-to-Senate-Finance-RFI-on-behavioral-health.pdf.
    \11\ Ibid.
    \12\ Laura Tollen, ``Health Policy Brief: Medicaid Primary Care 
Parity,'' Health Affairs, May 15, 2015, https://www.healthaffairs.org/
do/10.1377/hpb20150511.588737/full/healthpolicybrief_
137.pdf.

      Direct CMS to review how EPSDT is implemented in the states to 
support access to prevention and early intervention services, as well 
as developmentally appropriate mental health services across the 
continuum of care, and provide guidance to states on Medicaid payment 
for 
evidence-based mental health services for children that promotes 
integrated care. The EPSDT benefit is tailored to children's unique 
needs and provides an important opportunity to support early 
identification even before diagnosis. Children's hospitals report that 
there are significant gaps in the intermediate level of care, including 
intensive outpatient services and day programs, which can prevent 
hospitalizations and help transition children back to their homes and 
community after a hospitalization. We can do a better job of 
implementing and supporting this benefit more consistently for children 
to ensure they receive care as early as possible and at every point 
---------------------------------------------------------------------------
along the continuum when needed.

      Facilitate access to mental health services through telehealth. 
Throughout the COVID-19 pandemic, greater state and federal regulatory 
flexibilities have increased the availability and convenience of 
telehealth services for children and families. Psychiatry continues to 
rely on telehealth at a far greater rate than any other physician 
specialty. Congress should extend these flexibilities past the COVID-19 
public health emergency, including covering audio-only services, 
lifting originating site restrictions and geographic limitations, and 
encouraging state Medicaid programs to continue telehealth coverage and 
payment. For children, Medicaid and private insurance are major 
insurers, and we ask the committee to ensure that telehealth support 
and flexibilities are supported across payers, in addition to Medicare, 
to give everyone the opportunity that telehealth provides.

      Ensure strong implementation, oversight and proactive 
enforcement of the Mental Health Parity and Addiction Equity Act. It is 
unacceptable that payers and plan administrators are failing to cover 
needed mental health and substance use disorder care by creating 
barriers to in-network mental health care, limited provider networks 
and establishing non-qualitative treatment limits not otherwise seen in 
medical and surgical benefits. In addition, public and private payers 
routinely exclude payment for mental health services provided by a 
primary care provider. Congress should work to remove payment barriers 
that hinder access to mental health services in the primary care 
setting.

      Increase investments to support the recruitment, training, 
mentorship, retention and professional development of a diverse 
clinical and non-clinical pediatric workforce. Currently, there are 
dire shortages of minority mental health providers, which represents an 
added burden on racial and ethnic minority communities who already face 
inequitable access to care. More dedicated support for a larger and 
more diverse pediatric workforce is critical to addressing children's 
mental health needs now and in the future. Stronger Medicaid 
investments supporting children's mental health services will improve 
engagement in the program and encourage more people to enter these 
fields.

       At the core of a strong pediatric mental health care delivery 
system is a strong, interconnected network of pediatric mental health 
providers and supportive services that are available to deliver high-
quality developmentally appropriate care. To expand and strengthen 
these networks at the community level, the Senate should consider H.R. 
4944, the Helping Kids Cope Act of 2021 (https://www.congress.gov/bill/
117th-congress/house-bill/4944), bipartisan legislation that provides 
flexible funding for communities to support a range of child and 
adolescent-centered community-based services, as well as efforts to 
better integrate and coordinate across the continuum of care. It also 
invests in pediatric mental health workforce development for a wide 
array of physician and non-physician mental health professions, to 
ensure children's long-term access to providers and services across the 
continuum of care.

      Dedicate support for the pediatric mental health system and 
infrastructure, which is currently woefully underfunded. Children's 
hospitals recommend that lawmakers take additional actions this year to 
strengthen pediatric behavioral health infrastructure and improve 
access to care, both immediately and long term. We urge Congress to 
provide resources to support efforts to scale up inpatient care 
capacity, including costs associated with the conversion of general 
beds to accommodate mental health patients. There is also a vital need 
to increase access to alternatives to inpatient and emergency 
department care including step-down, partial hospitalization, intensive 
outpatient services and day programs. These types of programs ensure 
that children and adolescents continue to receive intensive services 
and supports they need while alleviating pressure on acute care 
settings. We note that bipartisan legislation has been introduced in 
the House, H.R. 4943, the Children's Mental Health Infrastructure Act 
of 2021 (https://www.congress.gov/bill/117th-congress/house-bill/4943), 
which would provide grants to children's hospitals to increase their 
capacity to provide pediatric mental health services such as those 
described above.

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

                                 ______
                                 
                     Children's Trust Fund Alliance

                             P.O. Box 15206

                           Seattle, WA 98115

                           Generations United

                        80 F St., NW, 8th floor

                          Washington, DC 20001

                               FosterClub

                     620 S. Holladay Drive, Suite 1

                           Seaside, OR 97138

March 1, 2022

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

RE:  Testimony Submitted for ``Protecting Youth Mental Health: Part 
            II--Identifying and Addressing Barriers to Care,'' Hearing 
            Held on February 15, 2022

Dear Chairman Wyden, Ranking Member Crapo, and Members of the Senate 
Committee on Finance,

Thank you for your interest in improving access to mental and 
behavioral health services for children, young people, and their 
families. Testimony provided during the hearings on February 8th and 
15th demonstrated the urgent need to improve these services, the 
importance of involving young people and included ideas for 
improvement.

We write to you as add our voices organizations with networks of 
individuals with lived experience in foster care and kinship care and 
elevate the voices of those lived experience leaders.

The Children's Trust Fund Alliance is a national leader in promoting 
and supporting the voices of parents in policy and practice areas, in 
helping families build protective factors to gain capacity for life-
long changes and in preventing parental and societal neglect of 
children. Its national network of state children's trust funds invests 
almost $300 million annually in statewide and community-based 
initiatives to strengthen families and protect children.

Generations United's mission is to improve the lives of children, 
youth, and older people through intergenerational collaboration, public 
policies, and programs for the enduring benefit of all. We are home to 
the National Center on Grandfamilies, and our work is informed and 
driven by a national network of grandparents and other relatives 
raising children.

FosterClub is the national network for young people who experience 
foster care. FosterClub believes when young people have the support 
they need and opportunity to drive change in their life, they become 
self-determined and do better. We also believe when the system listens 
to young people, it does better.

We bring together young people, birth parents and relative caregivers 
to drive change within foster care. Collectively, these voices are 
referred to as lived experience leaders--each bringing their own 
experience engaging with the child welfare system.

During the February 15th hearing, Mr. Trace Terrell stated: ``My peers 
and I believe we deserve a seat at the table. While there are many ways 
we can do this, it starts by ensuring young people can meaningfully 
contribute to and be involved with legislative work on the local, state 
and federal level.'' Our organizations agree fully and we are thankful 
for Chairman Wyden's, Ranking Member Crapo and the Committee Members' 
commitment to ensuring young people have a seat at the table as work on 
this critical issue continues. In addition to young people, we are 
asking that parents and kinship caregivers be included at the table 
when identifying challenges and solutions.

While the February 8th and 15th hearings were focused on protecting 
youth mental health, we know providing mental health support to parents 
and caregivers, along with young people, leads to better outcomes. 
Robust, quality and accessible mental and behavioral health services 
can lead to children and youth staying safely together with their 
family, rather than experiencing the trauma of entering the foster care 
system.

In April 2021, we asked young people, parents and relative caregivers 
about the support services for families that are facing mental or 
behavioral health challenges (including addiction). We received 80 
total responses that came through with 5 key themes of recommendations. 
Lived experience leaders discussed the types of support services and 
resources that will help families who are facing mental, behavioral 
health and/or addiction challenges receive support, build on their 
strengths and stay safely out of the foster care system, wherever 
possible.

It is clear from the responses, that the whole family must be able to 
access and engage in mental and behavioral health services and 
supports.

The recommendations from young people, parents and caregivers are 
below:

    1.  Provide us with timely, unbiased, culturally relevant, and 
evidence-based prevention services that center family engagement.
    2.  We need rehabilitation and treatment programs that serve and 
support the entire family, to include caregivers, and children, when 
providing treatment services for mental health or substance use.
    3.  Create space for individuals with lived experience to serve as 
peer mentors and work to deliver treatment programming and services to 
families.
    4.  Connect us with trauma-informed mental health and family 
engagement services that address the root and systemic challenges and 
reasons for addiction including adverse childhood experiences and 
trauma.
    5.  Address and support our basic needs by providing services such 
as: housing, transportation, food, education, employment, and child 
care assistance.

We've selected perspectives and quotes from lived experience leaders to 
further demonstrate the above recommendations.

    1.  Provide us with timely, unbiased, culturally relevant, and 
evidence-based prevention services that center family engagement.

        Having equitable mental health services like being able to do 
        therapy through the phone, having a daycare connected, every 
        insurance covered or no cost at all to get help. Teaching 
        children and parents and adults about boundaries, and how to 
        communicate when they are disrespected.
        -- Grace Gold, Former Foster Youth from New York with New York 
        State Youth Advisory Board and BraveHearts MOVE

        Culturally appropriate services.
        -- Robyn Wind-Tiger, Kinship caregiver from Oklahoma

        A parent's mental health and or behavioral health is often 
        thought of as a weakness because of the parent's inability to 
        receive the appropriate care. The child welfare system and or 
        child protection does not realize the difficulty that families 
        have to try to receive the health care benefits to begin to 
        access services. In addition, are the services located in the 
        community in which they live? Are the services family-friendly 
        allowing for the consideration of holistic treatment which 
        considers the entire family and is culturally sensitive? Child 
        welfare/child protection [can] help expedite services with the 
        family without judgment and when parent/parents cannot do 
        homework with the family to establish a care plan specifically 
        for their family. It's important for the caseworker, child 
        welfare/child protection to know what's available in the 
        community and how to tap into those resources in a way that 
        families that may not have access to. Understanding the wait 
        list and the lack of appropriate services in all communities. 
        Most importantly acknowledge the strength of the family that 
        may not be like your family or any other family but unique 
        family strengths to their culture and environment.
        -- Sandra Killett from New York with We All Rise and The 
        Alliance

    2.  We need rehabilitation and treatment programs that serve and 
support the entire family, to include caregivers, and children, when 
providing treatment services for mental health or substance use.

        Preventative resources that could support families staying 
        together could be youth and parent peers and mentors with lived 
        experience who can illuminate hope, offer support and connect a 
        parent or youth to other resources and model recovery. Also, 
        support groups and community volunteer programs that focus on 
        prevention and support keeping families together. One example 
        of a good model is Safe Families whose focus is to prevent 
        children from entering into the foster care system and another 
        great model program for support is the Parents Anonymous 
        support groups.
        -- Leanne Walsh, Birth parent from Oregon with Oregon Parent 
        Advisory Council

        As a former foster child of a mother who struggled with 
        substance addiction, my siblings and I were separated and 
        placed in different foster homes at an early age. This was 
        devastating for the entire family. I believe it could have been 
        avoided if support services would have included rehabilitation 
        services for my mother and an in-home caregiver (with temporary 
        conservatorship) for my siblings and me vs. foster care. 
        Perhaps counseling services for the entire family as well.''
        -- Lorna Jackie Wilson, Former Foster Youth from Michigan

        From my personal experience, I didn't have enough support and 
        that is why some of my children went into foster care and some 
        went to kinship care. I truly believe that if we had more 
        facilities that welcome both mom and dad to get treatment while 
        children remain with them in the facility would help with the 
        prevention of going into care, but the root is truly more 
        support. Some families don't have relatives or people that 
        would want to help out during a crisis and the unfortunate 
        event is entering foster care.
        -- Pasqueal Nguyen, Birth parent from Louisiana with The Extra 
        Mile and Youth Law Center

    3.  Create space for individuals with lived experience to serve as 
peer mentors and work to deliver treatment programming and services to 
families.

        Working with a Certified Peer Support Specialist (someone with 
        lived experience with addiction/mental health) or a Family 
        Partner (someone with lived experience in child welfare). 
        Access to MAT-Medication-Assisted Treatment for Substance 
        Misuse.
        -- Kelly Kirk, Birth parent from North Carolina with Sandhills 
        Opioid Response Consortium, NC DHHS Child Welfare Family 
        Advisory Council, Drug Free Moore County, Richmond County DSS, 
        Richmond County--DEFT (Drug Endangered Families Task Force)

        I think support groups would help a parent's mental health, I 
        think that if they had a group they would be able to share 
        their thoughts vs. having to go through struggling with inside 
        problems alone.
        -- Former Foster Youth from South Carolina

        For African American families, education and awareness 
        campaigns run by grassroots trustworthy organizations to 
        decrease the stigma of mental health and provide resources,[ 
        including] access to culturally relevant mental health 
        services. Anything that encourages early awareness of problems 
        and a safe place for caregivers to share and explore options 
        would help. This is such a HUGE problem in communities of color 
        and progress in this area would definitely benefit the welfare 
        of our families.
        -- Melodye James, Kinship caregiver from Ohio with Restored 
        Vision

    4.  Connect us with trauma-informed mental health and family 
engagement services that address the root and systemic challenges and 
reasons for addiction including adverse childhood experiences and 
trauma.

        A trauma-informed therapist would have helped me process what I 
        went through and aided my dad's understanding of my behavior 
        and how to properly support me.
        -- Zoe Jones-Walton, former foster youth, Texas, FosterClub

        When there are not affordable centers to treat and give mental 
        therapy, people don't go. We all know addiction and mental 
        health issues go hand in hand, but when there is no access . . 
        . they continue on their journey with drugs.
        -- Terri, Kinship caregiver from Alabama

        As a former foster youth who aged out of care and as a parent 
        who returned to the system and accused of having undiagnosed 
        mental health issues, and the biases that it brings is 
        heartbreaking. It would have been helpful to receive 
        dialectical behavioral therapy or cognitive processing therapy 
        as a mechanism to help revert the issues they were bringing me 
        in for and remove my children as a consequence of something I 
        didn't have.
        -- Ashley Alber, current foster youth from Washington with 
        Washington State Parent Ally Committee

    5.  Address and support our basic needs by providing services such 
as: housing, transportation, food, education, employment, and child 
care assistance.

        Extended family and friends should be considered as resources 
        with funding being provided to aid them in keeping the family 
        together.
        -- Marquetta King, foster/adoptive parent, Maryland, Treatment 
        Foster Care Parent Advisory Board, Arc Northern Chesapeake; 
        Together as Adoptive Parents

        Such resources as therapy, skills training, transportation 
        assistance, food assistance, housing assistance can make a big 
        change in a family's life. Prevention and Education are key to 
        helping families stay out of the system.
        -- Isabel, Birth parent from Arizona

        I went into foster care for the first time when I was 11, it 
        was due to my mother's addiction to methamphetamine. I think 
        being able to provide an adequate amount of support for the 
        parent, whether it be resources in the community or even a 
        government stipend for the right treatment would help 
        immensely. Most parents feel as if they are fighting this 
        battle on their own and I think helping them realize they 
        aren't would be incredible for them and the reunification 
        process.
        -- Charles Lewis, Former Foster Youth from Indiana

Our organizations are pleased to share these priorities with the 
Committee as you continue looking at how to improve mental health 
supports for young people and their families. If you would like to 
discuss further, please contact Binley Taylor, System Change Director 
at FosterClub, 503-717-1552 or [email protected], Jaia Lent, 
Deputy Executive Director at Generations United, 202-777-0115 or 
[email protected] and Teresa Rafael, Executive Director at Children's Trust 
Fund Alliance, 206-650-5317 or [email protected].

Sincerely,

Children's Trust Fund Alliance

Generations United

FosterClub

                                 ______
                                 
                  Citizens Commission on Human Rights

                          1701 20th Street, NW

                          Washington, DC 20009

             Statement of Anne Goedeke, Executive Director

The Citizens Commission on Human Rights (CCHR) recognizes that children 
have faced unprecedented and stressful disruptions in their lives 
during the pandemic. However, we have a serious concern, supported by 
substantial research, that increased screening of children and at 
earlier ages, as now called for by mental health providers, will result 
in many more children being inaccurately diagnosed with mental 
disorders and further escalate the number of American children 
prescribed powerful psychotropic drugs, putting them at risk of serious 
physical and psychological side effects.

Research studies have found mental health screening is ineffective and 
potentially harmful to children.

Allen Frances, M.D., a psychiatrist and Professor and Chairman Emeritus 
of the Department of Psychiatry and Behavioral Sciences at Duke 
University School of Medicine, chaired the task force on the 4th 
edition of the American Psychiatric Association's Diagnostic and 
Statistical Manual of Mental Disorders.

Writing in The Wall Street Journal in 2016, Dr. Frances stated: 
``Screening for depression is one of those ideas that is terrific in 
theory but terrible in practice. Proponents see only the potential 
benefits and remain blind to the many risks. They imagine an ideal 
world in which troubled teens are accurately identified as depressed or 
pre-depressed and receive just-in-time care that reduces the burden of 
illness and the risk of suicide. They fail to imagine the many 
limitations and unintended consequences that make testing much more 
harmful than helpful.''

Dr. Frances stated that no screening method can differentiate between 
the sadness which is very common in teens, and clinical depression 
requiring treatment. He says that teens are ``especially tough to 
diagnose'' because their symptoms are fluid and highly responsive in 
the short run to pressure from family, friends and school. He warns 
that ``mislabeling a teen as mentally ill changes the way they see 
themselves and can ruin their lives.'' He further notes that ``medical 
efficacy in adolescence is questionable and medications may increase 
the risk of agitation, impulsivity, suicide and/or violent behavior.''

The late Karen Effrem, M.D., a well-known pediatrician and researcher, 
found that increased screening results in the increased psychiatric 
drugging of children and adolescents, with significant evidence of 
harmful, even life-threatening side effects, including suicide, 
violence, psychosis, hallucinations, diabetes, and movement disorders.

A study by researchers at McGill University, published in 2016 in the 
Canadian Journal of Psychiatry, found after an exhaustive search of 
medical literature that there was not a single screening tool with even 
moderate evidence of sufficient accuracy to effectively identify 
depressed children and adolescents without also mistakenly identifying 
many non-depressed children and adolescents. They noted that screening 
leads to the unnecessary prescribing of potentially harmful psychiatric 
drugs, as well as giving negative messages about their mental health to 
children who do not have mental health disorders.

That was precisely the case from 1999 to 2012, when an untold number of 
adolescents were screened for depression using the TeenScreen 
questionnaire. The screening tool was widely promoted and utilized, 
even though psychiatrist David Shaffer, M.D., who led the Columbia 
University team that developed TeenScreen, admitted the screening tool 
would result in 84 non-suicidal teens being referred for further 
psychiatric evaluation for every 16 youths correctly identified--a 
staggering number of false positives. CCHR was instrumental in ending 
the use of TeenScreen.

Further confirming the lack of evidence of effectiveness in screening, 
research published in 2017 in BMC Medicine found there have been no 
randomized, controlled trials, considered the gold standard for 
research, with any direct evidence of improved health or other 
beneficial outcomes from depression screening.

The United Kingdom National Screening Committee and the Canadian Task 
Force on Preventive Health Care recommended against all questionnaire-
based screening because of the lack of direct evidence of benefit and 
the potential harm to patients and waste of resources. The U.S. 
Preventive Services Task Force did recommend screening of adolescents 
ages 12 and older, but ``with adequate systems in place to ensure 
accurate diagnosis.''

However, accuracy in psychiatric diagnoses cannot be ensured. A 
fundamental flaw in the present-day field of mental health is that 
there are no objective, scientific diagnoses of psychiatric conditions, 
as there are in physical medicine, a fact which was acknowledged by the 
former director of the National Institute of Mental Health, Thomas 
Insel, M.D.

Therefore, what constitutes a child's ``elevated symptoms'' requiring 
treatment is entirely subjective--and can vary from one provider to the 
next. There is no consistency and no valid standards in the 
determination of a psychiatric diagnosis and, therefore, no accuracy.

The result of this subjectivity in diagnosing is reflected in the ever-
growing number of children and adolescents estimated by mental health 
providers to need mental health treatment.

CCHR has long recommended that before any rush to judgment about a 
child having a mental disorder, the child should receive a complete 
physical exam with laboratory tests to discover any undiagnosed 
physical condition--illness, infection, injury or other condition--that 
could account for the child's behavioral symptoms. If found and 
corrected, this spares the child from being inappropriately labeled and 
treated for a psychiatric condition the child does not have.

CCHR further recommends the child should be checked for allergies, food 
intolerances, nutritional deficiencies, and environmental toxins, which 
are all known to cause behavioral symptoms. A recent study published in 
JAMA Pediatrics found that of the 1.1 million American children tested 
for lead, 50.5% have detectable levels of lead in their blood. Even the 
lowest levels of lead in children can cause irritability and nervous 
system damage.

The diagnosis of a psychiatric condition in a child with a behavioral 
problem in school often overlooks the fact that the child's educational 
needs are not being met, resulting in unwanted classroom behavior. This 
applies both to children falling behind in their studies and children 
bored because they are not sufficiently challenged. Screening the child 
for a mental disorder is the wrong approach. Applying correct 
educational solutions would prevent children from being diagnosed with 
ADHD and prescribed stimulant drugs.

As Mary Ann Block, M.D., author of No More ADHD, has stated, ``By 
taking a thorough history and giving these children a complete physical 
exam as well as doing lab tests and allergy testing, I have 
consistently found that these children do not have ADHD, but instead 
have allergies, dietary problems, nutritional deficiencies, thyroid 
problems and learning difficulties that are causing their symptoms. All 
of these medical and educational problems can be treated, allowing the 
child to be successful, without being drugged.''

In 2020, some 6.2 million American children ages 0 to 17--roughly one 
in 12--were prescribed psychiatric drugs, including antidepressants, 
antipsychotics, antianxiety drugs and ADHD drugs, according to IQVia, a 
healthcare data source. This includes 418,000 youngsters 0 to 5 years 
old. These troubling numbers of drugged youth could dramatically 
increase with even more widespread screening.

Of note, the number of children and adolescents taking psychiatric 
drugs has decreased by 8% since 2017. This may reflect a growing 
awareness on the part of parents and others of both the ineffectiveness 
and the unwanted side effects of these drugs, which may have led to 
their refusal to consider giving them to children. The CCHR psychiatric 
drugs side effect search engine currently lists some 300 warnings from 
international drug regulatory agencies and research studies on the 
adverse effects of psychiatric drugs for children 0 to 17 years old.

Half of these warnings pertain to antidepressants' adverse effects on 
children, especially suicide and aggressive behavior. The FDA's most 
serious black box warning is required on the labels of antidepressants, 
advising they can cause suicidal thoughts and actions in children and 
young adults. Nearly 2.2 million children and adolescents ages 0 to 17 
are currently taking antidepressants, 35,000 of them during the tender 
ages of 0 to 5.

Researchers led by professor of psychology Glen I. Spielmans, Ph.D., 
analyzed data from antidepressant clinical trials for a study, 
published in Frontiers in Psychiatry in 2020, that concluded, 
``Increasing antidepressant prescriptions are related to more youth 
suicide attempts and more completed suicides among American children 
and adolescents.''

In 2017, researchers Martin Ploderl, Ph.D., a clinical psychologist, 
and Michael P. Hengartner, Ph.D., a senior researcher and lecturer in 
clinical psychology and psychopathology, concluded: ``If you look at 
the past 10 years, antidepressant rates are associated with increased 
suicide rates,'' adding that antidepressants ``most likely cause 
suicidal behavior in young people'' and that the ``data strongly 
suggest that antidepressants can cause suicides and aggressive 
behavior.''

A study from the Nordic Cochrane Centre and the University of 
Copenhagen published in the British medical journal, The BMJ, in 2016 
also concluded that antidepressants are linked to suicide and 
aggression in teens and that ``children and young people are more 
likely to think about or attempt suicide while taking 
antidepressants.''

Peter Breggin, M.D., a Harvard-trained psychiatrist and former 
consultant to the National Institute of Mental Health, describes 
antidepressants as neurotoxins because they harm and disrupt the 
functions of the brain, causing abnormal thinking and behaviors that 
include anxiety, irritability, hostility, aggressiveness, loss of 
judgment, impulsivity and mania, which can lead to violence and 
suicide. He says that the harmful mental and behavioral effects of 
antidepressants are especially prevalent and severe in children and 
adolescents.

In draft guidance published in November, the London-based National 
Institute for Health and Care Excellence advised that antidepressant 
drugs should not be considered first-line treatment for any patients. 
Instead, those with depression should be offered and able to choose 
from a variety of treatment options, including non-drug options. CCHR 
supports this shift in thinking to non-drug solutions to children's 
emotional problems.

Another 829,000 children ages 0 to 17 are prescribed antipsychotic 
drugs, 31,000 of them age 0 to 5 years, for ADHD, aggression, mood 
swings, and conduct problems. The CCHR psychiatric drugs side effect 
search engine currently lists 42 research studies and 13 drug 
regulatory agency warnings about adverse effects of antipsychotic drugs 
for children and adolescents. Among the many adverse effects, the drugs 
are widely known to cause weight gain, diabetes, cardiovascular 
problems, and the risk of sudden death.

A study published in JAMA Psychiatry in 2018 found that children and 
teens taking higher doses of antipsychotics were 1.8 times more likely 
to die for any reason, 3.5 times more likely to die unexpectedly 
(excluding overdose), and 4.29 times more likely to die from 
cardiovascular or metabolic problems.

Antipsychotic drugs have long been linked with akathisia, a state of 
restlessness and agitation that can induce suicidality or violence in 
children. David Healy, M.D., a psychiatrist and professor of 
psychopharmacology, stated in a 2009 interview for a blog on the 
Psychology Today website that antipsychotics are universally recognized 
as causing akathisia and that akathisia is recognized as increasing the 
risk of suicidality and violence. He stated that since the introduction 
of antipsychotics, the rates of suicide have risen 10- or 20-fold.

The drugs are also known to cause the devastating neurological damage 
called tardive dyskinesia, an involuntary jerkiness of the face, 
tongue, torso and limbs that can be disabling and permanent and may 
also lead to suicide.

An analysis of those aged 10-18 found that antipsychotic drug use was 
associated with a 50% increase in the risk of developing type 2 
diabetes. This was higher for youth who used antidepressants and 
antipsychotics concurrently.

For all the risk to children of psychiatric drugs, research studies 
show the drugs may be largely ineffective and do more harm than good.

In a study recently published in The BMJ Drug and Therapeutics 
Bulletin, researchers reviewed meta-analyses of studies of newer 
generation SSRI and SNRI antidepressants. They found no clinically 
significant difference in measures of depression symptoms between 
children and adolescents treated and not treated with antidepressants. 
They noted that published accounts of clinical studies involving 
adolescents exaggerated benefits and understated adverse events, such 
as by coding suicide attempts as ``mood swings.''

In a 2018 study published in Frontiers in Psychiatry, Michael P. 
Hengartner, Ph.D., a senior researcher and lecturer in clinical 
psychology and psychopathology, concluded after thoroughly examining 
the medical literature that antidepressants are largely ineffective and 
potentially harmful.

Researchers led by Paul W. Andrews, Ph.D., a professor psychology and 
evolutionary biologist, analyzed previous studies to determine the 
overall physical impact on the human body of antidepressants that 
target serotonin. Serotonin regulates emotion, development, nerve 
cells, attention, electrolyte balance and reproduction. The study, 
published in Frontiers in Psychology in 2012 found that antidepressants 
generally do more harm than good by disrupting a number of adaptive 
processes regulated by serotonin.

Jose Luis Turabian, M.D., Ph.D., reviewed the medical literature and 
concluded in a study, published in 2021 in the Journal of Addictive 
Disorders and Mental Health, that psychiatric drugs can lead to a 
structural remodeling of the brain that adversely affects emotions and 
other aspects of mental function and may become irreversible. He says 
that the drugs block the expression of feelings, affect the problem-
solving process, and make the person passive.

Decades of increasing mental health screening and the drugging of 
children with mind-altering psychotropic drugs has done nothing to 
reduce the rate of child and adolescent suicide, reduce school 
violence, or improve students' educational performance, but has exposed 
children to substantial harm.

There are global concerns about a growing dependency upon a biological 
approach to treating mental health issues. In 2017, Dainius Puras, the 
United Nations Special Rapporteur on the right to physical and mental 
health, reported: ``There is now unequivocal evidence of the failures 
of a system that relies too heavily on the biomedical model of mental 
health services, including the front-line and excessive use of 
psychotropic medicines, and yet these models persist.''

A 2020 report from the World Health Organization (WHO) criticizes the 
mental health field's ``entrenched overreliance on the biomedical model 
in which the predominant focus of care is on diagnosis, medication and 
symptom reduction while the full range of social determinants that 
impact people's mental health are overlooked, all of which hinder 
progress toward full realization of a human rights-based approach.''

The WHO calls for holistic mental health services to replace today's 
narrow focus on the diagnosis and drugging of individuals to suppress 
symptoms, a mental health approach that results in ``an over-diagnosis 
of human distress and over-reliance on psychotropic drugs.''

CCHR's co-founder, the late Thomas M. Szasz, M.D., a professor of 
psychiatry and humanitarian recognized by many academics as modern 
psychiatry's most authoritative critic, wrote: ``Labeling a child as 
mentally ill is stigmatization, not diagnosis. Giving a child a 
psychiatric drug is poisoning, not treatment.''

CCHR advocates against mental health screening, which experts have 
proven does not reduce the burden of mental health issues or the risk 
of suicide in children and teens, but does lead to mislabeling normal 
children and prescribing them psychiatric drugs that are harmful to 
them.

CCHR advocates that children experiencing emotional difficulties should 
be given a complete physical exam with lab tests to discover any 
underlying physical cause for their behavioral symptoms, and that 
parents be made aware of the importance of proper sleep, nutrition, and 
exercise for their children's mental health. It advocates for proper 
educational solutions to be used for children's problems in school. It 
advocates for the full disclosure of the risks of serious side effects 
when taking and withdrawing from psychiatric drugs, so that parents can 
make fully informed decisions about the use of these drugs for their 
children.

CCHR supports evidence-based, non-drug and educational solutions for 
youth mental health issues and public funding directed to programs 
utilizing those solutions, handling the underlying causes of children's 
behavioral problems instead of compounding their problems with 
psychiatric labels and drugs that are proving to do more harm than 
good.

                                 ______
                                 
                         Driscoll Health System

                      Driscoll Children's Hospital

                         3533 S. Alameda Street

                      Corpus Christi, Texas 78411

                             (361) 694-5000

                  Statement of Dr. Mary Dale Peterson

Chairman Wyden, Ranking member Crapo and members of the Senate Finance 
Committee, my name is Dr. Mary Dale Peterson and I am the Executive 
Vice President and Chief Operating Officer for the Driscoll Health 
System (Driscoll), which comprises Driscoll Children's Hospital, 
Driscoll Health Plan (DHP), physician practices, clinics, and specialty 
centers. We serve over 31 counties in South Texas, which is roughly the 
size of Senator Scott's State of South Carolina. We would like to thank 
Senator Cornyn for his continued leadership in South Texas. He visited 
our hospital back in February 2020 to promote his vaping legislation 
and we support his and the Committee's commitment to strengthen 
pediatric behavioral health's infrastructure, personnel, and services. 
He also cosponsored legislation (S. 1798, called the TIKES Act) 
allowing the pediatric workforce to identify and break down barriers in 
using telemedicine and telehealth, so we understand and support his 
passion for the issue. Driscoll welcomes working with the Committee in 
addressing complex behavioral and mental health issues that impact 
service delivery in our service region. We submit comments in support 
of the Committee identifying critical issues, but more importantly, we 
respectfully request a commitment in funding to address barriers of 
care for children's hospitals.

The Driscoll Way

Historically, the inequalities along the Texas-Mexico border in 
healthcare are prevalent and COVID-19 exposed new challenges. Poverty 
in South Texas exacerbates healthcare inequities by limiting access to 
transportation, Internet, and food. Additionally, retention and 
recruitment of pediatric physicians, nurses and medical support 
personnel is challenging. Despite these barriers to care, in 2020 
Driscoll provided $126.6 million in community benefits for South Texas 
and provided 93% of pediatric, in-patient care in the Rio Grande 
Valley, the most southern portion of our services area. Additionally, 
our health plan, a Medicaid Care Organization, covers over 220,000 
children and families with many value added services.

Our commitment to our service area is so strong that Driscoll is 
building the only designated, freestanding children's hospital in the 
Rio Grande Valley and want to invite the Senate Finance Committee to 
visit the new hospital when completed. Without Driscoll's commitment to 
the US-Mexico border, the region would experience significant delays in 
preventative pediatric care that would cost the State of Texas 
massively. In 2020, Driscoll flew over 600 flights to the region with 
pediatric subspecialists who provided over 40,000 clinic visits. If 
Driscoll did not transport this care or build infrastructure and cover 
these costs, pediatric services would be limited or unavailable in 
these communities. We call our commitment to ensure all children remain 
well the ``Driscoll Way.''

Pandemic's Impact on Behavior Health in South Texas

From Driscoll's perspective, evaluation, stabilization, case 
management, inpatient discharge, and transport process is complicated 
further by COVID-19. Our Emergency Department (ED) requires more space 
capacity to ensure that injured and sick children do not impede 
children presenting with mental health issues. Additionally, children 
and adolescents with mental health issues require additional separate, 
safe spaces that are age appropriate. As experienced before and during 
the COVID-19 pandemic, recruiting and retaining mental health 
professionals continues to be an issue in South Texas. These 
professionals are needed to ensure adequate staffing for children 
suffering from extreme emotional or mental distress. When Driscoll 
completes its assessment and medical clearance approved, locating safe 
transport for a child to a local mental health facility from our 
facility is currently not available in South Texas. It is important to 
note a child may have to travel hundreds of miles to an inpatient 
behavioral health facility in South Texas, further complicating the 
needed family interactions in the care plan and discharge.

Driscoll Mental and Behavioral Health Data

In 2021, Driscoll had 652 ED visits, 100 observations, and 43 
admissions (including 20 in the ICU) for medical stabilization of 
behavioral health patients.We have transferred 428 patients to 
psychiatric facilities, about 155 of those hundreds of miles away. 
Average length of stay in the ED is about 7 hours with some difficult 
placements up to 26 hrs. Most of these patients require a 1:1 staffing 
ratio throughout their stays, which is quite challenging in our current 
labor shortage environment. When looking at year over year data, the ED 
visits are slightly down but the acuity is significantly up, as 
evidenced by the 80 patient increase in transfers to psychiatric 
facilities.

Additionally, mental health cases grew at Driscoll by 48% from FY2019 
thru FY2021. FY 2022 is on target to increase another 51% over FY2020.

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


In just the first two months of FY2022, Driscoll already 
accumulated 73% of the suicide attempts experienced in FY2021, and on 
track for a 70% increase in suicidal ideation for the same period.

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


Mental health patients ED length of stay times are increasing.

                     THE PRESIDENT OF THE UNITED STATES

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

Recommendations

Driscoll recommends the Committee study the feasibility and funding for 
the following items:

      Additional funding for children's hospitals for construction and 
expansion of sites for pediatric mental health services, digital 
infrastructure such as telehealth, and conversion of existing beds used 
for non-mental health care.
          We recommend continuing to fund Internet 
infrastructure development in rural and economically disadvantaged 
areas, similar to South Texas, is critical to improve children's access 
to telehealth and mental health professionals.
      Additional funding to support workforce initiatives for 
children's hospitals to support and improve training, retention, and 
recruiting their mental health workforce.
          We recommend incentivizing community partnerships 
between children's hospitals and higher education programs that improve 
the number of pediatric and family counselors, pediatric social 
workers, care coordinators, child and adolescent psychiatrists, and 
other support professionals.
          Full and rapid tuition reimbursement for programs 
that place professionals directly in communities of need like South 
Texas. Develop stipends that children's hospitals can utilize for 
relocation costs, continued education and training.
      Additional funding to fill in the gaps in the continuum of care 
which include early intervention, detention through crisis intervention 
and stabilization, safe transportation between facilities, and improved 
case management that follows the child to adolescent to adulthood.
          We recommend funding transportation partnerships 
in rural communities. In many communities with limited resources, a 
child and their family have no support after discharge.
          Long distances between a child's home and 
facilities prevents the child from seeking care if reliable transport 
is not available. COVID complicates this transport further.
      Additional funding for mobile mental health clinics that travel 
to rural areas so that professionals and support personnel can go out 
to the community.

Conclusion

The COVID-19 pandemic's impact on the mental health of children is 
difficult to assess. The pandemic compromised children's mental health 
as they lost loved ones suddenly, were forced into isolation as schools 
went virtual, and ongoing family violence and abuse went unreported. 
Further, before the pandemic, modern anxieties such as social media 
bullying and school violence plagued children and adolescents. Now add 
the complexities and awkwardness of simply growing up, the need to 
assist children's mental health is overdue. Because of these external 
factors, children's hospitals require adequate funding and resources to 
support early intervention, physical and IT infrastructure capacity, 
and filling in the gaps of the continuum of care to ensure children do 
not fall through the cracks. As illustrated in the data provided from 
Driscoll in my testimony, we have cause for concern.

The U.S. Senate now has the opportunity to develop a solution that 
assists all partners of care--children's hospitals, mental and behavior 
health professionals, school districts, juvenile services, and other 
community stakeholders. It is unfortunate that it took a pandemic to 
shed light on the long-standing void in youth mental health services, 
but getting it right now is critical and COVID-19 offers us an 
opportunity to reset. The fact is we may never know the impact COVID-19 
has on our children's mental health, but they were struggling well 
before the pandemic. We need to act quickly to alleviate this mental 
health crisis in children. Driscoll is ready to work with the Senate 
Finance Committee on solutions to erode barriers and improve how 
children's hospitals around the nation can better serve the communities 
they call home.

                                 ______
                                 
                        First Focus on Children

                     1400 Eye Street, NW, Suite 650

                          Washington, DC 20005

                            t: 202-657-0670

                            f: 202-657-0671

                        https://firstfocus.org/

Chairman Wyden, Ranking Member Crapo, and Members of the Senate 
Committee on Finance, we thank you for the opportunity to submit this 
statement for the record. First Focus on Children is a bipartisan 
children's advocacy organization dedicated to making children and 
families a priority in federal policy and budget decisions.

Our country is facing a youth mental health crisis, and the COVID-19 
pandemic has only sharpened the lens on an existing issue. Even before 
the pandemic, 13-20% of children under the age of 18 \1\ experienced a 
mental disorder, and the suicide rate among youth aged 10 to 24 has 
increased nearly 60% \2\ since 2007. The issue has only worsened due to 
the pandemic. In the first 6 months of 2021, children's hospitals 
reported a 45% increase \3\ in the number of cases of self-injury and 
suicide in children ages 5 to 17 compared to the first 6 months of 
2019. While children from all backgrounds have been impacted by mental 
health challenges during the pandemic, children of racial and ethnic 
minorities are disproportionately impacted.
---------------------------------------------------------------------------
    \1\ https://www.cdc.gov/childrensmentalhealth/basics.html.
    \2\ https://www.cdc.gov/nchs/data/nvsr/nvsr69/nvsr-69-11-508.pdf.
    \3\ https://www.soundthealarmforkids.org/a-national-emergency/.

Unfortunately, demand for services has gone up, but there is a severe 
lack of resources available to children and teens. Currently, there are 
10 child psychiatrists per 100,000 kids; it is estimated that we need 
47 per 100,000 \4\ to address the current crisis. Many parents, 
regardless of whether they have private insurance or are covered 
through Medicaid, are not able to find providers for their children 
because insurance networks are limited and there is a severe workforce 
shortage. These issues must be addressed to get our children the care 
they need.
---------------------------------------------------------------------------
    \4\ https://pubmed.ncbi.nlm.nih.gov/31685696/.

In addition to school closures and isolation, the COVID-19 pandemic has 
caused 175,000 children and youth \5\ in this country to lose a primary 
caregiver, exacerbating the mental health crisis even further and 
disproportionately impacting children of racial and ethnic minorities.
---------------------------------------------------------------------------
    \5\ https://publications.aap.org/pediatrics/article/148/6/
e2021053760/183446/COVID-19-Associated-Orphanhood-and-Caregiver-
Death?autologincheck=redirected?nfToken=00000000-0000-0000-0000-
000000000000.

In December 2021, the Surgeon General issued a report \6\ on youth 
mental health, citing the alarming increases in the prevalence of 
mental health challenges. We appreciated his powerful testimony at the 
February 2022 hearing before this Committee, in which he outlined what 
steps need to be taken to address this crisis for our children.
---------------------------------------------------------------------------
    \6\ https://www.hhs.gov/sites/default/files/surgeon-general-youth-
mental-health-advisory.pdf.

Below are a few of our recommendations to address the youth mental 
health crisis in America.

Expand and Improve the Mental Health Workforce

Demand for mental health services has gone up dramatically, but there 
is a severe lack of providers to meet this increased need. The federal 
government should bolster training programs for providers in children's 
mental health. Currently, the government spends $15 billion \7\ on 
health care workforce development but only 1% of that is spent on 
children's mental health workforce development.
---------------------------------------------------------------------------
    \7\ https://www.gao.gov/products/gao-18-
240#::text=Federal%20agencies%20and%20state%20
Medicaid,Medicaid%20agencies%20spent%20%252$15%20billion%20annually.

---------------------------------------------------------------------------
Some ideas to address the workforce shortage include:

      Expand loan repayment programs, access to scholarships, and 
training programs for mental health professionals committed to 
practicing in rural and other underserved communities.
      Raise the Medicaid reimbursement rate for mental health 
providers.
      Integrate mental health services with primary care.
      Encourage young people to consider the mental health profession 
as a career to expand the pipeline of behavioral health providers.

Invest in Community-Based Mental Health Services

Children need improved and increased access to community-based mental 
health services. These are often more appropriate and effective for 
children and youth than in-patient care, and they are less expensive. 
The Certified Community Behavioral Health Clinics (CCBHCs) model is an 
example of a program that increases access to comprehensive mental 
health and substance use disorder services for populations including 
children. This model encourages collaboration between social service 
systems and school-based settings, reaching children where they are. 
Making mental health services as accessible as possible is vital to 
decreasing the stigma attached to these services and allowing children 
to continue living their lives in their communities, with their 
families.

 Invest in School-Based Mental Health Models to Meet Children Where 
                    They Are

School-based mental health models are an extremely effective way to 
deliver mental health services to children. However, such programs vary 
across states and many schools are underfunded and understaffed. These 
programs need additional investments and support to ensure they are 
reaching all children who need help.

Schools should provide a continuum of supports to meet student mental 
health needs, including evidence based prevention practices and trauma-
informed mental health care. Tiered supports should include 
coordination mechanisms to ensure students get the right care at the 
right time.

The school-based mental health workforce needs to be expanded. This can 
be done through the sustained use of local, state, and federal funds to 
hire and train additional staff, such as school counselors, nurses, 
social workers, and school psychologists, including dedicated staff to 
support students with disabilities.

School districts should be encouraged to access Medicaid funding for 
health and mental health services. The Centers for Medicare and 
Medicaid should update guidance to states that will enable them to 
equitably access Medicaid reimbursement and require Medicaid to 
simplify the billing process for schools to ensure access and decrease 
the money spent on administration expenses.

Mental health needs to be fully integrated into our education system. 
Social and emotional learning should be integrated into K-12 
curriculums, and discussions on mental health should be included in 
health discussions the way schools currently do for nutrition, 
exercise, cancer prevention, and other physical health topics.

 Ensure All Children Have Access to High-Quality and Affordable Mental 
                    Health Care by Addressing Parity

By law, children (whether on Medicaid or covered by private insurance) 
are entitled to preventive services which include mental health 
diagnosis, prevention and treatment but they are often not receiving 
services because these laws are not being strongly enforced. Therefore, 
millions of children are falling through the cracks and unable to 
receive the care they need. On average, nearly 11 years lapse between 
the presentation of mental health disorders and the professional 
diagnosis of symptoms. We are failing our children when we force them 
to wait on average 11 years for treatment.

Three laws are important to the improvement of our mental health system 
for children. The Social Security Amendments of 1967 included 
provisions to ensure that early and periodic screening, diagnostic, and 
treatment services (EPSDT) are available to children in Medicaid. Over 
forty years later, the Affordable Care Act (ACA) defined ``essential 
health benefits'' for children as mental health, preventive care and 
pediatric care, as well as requirements to ensure the adequacy of 
provider networks to offer those services. For children covered by 
private health insurance, these provisions guarantee access to a 
relatively similar scope of preventive services as EPSDT under 
Medicaid. Finally, the passage of the Mental Health Parity and 
Addiction Equity Act of 2008 (MHPAEA) promotes equal access to 
treatment for mental health and substance abuse disorders by 
prohibiting coverage limitations that apply more restrictively for 
mental health and substance abuse than for medical and surgical 
benefits.

The high rates of depression, anxiety and suicides are a result of 
these laws not being enforced, a lack of investment in the mental 
health workforce and the failure of our school systems to provide more 
support to children with mental health needs. Together, these laws 
provide the framework for a more comprehensive and equitable system. We 
have the right laws, we simply need to implement and enforce them.

Network adequacy is a critical piece to the mental health continuum of 
care. It is important to all children to have access to a range of 
services from qualified providers in a geographic area--whether the 
children are on Medicaid or have private health insurance. Without 
adequate networks, parents may not be able to find providers who accept 
Medicaid or their particular type of private insurance. Oftentimes, 
once a provider is identified, wait lists can be one to four months 
which is not acceptable when a crisis occurs for a child, teen or 
adolescent. Or, parents with Medicaid may only be able to find in-
patient care for their children when research suggests that in most 
cases, community-based care delivers better outcomes. Those parents 
with private insurance might find a ``provider network list'' but 
cannot find anyone in their geographic area, or the list might only 
have a few names on it, or the providers may not be taking new 
patients, or lists may be outdated--all of which can lead to roadblocks 
and barriers to finding viable provider options for their children.

Improve Crisis Response Services

We have seen the numbers of children in mental health crises increase 
dramatically in recent years, and we must ensure that these children 
and youth are able to access services when and where they need them.

This year, states must implement the new 988 behavioral health crisis 
response system. This should be a more responsive crisis system that 
avoids unnecessary and often harmful interventions such as a police 
presence and visits to emergency rooms. This approach is especially 
important for children and youth and for achieving equity in mental 
health. These crisis systems must address the special needs of 
children, youth, and young adults as well as be culturally competent 
and able to help populations including LBGTQ youth.

One helpful tool in responding to mental health crises for children and 
youth in appropriate and accessible ways is the mobile crisis response 
unit. Several states, including Oregon,\8\ are implementing mobile 
crisis response systems that increase equity and accessibility for 
children and youth in addressing their mental health needs, and these 
should be incorporated into states' implementation of the new 988 
number.
---------------------------------------------------------------------------
    \8\ https://www.clasp.org/publications/report/brief/youth-mobile-
response-services-investment-decriminalize-mental-health/.
---------------------------------------------------------------------------

 Address the Needs of Children Who Have Lost Caregivers Due to 
                    COVID-19

In October 2021, even prior to the arrival of the Omicron variant, the 
number of children who had lost a parent or grandparent primary 
caregiver due to COVID-19 was 175,000,\9\ a staggering statistic. And 
over five million children worldwide \10\ have lost a parent or primary 
caregiver. Children of racial and ethnic minorities accounted for 65% 
of those who lost a primary caregiver,\11\ while making up only about 
50 percent of the child population. These children currently have great 
needs and will continue to have many into the future.
---------------------------------------------------------------------------
    \9\ https://www.npr.org/sections/health-shots/2021/10/07/
1043881136/covid-deaths-leave-thousands-of-u-s-kids-grieving-parents-
or-primary-caregivers.
    \10\ https://www.nytimes.com/live/2022/02/24/world/covid-19-tests-
cases-vaccine#children-parents-caregiver-covid-deaths.
    \11\ https://spectrumlocalnews.com/tx/south-texas-el-paso/news/
2021/10/25/175-000-children-parentless-due-to-covid-deaths.

The needs of this population of children should be met in a 
comprehensive way after identifying who they are. These children should 
have expanded access to mental health services, including in schools, 
regardless of their insurance coverage (public or private.) We must 
ensure that children who have lost caregivers during the COVID-19 
pandemic receive the benefits that they are entitled to under current 
law and make them categorically eligible for other public programs and 
economic aid including early learning programs like the Child Care and 
Development Block Grant and Head Start, the Temporary Assistance for 
Needy Families, the Supplemental Nutrition Assistance Program, 
Medicaid, the Child Tax Credit, and others.

Conclusion

We appreciate the Committee's focus on the mental health crisis of our 
country's children and youth and the two valuable and impactful 
hearings that the Committee hosted in February 2022. First Focus on 
Children commends the Committee's bipartisan approach to this topic and 
we look forward to seeing the proposals that emerge from the five work 
groups that the Committee has established. We share your concern for 
the mental health of America's children and youth and we look forward 
to continuing to work with you as you craft legislation and funding 
proposals.

For questions or comments, please reach out to Averi Pakulis, Vice 
President of Early Childhood and Public Health Policy 
([email protected]), Elaine Dalpiaz, Vice President of Health 
Systems and Strategic Partnerships (ElaineD@firstfocus.
org) or Olivia Gomez, Director of Health and Nutrition Policy 
(OliviaG@firstfocus.
org).

                                 ______
                                 
                               FosterClub

                         620 South Holladay #1

                           Seaside, OR 97138

                            PH: 503-717-1552

                           FAX: 503-717-1702

                    WEB: https://www.fosterclub.com/

                            EIN: 93-1287234

                               CFC: 76187

March 1, 2022

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

RE:  Testimony Submitted for ``Protecting Youth Mental Health: Part 
II--Identifying and Addressing Barriers to Care,'' Hearing Held on 
February 15, 2022

Dear Chairman Wyden, Ranking Member Crapo, and Members of the Senate 
Committee on Finance,

Thank you for your interest in improving access to mental and 
behavioral health services for children, young people, and their 
families. Testimony provided during the hearings on February 8th and 
15th demonstrated the urgent need to improve these services and the 
importance of engaging young people. During the February 15th hearing, 
Mr. Trace Terrell stated: ``My peers and I believe we deserve a seat at 
the table. While there are many ways we can do this, it starts by 
ensuring young people can meaningfully contribute to and be involved 
with legislative work on the local, state and federal level.'' We agree 
fully and we are thankful for Chairman Wyden's, Ranking Member Crapo 
and the Committee Members' commitment to ensuring young people have a 
seat at the table as work on this critical issue continues.

FosterClub is writing to ask for assistance in adding the voices of 
young people who have lived experience in the foster care system who 
face unique challenges in accessing and receiving mental and behavioral 
services and support.

FosterClub is the national network for young people who experience 
foster care. While foster care provides a critical safety net in our 
society for children and youth, we know that being in foster care can 
be a very difficult experience for a young person. FosterClub believes 
that when young people have the support they need and the opportunity 
to drive change in their life, they are able to develop into self-
determined individuals. We also believe that when the system listens to 
young people, it develops a better understanding of how best to support 
them.

For the past two decades, FosterClub has worked with young people about 
the need for mental and behavioral health support in child welfare. 
We've heard from young people about the diverse challenges they face. 
These include but are not limited to: a lack of awareness about 
available health care and services; difficulty getting to the resources 
that will help their needs; changes in services available from 
jurisdiction to jurisdiction and state to state; and difficulty forming 
close relationships with peers while in foster care.

The challenges young people elevated inspired them to find creative 
solutions to the problems they and their peers are facing. The 
continued meaningful engagement of young people is critical to solving 
both these and future challenges to improve the well-being of young 
people in and from foster care. The involvement of young people in 
service delivery should extend beyond their role as recipients of 
services. Young people should be involved in every aspect of the 
design, implementation, delivery and evaluation process.

Increase awareness of health care eligibility.

Although states have been enrolling former foster youth in Medicaid for 
several years, implementation varies. Some states automatically enroll 
young people and some states ask young people to complete a several-
page application. Some states cover young people who relocate to a new 
state and some do not.

States need to improve outreach to young people, simplify the 
enrollment process and cover young people who experienced foster care 
in another state.

        I think that the need to do outreach is so important. Had it 
        not been for some former foster youth campaigning and doing 
        outreach I would not have found out that I could get insurance 
        and I honestly don't know if I would have still been here 
        today. I didn't know I could still get insurance and because of 
        that I failed to go to the hospital and get the help I needed 
        and that made things worse in the long run.
        -- Dashun Jackson, FosterClub Lived Experience Leader who spent 
        4 years in Nevada's foster care system.

        I could have lost my health care if I had left New York to go 
        to Texas for a surgery that I needed. Losing my health care 
        could have jeopardized all of my hard work and progress toward 
        earning my college degree.
        -- Cody Rivera, FosterClub Lived Experience Leader who spent 12 
        years in New York's foster care system

Facilitate improved navigation to services.

Young people need support in navigating the services that can meet 
their unique needs. FosterClub frequently receives calls from young 
people and professionals who are trying to support young people to 
connect with services. Currently, the resources that exist to provide 
these services are not accessible for young people, and frequently, 
they are not accessible for professionals.

We need dedicated foster care navigators who can support connection to 
the right mental health resources and understand what foster youth are 
eligible for. Navigators can be young people with lived experience who 
are trained and equitably compensated.

Streamline services young people are eligible for.

When young people come together from across the country, they report 
vastly different services that they are eligible for. Large disparities 
exist in the quality of services available to young people across the 
country.

Regardless of their location, young people should have access to and be 
eligible for a core set of services. We must ensure diverse communities 
have equitable access to both services and supports.

Increase Access to Peer Support

Young people who are in foster care often feel isolated, as they know 
few other young people who are also in foster care. Young people are 
often more likely to listen to and accept information from their peers 
than they are from professionals.

We must ensure young people have access to peer-delivered services and 
peer support groups, including those with the expertise to conduct 
initial conversations on the importance of health and well-being, 
provide accurate information on the benefits of regular health care 
coverage. Peer support can occur in structured, ongoing opportunities 
for youth in foster care to gather in person or virtually to connect 
with one another. Youth should be supported by trained facilitators who 
are themselves foster youth. There are strong examples of successful 
peer support implementation including in Oregon where FosterClub has 
hosted teams of Peer Navigators who are providing support to fellow 
foster youth during the pandemic.

In summary, FosterClub recommends the following considerations from 
young people with lived experience in foster care in order to improve 
mental and behavioral health supports:

    1.  Meaningfully engage young people in the design, implementation, 
delivery and evaluation process.
    2.  Increase awareness of health care eligibility.
    3.  Facilitate improved navigation to services.
    4.  Streamline services young people are eligible for.
    5.  Provide regular access to peer support.

FosterClub is pleased to share these priorities with the Committee as 
it continues discussions about how to improve mental health supports 
for young people in and from foster care. If you would like to discuss 
further, please contact Celeste Bodner, FosterClub, 503-717-1552 or 
[email protected].

Sincerely,

Celeste Bodner
Executive Director

                                 ______
                                 
                               FosterClub

                     620 S. Holladay Drive, Suite 1

                           Seaside, OR 97138

                     Foster Care Alumni of America

               5810 Kingstowne Center Dr., Suite 120-730

                          Alexandria, VA 22315

March 1, 2022

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

RE:  Testimony Submitted for ``Protecting Youth Mental Health: Part 
II--Identifying and Addressing Barriers to Care,'' Hearing Held on 
February 15, 2022

Dear Chairman Wyden, Ranking Member Crapo, and Members of the Senate 
Committee on Finance,

Thank you for investing in improving the access and resources children, 
young people and their families have to mental and behavioral health 
supports. Testimony given during the hearings on February 8th and 15th 
revealed the urgency of improving these services and the importance of 
engaging young people in these improvements.

FosterClub is the national network for young people who experience 
foster care. FosterClub believes when young people have the support 
they need and opportunity to drive change in their life, they become 
self-determined and do better. We also believe when the system listens 
to young people, it does better.

Foster Care Alumni of America's vision is that all people in and from 
foster care are connected, empowered, and flourishing.

During the February 15th hearing, Mr. Trace Terrell stated: ``My peers 
and I believe we deserve a seat at the table. While there are many ways 
we can do this, it starts by ensuring young people can meaningfully 
contribute to and be involved with legislative work on the local, state 
and federal level.'' FosterClub and Foster Care Alumni of America agree 
with Mr. Terrell fully. We are writing to elevate the recommendations 
that we've received from members of our networks regarding mental 
health services and supports that can improve the well-being of young 
people in and from foster care. We are thankful for Chairman Wyden's, 
Ranking Member Crapo and the Committee Members' commitment to ensuring 
young people have a seat at the table as work on this critical issue 
continues.

Young people and alumni in our networks consistently share challenges 
they encounter in accessing and engaging in high-quality mental and 
behavioral health services. Our networks haven't stopped at raising 
challenges; they've developed solutions. We've included several key 
solutions that we have heard from young people in our networks below. 
Much of the information we are outlining can be viewed in further 
detail in the referenced published documents.

        (1) Educate and inform us of our choices regarding treatment 
        and medication.\1\ This includes education for our families 
        before reaching a crisis point and grief services. Young people 
        must be provided with youth-friendly information regarding the 
        medications they receive.
---------------------------------------------------------------------------
    \1\ See Older Youth Successful Transition to Adulthood (December 
2020, https://nationalpolicy
council.org/sites/default/files/docs/blogs/
_Older%20Youth%20Successful%20Transition%20to%
20Adulthood.pdf); Quality Residential Services (February 2020, https://
nationalpolicycoun
cil.org/sites/default/files/docs/blogs/
Quality%20Residential%20Services_Feb.%202020_Final%
20.pdf); and Improving Youth Engagement and Access to Mental Health 
Services, (April 2013, https://nationalpolicycouncil.org/sites/default/
files/docs/landingpage/Mental%20Health%20
Priorities.pdf).

        Mental health services offered to me never felt like they were 
        presented as a choice. It was as if my trauma and the 
        subsequent behavior challenges that came with it was a burden 
        and something to be fixed. I almost always felt like my 
        autonomy was denied
        -- Brittney Lee, experienced foster care in Washington State

        People think that, because you've been removed from your home 
        of origin, you've been ``saved.'' Youth are rarely provided 
        with support to grieve. Unresolved loss can prevent us in 
        moving forward in finding and retaining permanence.
        -- Youth Voice

        (2) Provide us with peer support and peer navigation.\2\ Build 
        opportunities for youth to have access to peer groups 
        throughout their transitions into adulthood as young people 
        tend to turn to peers for support. Youth organizations have had 
        youth and alumni speak out about mental health challenges and 
        witnessed attitudes among youth in care shift instantly.
---------------------------------------------------------------------------
    \2\ See Older Youth Successful Transition to Adulthood (December 
2020, https://nationalpolicy
council.org/sites/default/files/docs/blogs/
_Older%20Youth%20Successful%20Transition%20to%
20Adulthood.pdf); and Improving Youth Engagement and Access to Mental 
Health Services (April 2013, https://nationalpolicycouncil.org/sites/
default/files/docs/landingpage/Mental%20
Health%20Priorities.pdf).

        (3) Curb over-reliance on medication.\3\ Based on personal 
        experiences, medication is often offered as the ``first fix'' 
        when we start to exhibit issues due to trauma. Part of curbing 
        the over-reliance of medication is to ensure informed consent 
        and have an established and independent appeal process 
        available to us if we have a medication regimen (especially 
        while the regimen is being considered regardless of whether the 
        medication is over the counter or prescribed including off 
        label use).
---------------------------------------------------------------------------
    \3\ See Quality Residential Services (February 2020, https://
nationalpolicycouncil.org/sites/default/files/docs/blogs/
Quality%20Residential%20Services_Feb.%202020_Final%20.pdf); and 
Improving Youth Engagement and Access to Mental Health Services (April 
2013, https://nationalpolicycouncil.org/sites/default/files/docs/
landingpage/Mental%20Health%20Priorities.
pdf).

        When I was thirteen I was given 7 medications at one time and 
        later came to find out two of those medications were found to 
        be dangerous when used together and one of those medications 
        was not even approved for use for anyone under the age of 18.
        -- Former Foster Youth from Iowa

        (4) Prevent ``diagnosis-for-dollars.''\4\ We've heard anecdotal 
        stories from young people who portray a diagnosis being made in 
        their case to bump-up the reimbursement rate for caregivers. In 
        some states, caregivers receive triple or quadruple 
        reimbursement rates for youth with a mental health diagnosis. 
        Placement in foster care should be sufficient for our 
        eligibility for Medicaid services.
---------------------------------------------------------------------------
    \4\ See Improving Youth Engagement and Access to Mental Health 
Services (April 2013, https://nationalpolicycouncil.org/sites/default/
files/docs/landingpage/Mental%20Health%20
Priorities.pdf).

        (5) Guide us so we are adequately prepared to transition to 
        adult mental health services.\5\ Ensure we are aware of how to 
        access mental health support after we transition out of foster 
        care to permanency or to adulthood. Peer navigators and 
        opportunities for group therapy are valuable supports.
---------------------------------------------------------------------------
    \5\ See Older Youth Successful Transition to Adulthood (December 
2020, https://nationalpolicy
council.org/sites/default/files/docs/blogs/
_Older%20Youth%20Successful%20Transition%20to%
20Adulthood.pdf).

        (6) Ensure special populations, including those of us who are 
        LGBTQ2S+,\6\ can access specific and inclusive services to 
        bolster our health and well-being foundations.\7\ This can be 
        accomplished through training for caregivers and child welfare 
        professionals.
---------------------------------------------------------------------------
    \6\ When we use the acronym LGBTQ2S+, we are referring to members 
of the LGBTQ community, Two-Spirit youth and queer-identifying youth.
    \7\ See Improving Youth Engagement and Access to Mental Health 
Services (April 2013, https://nationalpolicycouncil.org/sites/default/
files/docs/landingpage/Mental%20Health%20
Priorities.pdf).

        (7) Ensure we know our rights.\8\ Ensure we have access to and 
        are educated on our rights; we must be able to report 
        violations of our rights.
---------------------------------------------------------------------------
    \8\ See Older Youth Successful Transition to Adulthood (December 
2020, https://nationalpolicy
council.org/sites/default/files/docs/blogs/--
Older%20Youth%20Successful%20Transition%20to
%20Adulthood.pdf); Quality Residential Services (February 2020, https:/
/nationalpolicycoun
cil.org/sites/default/files/docs/blogs/
Quality%20Residential%20Services_Feb.%202020_Final%2
0.pdf); and Improving Youth Engagement and Access to Mental Health 
Services (April 2013, https://nationalpolicycouncil.org/sites/default/
files/docs/landingpage/Mental%20Health%20
Priorities.pdf).

        Mental health professionals were talking to others involved 
        with my case. There was a sense of violation and 
        disempowerment. I knew that information I shared could be used 
        against me.
        -- Youth Voice

We are pleased to share these priorities with the Committee as you 
continue looking at ways to improve mental health outcomes for young 
people. If you would like to discuss further, please contact Angel 
Petite, Senior Policy Manager at FosterClub, 503-717-1552 ext. 105 or 
[email protected] or Kodi Baughman, Lived Expertise Policy 
Director at Foster Care Alumni of America, (515) 402-2238, or 
[email protected].

Sincerely,

Angel Petite
Senior Policy Manager
FosterClub

Kodi Baughman
Lived Expertise Policy Director
Foster Care Alumni of America

                                 ______
                                 
                        Healthy Schools Campaign

                     2545 Diversey Ave., Suite 214

                           Chicago, IL 60647

                              312-419-1810

                  https://healthyschoolscampaign.org/

Dear Chairman Wyden and Ranking Member Crapo:

On behalf of Healthy Schools Campaign, thank you for the opportunity to 
submit a statement for the record for the hearing, ``Protecting Youth 
Mental Health: Part II--Identifying and Addressing Barriers to Care.'' 
We commend the U.S. Senate Committee on Finance for developing 
bipartisan legislation to address the challenges facing the United 
States' mental health care system. Schools play a critical role in 
meeting the behavioral health care needs of children and young people 
across the country and strengthening and supporting schools and school-
based providers is a critical component of any policy solution.

The COVID-19 pandemic has impacted the behavioral health and emotional 
well-being of students across the country. Mental Health America 
reported that in 2020, 14% of youth suffered from at least one major 
depressive episode in the past year. Data from the Centers for Disease 
Control and Prevention (CDC) indicates that mental health-related 
emergency department visits are up 24% for children (age 5-11) and 31% 
for youth (age 12-17). While schools serve as a key source of mental 
health programs and supports for children and youth, 68% of principals 
report having insufficient school-based mental health professionals to 
meet student needs.

While student and staff mental health issues are increasing as a result 
of the pandemic, this problem is not new. Mental health issues present 
a major challenge for students. Prior to the pandemic, it was estimated 
that as many as one in five children living in the United States 
experience a mental disorder in a given year, and approximately 40% of 
adolescents experience a mental health condition each year. Three 
quarters of all students receiving mental health services receive those 
services in schools.

Through Healthy Schools Campaign's work at the national, state and 
local levels, we have seen the critical role schools play in supporting 
coordinated, comprehensive and equitable access to behavioral health 
care. Healthy Schools Campaign leads the Healthy Students, Promising 
Futures Learning Collaborative which was launched by the U.S. 
Department of Education and U.S. Department of Health and Human 
Services in July 2016 and brings together 15 state teams focused on 
expanding Medicaid funded school health services. Core to the learning 
collaborative's work is identifying policy solutions that support 
expanded access to and resources for school-based behavioral health 
services. In addition, Healthy Schools Campaign has over two decades of 
experience providing on the ground support to school stakeholders, 
including families, school staff, youth and community members to 
advance healthy school environments, including access to behavioral 
health services and supports.

Through this work, Healthy Schools Campaign has identified a number of 
federal and state policy solutions that, if implemented, can ensure 
schools are supported as key providers of behavioral health services 
and programs.

1. Strengthen school-based Medicaid programs.

A key strategy for improving access to behavioral health care for 
children and young people is ensuring school districts are able to 
receive Medicaid reimbursement for behavioral health services delivered 
in schools. While Medicaid has a 30-year history of reimbursing for 
school-based health services, that reimbursement has primarily been 
limited to eligible services included in students' Individualized 
Education Programs or Individualized Family Service Plans. This means 
that the majority of behavioral health services delivered to Medicaid 
enrolled students in school settings are not Medicaid eligible.

In 2014, the Centers for Medicare and Medicaid Services (CMS) issued a 
state Medicaid director letter allowing states more flexibility in 
their school-based Medicaid programs by permitting school districts to 
bill Medicaid for health services delivered to all Medicaid-enrolled 
children, not just those with a special education plan documented by an 
Individualized Education Program (IEP). In order to implement this 
change, some states need to submit a state plan amendment (SPA) to CMS; 
other states are able to implement this change administratively without 
a SPA. This policy change presents a critical opportunity to expand 
access to and resources for school-based behavioral health services and 
yet, only 16 states have leveraged the opportunity to expand their 
school-based Medicaid programs. Federal support and guidance are needed 
to ensure the remaining states leverage this opportunity

Solutions to strengthen school Medicaid programs across the country 
include:

      Require that all states implement the free care policy to expand 
their school Medicaid programs to cover all medically necessary 
services--including prevention and early intervention--delivered to all 
Medicaid eligible students in a school setting.
      Require Centers for Medicare and Medicaid Services to update 
both the Medicaid School Health Technical Assistance Guide and the 
Administrative Claiming Guide to better support states in designing and 
implementing their school-based Medicaid programs, including how to 
address significant implementation barriers faced by schools. The last 
federal guidance on school Medicaid programs was issued in 2003 and the 
lack of updated guidance presents a significant challenge to states and 
school districts seeking to strengthen and expand their school Medicaid 
programs. The guidance should be updated with significant input from 
states and stakeholders.
      Provide an increased Federal Medical Assistance Percentage 
(FMAP) for health services provided in a school-based setting, 
including behavioral health services. An increased FMAP would both 
incentivize states and school districts to expand their school Medicaid 
programs and ensure school districts had access to sustainable funding 
to deliver behavioral health services to Medicaid enrolled students.
      Deepen funding for technical assistance (TA) to schools and 
state Medicaid programs by establishing a national Medicaid technical 
assistance center to support states and school districts in operating 
their school Medicaid programs. This could be modeled after the Mental 
Health Technology Transfer Center Network (https://mhttcnetwork.org/).
      Provide states with funding to support small and rural school 
districts implement and/or expand school mental health Medicaid 
programs--and provide ongoing technical assistance. This could include 
funds to train school health providers, educate school district billing 
departments, and provide dedicated state staff to coordinate between 
state Medicaid and Education departments. Initial funding can help 
ensure states and school districts are able to serve the most students 
possible.
      Issue a Request for Information on school-based Medicaid 
programs to better understand the challenges and opportunities facing 
school districts in billing Medicaid for school health services, 
including behavioral health services.

2. Support the delivery of school-based telehealth services.

During the COVID-19 pandemic, students have faced disruptions in access 
to school-based physical and behavioral health services as schools 
shifted from in-
person to virtual learning. Many schools adapted by delivering services 
through telehealth and states leveraged federal flexibilities to 
implement policies that allow Medicaid to reimburse for school-based 
telehealth services to support the health needs of students. These 
policies promote access to critical health services for students and 
support schools in meeting federal requirements to provide services to 
students with disabilities while reducing risk of COVID-19 
transmission. Supporting states in continuing to maximize the use of 
telehealth to deliver school-based behavioral health services is a key 
strategy to meeting student behavioral health care needs.

Solutions to strengthen the use of telehealth to deliver school-based 
behavioral health services include reimbursing behavioral telehealth 
services at the same rate as in-person services. Given the significant 
investments required of school districts to offer and maintain 
telehealth services, it is critical to ensure school districts are able 
to maximize resources for school-based telehealth services to support 
ongoing access for students.

3. Address shortages of school-based behavioral health providers.

School districts across the country are facing workforce shortages of 
school-based health providers, particularly school-based behavioral 
health providers. This issue is particularly critical as school 
districts develop and implement plans to spend American Rescue Plan 
funding. Many school districts have prioritized spending COVID-19 
relief funding on expanding access to school-based behavioral health 
providers and yet, they are unable to find enough providers to meet 
students' behavioral health care needs.

Solutions to strengthen the school-based behavioral health workforce 
include:

      Create and expand loan forgiveness, repayment and scholarships 
for healthcare students and professionals who pledge to work within 
school settings.
      Develop a National School Health Services Corp under the 
National Health Service Corp.
      Simplify the Public Service Loan Forgiveness program (PSLF) to 
make it easier for individuals who commit to serving as health 
professionals in schools to qualify for loan forgiveness. This could 
include partial, up-front loan forgiveness, as an alternative to the 
all-or-nothing back-end loan forgiveness currently provided by the PSLF 
program as well as forgiving a portion of the borrower's eligible loans 
every two years.
      Expand Health Resources and Services Administration's (HRSA) 
State Loan Repayment program to include school health professionals as 
eligible members of the healthcare workforce.
      HHS and ED should establish national certifications for all 
school health providers, such as the National Certified School 
Psychologist credential and grant state reciprocity for all school 
healthcare workers to remedy the shortages in rural and other 
underserved communities.

Thank you for considering our feedback on this important issue. We care 
deeply about the ability to meet the behavioral healthcare needs of 
students and believe strengthening the delivery of school-based 
behavioral health services is a key strategy to improve access to 
behavioral health care for children and young people.

Sincerely,

Rochelle Davis
President and CEO

                                 ______
                                 
                          Juvenile Law Center

                    1800 JFK Boulevard, Suite 1900B

                         Philadelphia, PA 19103

                              215-628-0551

                              800-875-8887

                            215-625-2808 fax

                          https://www.jlc.org/

Hello, my name is Alexis Andino; I go by Lexi. I am 24 years old, and I 
have been working with the Juvenile Law Center's Youth Advocacy Program 
as part of their Youth Fostering Change program for 4 years.

I was 10 years old when I first went into foster care. They picked us 
up from lunch, and I never got to go back home. I was scared, I was 
frustrated, being with a whole bunch of people I didn't know. We waited 
in one of the rooms in the DHS building for hours. I was in care for 
the whole time until I was about 17. I got discharged, because I got 
approved for Kinship care. I thought I could be with my great 
grandmother, but I had to move, and I had to find a place to go because 
shortly after I got out of care she passed away, and then I was 
homeless again.

It was hard to get in contact with people. When I was 18 and 19, they 
told me it would be hard to reenter, and that I'd be in a shelter for 
over a year before I got housing. They basically told me I would have 
to go back to a shelter, and that basically was my only option. I was 
hopping around from home to home. I tried to go back into foster care 
at age 19 and I didn't get help with anything until after I was 20.

It wasn't until a few months after I was 20 that I got help through AIC 
(The Achieving Independence Center). I wound up still staying with a 
family friend. I kept trying to get connected to Valley Youth House 
though AIC. AIC finally got me connected to Valley Youth House after I 
was 20. I only got about 10 months of support. The system is messed up. 
It shouldn't be like that. There's no reason that they can say that we 
can come back and get help and that we're able to get help until we're 
21 but when you try to get help, they literally deny you and tell you 
no and that you'll be in a shelter for over a year. They were basically 
telling me don't get back in the system because you're basically not 
going to get any help. They kept denying me services and resources 
until it was kind of too late. I ended up only getting services for 
less than a year when I should have been able to get it for that whole 
3 or 4 years, when I really needed it. Someone just told me that they 
think that AIC was extended until 23, and there are all of these other 
things like this Ombudsman hearing, and all of these other services--
nobody tried to contact me or help me with anything. And of course, all 
of that stuff changed and extended because of COVID but I already 
turned 23 so I couldn't receive those extra services.

Every time I tried to get connected to services, they acted like I 
should know who my family is, like I haven't been in the system for 10 
years. They separate you from your family, don't let you communicate, 
don't use to not let them come and see me or vice versa, sometimes for 
a punishment, that's not right. Literally restricted phone calls and 
you're supposed to magically know your family and have somewhere to 
live with when you age out. It doesn't make any sense, it's so dumb. 
They wonder why we age out of the system and don't have a support 
system or family. It's ridiculous.

Being in foster care growing up, I did go through a lot of things 
related to race. I was always in other people's homes--foster homes and 
group homes, of people I didn't relate to. They would look at me as if 
I was different. There was a lot of time I was the only white person in 
the home, or school, I got picked on a lot. Staff would be talking at 
youth instead of talking with youth. They wouldn't give you a chance to 
speak. This was the rule and that's it. You can't say how you feel, and 
you have to follow it or you're getting punished. I never had a sense 
of normalcy or a good childhood. They would take away stuff. I didn't 
have a cell phone until I was like 15. I was coming in and out of the 
city at the age of 13 on the buses with no phone. I was making my own 
doctor's appointments, I did almost everything on my own. Every time I 
asked for help, they would look at me like ``what do you need help 
for?, you can do it yourself.''

I felt like every time I asked for help they would give me the run 
around--``you gotta contact this person'', ``I don't know, you gotta go 
to this person'', ``I can't help you with this, go to this agency''. I 
didn't get help until I was going to everyone's supervisor and telling 
people in court that I was trying to get help, and nobody wanted to 
help me. I didn't get help with getting back into therapy until after I 
got discharged from DHS. I asked for help getting services and it was 
so much of a process that took forever. I didn't know if it was the 
process or if they weren't trying to help me in the beginning.

Youth questions about their case can often go unanswered by attorneys 
and the case workers assisting them. For example, I followed up every 
time I was experiencing challenges, or had questions, or when I needed 
help or wanted access to service. However, despite how many times I 
reached out, I never seemed to get clear answers, the outcome remained 
the same. I had no final answer, and no clear help to get answers. It 
seemed like I needed to figure out how to help myself and get myself 
access to services, even at such a young age. This made me feel 
frustrated and like I didn't want to follow up because they would give 
me general statements instead of action steps. This inconsistency 
process, and lack of clear follow-up impacts youth emotional health and 
well-being. For me, it made it feel alone, helpless, and truly I felt 
belittled, like I didn't matter, or neither did my opinions, or my 
life. I felt stuck, and like there was no value on my future- that 
people didn't care about me. My case planning team should have been 
honest and realistic about what was happening and what my options and 
next steps were. They should have explained my case to me and got me 
help and support much sooner than 3 months before I aged out. Since no 
one really taught me, anything growing up, this is why I'm struggling 
now. I believe if they would have been honest with me and communicated 
with me about my case and what I could do to better my life, to help 
myself, and directly connected me to supportive services I would have 
been better. I wouldn't have just been living day to day.

I recommend that there is a requirement to ensure that it is written in 
a youth case plan of which staff are required to actively engage with 
youth in their case planning, the specific services needed for youth, 
and who on the youth's team will connect them to these services and 
supports. This needs to be completely detailed for youth and written 
out more comprehensively so that it happens. I believe if this happened 
for me, I would be in a better place, because all I really needed was 
resources, a sense of guidance. All I needed was someone to tell me 
``this is life, you need X,Y,Z'', and I will help you through it, 
especially as a child and a teen. I was never able to be a child. I'm 
still learning and unlearning things. If I would have been more active 
in my case, I would have been engaged and have a say in my life.

Youth deserve a sense of normalcy, guidance, a good and reliable 
support system, someone to show them how to navigate through life. It's 
really not easy when nobody tells you or teaches you important things. 
To ensure what happened to me doesn't happen to other youth, I would 
also recommend incentivizing states and counties to Designate a mental 
health point person who can discuss youth therapeutic options and the 
benefits of therapies and work with youth and families to connect them 
with community agencies that will fit their needs--whether outpatient, 
partial, weekly, art therapy etc. This process must include discussing 
that various types of therapy are dependent on the age of the youth, 
and if there is an immediate mental health crisis taking place. I 
believe if there was someone like this available in my state or county 
it would have helped my case and me a lot. I still struggle every day 
because I don't have any guidance, anybody to call when I have 
questions. If I had someone involved in my life, I would have felt like 
I would have finally had someone in my life who cared about me.

Thank you.

                                 ______
                                 
My name is Aqilah David. I am 21 years old. This is my fourth year 
serving as an advocate with Juveniles for Justice at the Juvenile Law 
Center.

I first entered the child welfare system at age 15. It was a long, 
horrible journey. I've been bounced around through a few juvenile youth 
residential treatment facilities. I've had workers assigned to me 
through DHS and the courts. To this day I feel like I've encountered so 
many harmful and traumatic events while in the child welfare systems. I 
was expelled in the 11th grade due to truancy, ODD, and feeling 
frustrated with things happening in my life. After being expelled, I 
was sent to an alternative school, on probation, and later forced to go 
to a juvenile placement because of a GPS violation. When I got to the 
juvenile holding facility, no one notified the alternative, so they did 
not know I was in placement and constantly marked me absent while I was 
in the juvenile facility.

They held me at the juvenile holding facility until a placement became 
available. Finally placed at an official placement I suffered from 
depression, and I felt spiritless. I met with a psychiatrist there who 
I explained to that I was having trouble sleeping and was always sad. I 
was glad to talk to anyone, because I just wanted to express to someone 
how things were making me feel while I was at a residential treatment 
placement. The placement prescribed me medicine as a child, that was 
too high in dosage and made me lightheaded, dizzy and made me throw up. 
I told this to my Philly CUA worker who then told me the medicine was 
for my own good. So, I told the psychiatrist I did not feel the 
medicine was making me feel better, I made a mistake telling her 
because this only led to them increasing the medication they were 
giving me throughout my whole stay. I gained weight and I am scared of 
medicine to this day as an effect. Congress must work with HHS to 
develop policies that require first utilizing therapeutic services 
first, and medication must be provided only as needed, and after 
individualized assessments by qualified professionals and following 
full consideration of alternatives to pharmaceuticals.

While at placement I felt I had to advocate for myself a lot, including 
attending a school off-grounds from the placement; a local community 
school where I had to be tested and was accepted. I was glad because 
the placement school was horrible. I was discharged from the placement 
at age 18. I did not leave with the documents that I needed like my 
school documents, my health records, or vital docs. I had to find my 
vital documents on my own. The placement or the local public school 
never gave me my diploma, so I had no proof that I graduated from high 
school.

There was no aftercare support after I left placement. No one talked to 
me about my safety when I got home. I wish I had more support to 
prepare for college or had someone who could have guaranteed my 
educational transition would be successful. Also, any mental wellness 
support and medications that were started in placement needed to be 
continued but when youth leave, there is no person ensuring anything. 
There should also be a state office, like a Youth Ombudsman office in 
every state where youth could go there to file complaints and get 
accurate information on who is supposed to help and report when people 
are not supporting them. I could have used an Ombudsman office in my 
state this office when I was over-medicated, and when I didn't receive 
appropriate support in placement, and when I left. No child or youth 
should have to do this alone, but I did. I was a kid, I deserved 
better. To expect that youth who go to placement will experience 
success and complete school is unrealistic because youth are not given 
enough guidance support. We need better options.

Thank you.

                                 ______
                                 
Hello, my name is Alexandria Rivera. I am 21 years old, and I have 
entered eight different placements, including Foster Care. I have been 
working with the Juvenile Law Center, Youth Advocacy Program, as part 
of their Juveniles for Justice program for three years, and I have been 
an active alumna for one year. The reason I continue to work on issues 
youth face is because I was a youth who had issues. Now, I am an adult 
still trying to fix the damage the system causes. I believe that we 
don't need generation after generation to fall apart due to a broken 
system, so it is important for us to share our testimonies to fix the 
damaged system.

Before I even walked into the courtroom, my worker told me I was not 
going home. They did not tell me how long I was staying. They stated 
that I wasn't going home. That was a lot for me to think about so fast, 
because it happened before I even walked in and then,--when I walked 
into court, I didn't even understand what they were saying. They said 
that I would be with my brother at an ``on-grounds school'' because he 
was placed a week before me. My mom started crying. I figured I was 
being sent to placement because of the things that were going on at 
school--a school I didn't even want to go to because I knew what would 
happen to me if I went there. Before I entered the justice and foster 
care system, I was living at home and going to Edison, my community 
high school, but the school had a bad reputation. I knew that if I went 
to that school things would not go well. It had a lot of police and was 
a really chaotic environment with little to no structure. We didn't 
have a principal for about 2 months, or any support or programs. I 
didn't feel comfortable showing up to school, I felt like there was no 
point in going to school because I wasn't learning. It wasn't safe and 
was so unorganized in class. I remember my teacher gave me an 
assignment to complete that already had all the answers filled in. I 
told my mom I wanted to go to a better school that had more structure 
and more after-school programs so I would have a better experience, but 
I was sent to Edison instead. Instead of help, or the court asking me 
why I didn't want to go to school or what was happening at school- I 
was sent to placement.

When I got to the placement it was freezing, I didn't even know the 
name or location, how long or where or even the real reason why I was 
placed. The second day at the placement, there was a ``house meeting'' 
with two groups of youth housed at the placements and a big fight broke 
out. I didn't know what was going on. I was supposed to be meeting a 
staff member who would be assigned to me, but I didn't meet her until a 
week later. I should have met her within 24-48 hours. I wanted to talk 
with someone at the facility to know why I was placed, and why I did 
not get a warning. I kept thinking, did I get sent to placement, 
because my siblings went to placement, am I being sent here as a 
warning? I couldn't understand why they sent me when I had never been 
in trouble until I went to Edison.

Being in placement kind of destroyed my life. It destroyed my 
education. I didn't get proper education and none of my credits 
transferred. Being in placement feels like you're in a ``halfway'' 
house for children. Placement is what made me feel like I was a 
delinquent. No one offered me support from my community to go to a good 
school, the court should have given me support to stay home and offered 
to help me get into the right school I wanted to get into, not sending 
me to an unsafe community school. If our community had support for 
youth, I wouldn't have felt like I had to make certain choices to 
protect myself. I went from having to defend myself in school, to 
defending myself in a placement, just to go back home on my own and 
have to deal with the effects of all I went through before placement 
and while I was in placement. That is too much to worry about as a 
child. If I was offered support at home, I would have only had to worry 
about what a child should have been worrying about: how I was going to 
finish out my classes at the school.

I was a kid. I deserved better. We all deserve better. We deserve 
someone really fighting for us and for all youth in placement to 
require all states to have a Youth Ombudsman Office to be a place where 
youth can go, to have someone on their side. Someone who we could have 
gone to who worked outside of the placement, and outside of the system. 
The least people can do is give youth an alternative. Congress should 
also work to ensure that before a youth is placed in a group facility, 
agencies exhaust all efforts to make sure youth are placed in family-
based settings. Many people don't know what it's like to feel scared 
not knowing where you are going, and that you're going to be in 
placement. We deserve chances to get alternatives. We deserve support. 
We deserve to be offered programs, better schools, and resources. We 
deserve something better than being put away.

Thank you.

                                 ______
                                 
Hi, my name is I-sha-le Watson. I first entered into placement around 
15 and then entered into foster care. Being in group placements did not 
help me, especially not with school. The first placement that I went to 
did not have school. I did not know that I was supposed to have 
educational support in placement, so I did not ask about it. If I was 
never sent to placement, I would have graduated on time. While I was in 
juvenile placement, I experienced discrimination because I'm a LGBTQ 
youth. Discrimination and mistreatment in these facilities is a 
constant problem and one no person or child should ever have. Sometimes 
it happens because of our race, orientation, or sexuality and no one 
ever really knows, or is held accountable for what happens to us. 
Congress should work to enact legislation that would reduce the impact 
of racial bias in the foster care system, including requiring that 
states develop policies and protocols to ensure that all options for 
support are provided in the home and with other family members before 
removal.

We need an Ombudsman office, because obviously, youths are not being 
cared for in these placements. Youth deserve care and respect. Adults 
should have been carefully going through children's and youths' 
complaints and should be evaluating these places. How can you all look 
at these complaints, and cases and say to yourself, ``oh, a youth 
reported that,'' and then you just throw out or ``unfound'' these 
claims? That's wrong and it doesn't make any sense. The system needs to 
be held accountable for what has happened to us in these facilities.

As a society we should be investing money in youth and families, 
instead of the over $211,000 per kid it can costs in states like mine, 
in Pennsylvania to lock youth up. The same amount of money you all 
spent to incarcerate youth can be used to create many programs to keep 
youth off the street and in family-based setting. Youth need more 
physical activity programs, sports, like basketball, and recreational 
activities that support our mental health and physical growth. Youth 
and families shouldn't have their only option to be to go into foster 
care or to have them put into placement when they need help. Placing a 
child in a juvenile and or group facility is not helpful. It did not 
help me at all, especially with school. I'm still not sure I ever got 
credits while in placements. I found out because when I got home, I was 
trying to get into a local community school, and they couldn't locate 
any credits from the placement school I needed to transfer back to my 
community school.

My experiences in placement and in foster care are why I think that it 
should be a requirement to have all states have Ombudsman offices. If 
we had an office like this in our state maybe a lot of youth in 
placements and group homes might not be behind in their schooling, 
having to graduate after 19, 20 or older because they could report that 
they are not getting any education, or not getting the educational 
support they're supposed to get, and get help faster. This office could 
have also helped address when I was experiencing discrimination in 
placement from staff. Furthermore, Congress must work to develop 
policies and practices that end racism and all forms of oppression by 
ensuring child welfare staff, and child welfare agencies provide 
required training, and have process' to enforce all anti-discrimination 
practices. It also just means a lot to me if Congress works to address 
these issues and to know that someone is trying to help to make sure 
that youth have what they need when they need it.

Thank you.

                                 ______
                                 
Hello, my name is Briannah Stoves. I am 17 years old. I have been in 
seven different placements since I was 12 years old. This is my first 
year working at the Juvenile Law Center with their Youth Advocacy 
Program. I got involved with Juvenile Law Center's Youth Advocacy 
Program because I heard I could verbally advocate, and I've been in the 
juvenile system so I know how the system is, and if I can have a say so 
in changing it, then I want to.

The very first time I was arrested for running away, I was taken to a 
mental hospital. I felt safe at the hospital, but I was under 
medication the whole time. If there was any sort of conflict, they 
would always choose to sedate me. This was not the best method, what I 
needed was therapy for me and my family, I would like there to be less 
reliance on medication for children who are experiencing a crisis. We 
are resilient and can heal not only from medication. I wish they first 
would have provided me with another alternative before medication, 
because there are sometimes harsh side effects and long-term effects.

The second time I was arrested, it was a mistake. I let my anger get 
the best of me. Me and the police officer both could have done better, 
but I was immediately placed from that experience. We both could have 
deescalated. We both played a part in it, but I'm the only one that 
paid the consequences. I was 14 years old. I feel like the cop should 
have de-escalated the situation. He approached me with an angry 
attitude, which wasn't helpful. You cannot approach anger with anger. I 
wish the cop might have taken another second to have talked to me to 
de-escalate the situation, because as a teen I was experiencing a lot 
of traumas and was visibly upset. I don't think I needed to have been 
arrested immediately, as the first option. More steps could have been 
taken so that everything didn't have to occur the way that it occurred.

When I was placed after that experience, being in placement showed me 
that nowhere was safe. Staff was allowing the other kids to bully me, 
so I ran away. There was always a lot of fighting. Especially with a 
lot of females in one house. My sense of safety was gone. I stayed in 
my room a lot of the time and just read books.

I learned about the grievance procedures in a more disciplinary 
setting. I didn't file any grievances because I didn't believe that 
anything would be done. I know how long it takes to go through the 
chain of command, and it would have been dismissed before anything was 
one. I recommend Congress require federally funded, and state funded 
facilities to develop a truly youth-friendly grievance policy and 
connect youth to independent advocates who can assist youth in 
navigating the process. This should include reviewing and assisting 
youth with the grievance procedure. There also should be more staff 
support and training for staff running not only juvenile, but 
residential treatment and foster care group homes. There should not be 
limited staff members who also lack skills in working with kids. I 
remember the staff where I was staying didn't know how to deescalate 
situations and a lot of times when the kids would get upset, the staff 
would too.

Having safer environments for youth It would allow them to build 
healthy relationships that are helpful for growth and healing. Thank 
you for listening to my story and I hope you understand what is really 
going on and that you will help make a change.

Thank you.

                                 ______
                                 
                         Mending Minds Village

                        1594 West 400 South #28

                       Salt Lake City, Utah 84104

    Senators,

    We had the privilege of listening to the hearing the U.S. Senate 
held today regarding protecting youth mental health on a national 
level. Mending Minds Village was created specifically to facilitate 
change in the State of Utah, as well as on the national level to 
provide much needed resources for our youth starting immediately. We 
wanted to provide you a statement on this issue today, and provide our 
stance on this issue.

    Thank you to Senators Wyden and Crapo for putting bipartisan 
support on this very critical issue nationwide. The youth in Utah are 
having large difficulty in finding resources and treatment for their 
mental health issues across the board here. We have seen a major uptick 
in suicide and violence, especially across our minority groups in the 
state. We have heard from families and therapists alike in the mental 
health field, and what we are finding is very much equal across the 
board in the needs and detriments. We have found that the programs 
dedicated to providing services in this state are being highly slowed 
by details such as billing and reporting requirements, and in some 
cases they are not able to bill for certain services (i.e., autism 
care) that is preventing them from helping the clients they care for.

    My team at Mending Minds Village is dedicated to bridging the gap 
between families who need support, the providers who are trying to 
address those needs, and the medicaid and state/federal systems that 
are preventing them from doing their jobs. In listening to the 
testimony given in this hearing, we are moved to see such amazing, 
bipartisan leadership being dedicated to helping our youth and creating 
the changes that will help families going forward. Having recently 
heard of the CCBHCs, we have done our research on the program, and we 
are having the conversation with state and local leaders to bring that 
movement to Utah as well. We believe strongly that this program was 
dedicated to creating a better mental health system going forward, and 
to have the support and funding of the federal government could 
drastically change some lives of the families in our great state.

     We began Mending Minds Village in January of 2022, after having 
spent the last 4 years consecutively addressing the mental health needs 
of our amazing 7 year old daughter. In the last 4 years, we have been 
turned away, told there is no testing for her age (4-6), told that she 
did not qualify for mental health treatment, and many more frustrating 
and difficult things along the way. As we have delved into this 
organization and tried to understand the needs of providers and 
families alike, we are finding a general theme in those conversations: 
the need for financial and state assistance for both. We have created 
an organization (working on our 501(c)(3) status) that we feel could 
help provide the assistance needed to desperate families, as well as 
provide a private forum for providers and directors to create some much 
needed intervention and conversation.

    We come to you in support of the work that you are trying to 
accomplish, and in support of the members of your committee who spoke 
today regarding this issue. We applaud your work and constant attempts 
at bettering life for those with mental health concerns. We plead with 
you to work diligently to pass bills that will provide much needed 
relief for these families who have needed it for so long, and are 
losing the battle waiting on intervention. Too often we hear of 
families who have lost a child or a loved one due to mental health 
concerns that were not addressed by those they reached out to the most. 
Too often we hear of families being torn apart due to a child's 
uncontrolled behavior thanks in part to severe mental health. It is 
time these families are heard and their needs are met. And we know you 
are working hard to come to a resolution that will do just that.

    We would love the opportunity to address the committee in person 
(or on Zoom), and discuss with you the voices we are hearing in our 
short time since being formed. The providers voices who are working the 
frontlines and know what is so desperately needed. The families who are 
begging for help before their world falls apart and being at the mercy 
of the State and medicaid boards. We would love to share their stories 
with you in hopes of creating another strong push for intervention and 
assistance.

    Thank you for your time and your work in this matter, Senators. And 
thank you for your time, and allowing this statement to go on record.

    Sincerely,

    Kaden Mattinson
    Founder and Director

                                 ______
                                 
                      Mental Health Liaison Group

                      1400 K Street, NW, Suite 400

                          Washington, DC 20005

                         https://www.mhlg.org/

February 20, 2022

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

Re: Full Committee Hearing: ``Protecting Youth Mental Health: Part II--
Identifying and Addressing Barriers to Care''

On behalf of the Mental Health Liaison Group (MHLG), we submit this 
statement for the record for the U.S. Senate Finance Committee hearing 
entitled ``Youth Mental Health: Part II--Identifying and Addressing 
Barriers to Care.'' MHLG is a coalition of national organizations 
representing consumers, family members, mental health and addiction 
providers, advocates, payers, and other stakeholders committed to 
strengthening Americans' access to mental health and addiction care. We 
strongly support the committee's continued attention to addressing the 
needs of individuals with mental health and substance use disorders, 
including among children and adolescents. We are grateful for your 
leadership in convening this bipartisan hearing at a critical moment 
for our nation's youth.

Significant unmet child and adolescent behavioral health needs existed 
nationwide, even prior to COVID-19.\1\ Since 2007, suicide rates among 
children aged 10 and older have climbed significantly each year, making 
suicide the second most common cause of death among adolescents before 
the pandemic.\2\ COVID-19 has only exacerbated these trends, including 
among children who did not previously exhibit symptoms of a behavioral 
health disorder.\3\ This led to the American Academy of Pediatrics, the 
Children's Hospital Association, and the American Academy of Child and 
Adolescent Psychiatry to declare a national state of emergency on 
children's mental health, last fall.\4\ This was followed by a December 
2021 U.S. Surgeon General advisory calling for a unified national 
response to the mental health challenges young people are facing.\5\ 
Considering the rarity of such advisories, this further underscores the 
need for action to help stem the long-term impacts of the pandemic on 
the mental health and well-being of children and adolescents. We 
applaud you for inviting the Surgeon General to speak before the 
committee to discuss the steps which can be taken to promote child and 
adolescent mental health and improve their access to care.
---------------------------------------------------------------------------
    \1\ Centers for Disease Control and Prevention. (2020). Youth Risk 
Behavior Surveillance. Retrieved from: https://www.cdc.gov/mmwr/
volumes/69/su/pdfs/su6901-H.pdf; Substance Abuse and Mental Health 
Services Administration. (2017b). Age and gender-based populations.
    \2\ Centers for Disease Control and Prevention. (2020). National 
Vital Statistics Reports. State Suicide Rates Among Adolescents and 
Young Adults Aged 10-24: United States, 2000-2018. Retrieved from: 
https://www.cdc.gov/nchs/data/nvsr/nvsr69/NVSR-69-11-508.pdf.
    \3\ Osgood, K., Sheldon-Dean, H., and Kimball, H. (2021). 2021 
Children's Mental Health Report: What we know about the COVID-19 
pandemic's impact on children's mental health--and what we don't know. 
Child Mind Institute. Retrieved from: http://wvspa.org/resources/CMHR-
2021-FINAL.pdf.
    \4\ American Academy of Pediatrics. (October 2021). AAP-AACAP-CHA 
Declaration of a National Emergency in Child and Adolescent Mental 
Health. Retrieved from: https://www.aap.org/en/advocacy/child-and-
adolescent-healthy-mental-development/aap-aacap-cha-dec
laration-of-a-national-emergency-in-child-and-adolescent-mental-
health/.
    \5\ Office of the U.S. Surgeon General. (December 2021). Protecting 
Youth Mental Health: The U.S. Surgeon General's Advisory. Retrieved 
from: https://www.hhs.gov/sites/default/files/surgeon-general-youth-
mental-health-advisory.pdf.

The stakes of untreated mental and behavioral health symptoms for 
children and adolescents are exceptionally high, both on an individual 
and societal level. Failing to detect and address early indicators of a 
mental or behavioral health disorder can have profound consequences on 
the overall trajectory of a child's life, including a greater 
likelihood of difficulties with learning, addiction to substances, 
lower employment prospects, and involvement with the criminal justice 
system.\6\
---------------------------------------------------------------------------
    \6\ Sacks, V., and Murphey, D. (2018). The prevalence of adverse 
childhood experiences, nationally, by state, and by race/ethnicity. 
Bethesda, MD: Child Trends; National Collaborative on Education and 
Health. (2015). Brief on chronic absenteeism and school health. 
Chicago, IL: Healthy Schools Campaign.

The mental health of children is frequently tied to the overall health, 
safety, and stability of their surroundings. The social isolation, 
upheaval, and disrupted routines brought on by COVID-19, has placed 
considerable stress on children and their families, which typically has 
a downstream effect on their mental health. Ongoing national surveys of 
households with young children have found high levels of childhood 
hunger, emotional distress among parents, and frequent disruptions in 
child-care services.\7\ Even before COVID-19, nearly 10% of U.S. 
children lived with someone who was mentally ill or severely 
depressed.\8\ Furthermore, since the start of the pandemic, over 
167,000 children have lost a parent or caregiver to the virus.\9\ This 
kind of profound loss can have significant impacts on the mental health 
of many children, leading to anxiety, depression, trauma, and stress-
related conditions.
---------------------------------------------------------------------------
    \7\ Center for Translational Neuroscience. November 2021. Still in 
Uncertain Times; Still Facing Hunger. RAPID-EC Fact Sheet. Eugene, OR: 
University of Oregon; Center for Translational Neuroscience. November 
2021. Emotional Distress On the Rise for Parents . . . Again. RAPID-EC 
Fact Sheet. Eugene, OR: University of Oregon; Center for Translational 
Neuroscience. November 2021. Child Care Shortages Weigh Heavily on 
Parents and Providers. RAPID-EC Fact Sheet. Eugene, OR: University of 
Oregon.
    \8\ Ullmann, H., Weeks, J.D., and Madans, J.H. Disparities in 
stressful life events among children aged 5-17 years: United States, 
2019. NCHS Data Brief, no 416. Hyattsville, MD: National Center for 
Health Statistics. 2021. DOI: https://www.cdc.gov/nchs/data/databriefs/
db416.pdf.
    \9\ Treglia, D., Cutuli, J.J., Arasteh, K., J. Bridgeland, J.M., 
Edson, G., Phillips, S., and Balakrishna, A. (2021). Hidden Pain: 
Children Who Lost a Parent or Caregiver to COVID-19 and What the Nation 
Can Do to Help Them. COVID Collaborative.

Additionally, the COVID-19 pandemic has not been a short-term event. As 
we move into the third year of this emergency, it is essential to 
recognize that the pandemic has impacted children for multiple years of 
their social, emotional, and cognitive development, allowing challenges 
and adversities to compound. Parents continue to report being more 
concerned about their children's social and emotional development and 
well-being than they were prior to the pandemic,\10\ and recent data 
show increased behavioral concerns among students who are having 
difficulties transitioning back from remote to in-person learning.\11\
---------------------------------------------------------------------------
    \10\ Jung, Kwanghee, and Barnett, W. Steven. 2021. Impacts of the 
Pandemic on Young Children and Their Parents: Initial Findings from 
NIEER's May-June 2021 Preschool Learning Activities Survey. New 
Brunswick, N.J.: National Institute for Early Education Research
    \11\ Kurtz, H. (January 12, 2022). Threats of Student Violence and 
Misbehavior Are Rising, Many School Leaders Report. Education Week. 
Retrieved from: https://www.edweek.org/leadership/threats-of-student-
violence-and-misbehavior-are-rising-many-school-leaders-report/2022/01.

Youth within marginalized populations, including racial and ethnic 
minority children and adolescents, those who identify as LGBTQ+, and 
children with developmental and physical disabilities, 
disproportionately have experienced some of the most severe 
consequences of the pandemic. Black and Hispanic children lost a parent 
or a caregiver at more than two times the rate of White children, while 
American Indian, Alaska Native, and Native Hawaiian and Pacific 
Islander children lost caregivers at nearly four times that rate.\12\ 
Two thirds of LGBTQ+ teens and young adults report that the combination 
of COVID-19 and recent state actions targeting transgender youth 
participation in school sports, has negatively impacted their mental 
health.\13\ At the same time, young people from these communities faced 
significant barriers accessing behavioral health services, even before 
the pandemic.\14\
---------------------------------------------------------------------------
    \12\ Treglia, D., Cutuli, J.J., Arasteh, K., J. Bridgeland, J.M., 
Edson, G., Phillips, S., and Balakrishna, A. (2021). Hidden Pain: 
Children Who Lost a Parent or Caregiver to COVID-19 and What the Nation 
Can Do to Help Them. COVID Collaborative.
    \13\ Morning Consult and the Trevor Project. (January 2021). Issues 
Impacting LGBTQ Youth. Retrieved from: https://
www.thetrevorproject.org/wp-content/uploads/2021/12/TrevorProject_
Public_Final-1.pdf.
    \14\ Austin, A., and Wagner, E.F. (2010). Treatment attrition among 
racial and ethnic minority youth. Journal of Social Work Practice in 
the Addictions, 10, 63-80.

Increases in demand for pediatric inpatient mental health services are 
also a concerning indicator of the growing crisis in child and 
adolescent mental health. Between April and October 2020, the 
proportion of children between the ages of 5 and 11 and adolescents 
ages 12 to 17 visiting an emergency room due to a mental health crisis, 
increased by 24% and 31%, respectively.\15\ Moreover, due to the lack 
of alternative placement options, hospitals are boarding a growing 
number of children awaiting treatment in their emergency departments. 
In recent months, several children's hospitals reported boarding their 
highest number of children at one time and for longer stays before they 
could be discharged to an appropriate alternate care setting.\16\ In 
the first three quarters of 2021, children's hospitals reported a 14% 
increase in mental health related emergencies and a 42% increase in 
cases of self-injury and suicide, compared to the same time period in 
2019.\17\ Shortages of mental and behavioral health professionals, 
including those specifically trained to treat young people,\18\ further 
exacerbate insufficient capacity to provide needed care and support 
more effective integration of services.
---------------------------------------------------------------------------
    \15\ Leeb, R.T., Bitsko, R.H., Radhakrishnan, L., Martinez, P., 
Njai, R., and Holland, K.M. Mental Health--Related Emergency Department 
Visits Among Children Aged <18 Years During the COVID-19 Pandemic--
United States, January 1-October 17, 2020. MMWR Morb Mortal Wkly Rep 
2020;69:1675-1680. DOI: https://www.cdc.gov/mmwr/volumes/69/wr/
mm6945a3.htm.
    \16\ Children's Hospital Association. Emergency Room Boarding of 
Kids in Mental Health Crisis. Retrieved from: https://
www.childrenshospitals.org/-/media/Files/CHA/Main/Issues_and_Ad
vocacy/Key_Issues/Mental%20Health/2021/Boarding_fact_sheet_121421.pdf.
    \17\ Children's Hospital Association (September 17, 2021). COVID-19 
and Children's Mental Health. Retrieved from: https://
www.childrenshospitals.org/-/media/Files/CHA/Main/Issues
_and_Advocacy/Key_Issues/Mental-Health/2021/
covid_and_childrens_mental_health_factsheet_
091721.pdf?la=en&hash=F201013848F9B9C97FAE16A89B01A38547C7C5C7.
    \18\ Ellison, K. (August 14, 2021). Children's mental health badly 
harmed by the pandemic. Therapy is hard to find. The Washington Post. 
Retrieved from: https://www.washington
post.com/health/child-psychiatrist-counselor-shortage-mental-health-
crisis/2021/08/13/844a036
a-f950-11eb-9c0e-97e29906a970_story.html.

Taken individually, these data are striking, but in aggregate, they 
further illuminate the urgent need for action. In November, MHLG 
responded to Chairman Wyden's and Ranking Member Crapo's request for 
policy proposals on improving mental health outcomes and addressing 
unmet needs, which included the following specific recommendations for 
---------------------------------------------------------------------------
improving access to coverage and care for young people and children:

      Passing the permanent authorization of CHIP and the bipartisan 
Stabilize Medicaid and CHIP Coverage Act (S. 646/H.R. 1738), which will 
provide 12 months of continuous enrollment for Americans who are 
eligible for Medicaid and CHIP.

      Passing the bipartisan Helping MOMS Act (H.R. 3345) to 
permanently ensure that all pregnant women on Medicaid and CHIP retain 
their health coverage during the critical first year postpartum to 
address serious health inequities in maternal health.

      Directing the Centers for Medicare and Medicaid Services (CMS) 
to review the early and periodic screening, diagnostic, and treatment 
(EPSDT) requirements and whether they are being implemented 
successfully at the state level to support access to prevention, early 
intervention services, and developmentally appropriate services across 
the continuum of care.

      Directing CMS to coordinate with the U.S. Department of 
Education to help the Department, states, and other stakeholders remove 
barriers to full participation in school-based Medicaid programs.

      Passing the bipartisan Telehealth Improvement for Kids' 
Essential Services (TIKES) Act (S. 1798), which would promote access to 
telehealth services for children through Medicaid and CHIP and study 
children's utilization of telehealth to identify barriers, 
opportunities, and outcomes.

The workforce shortage of mental and behavioral health clinicians 
existed before the pandemic, but it is now a top concern throughout the 
sector. The shortage of practitioners specializing in mental and 
behavioral health care for infants, children, and adolescents is 
particularly acute. MHLG therefore recommends that Congress increase 
investments to support the recruitment, training, retention, and 
professional development of a diverse clinical and non-clinical 
workforce, both generally and with specialized training for child and 
adolescent populations. This should include new incentives and 
opportunities to practice in rural and underserved areas, additional 
measures to incentivize more individuals to enter the field, and 
increasing reimbursement rates. Low payment rates to providers for the 
provision of behavioral health services heavily contribute to the 
workforce shortage. We therefore recommend increasing payment rates for 
mental and behavioral health care by passing the Medicaid Bump Act (S. 
1727/H.R. 3450), which proposes to raise the federal reimbursement rate 
for mental health and substance use disorder care under Medicaid.

MHLG also calls the Committee's attention to additional measures that, 
while not focused specifically on children and youth, are all critical 
components of a comprehensive and more effective mental health system 
able to meet the increased need for services among children and 
adolescents. We therefore recommend the following additional measures 
be included in any forthcoming legislative package:

      Ensuring parity in reimbursement for mental health and substance 
use treatment, both through Medicaid and TRICARE;

      Promoting the integration of primary and mental health care 
through a range of measures, including by passing the Excellence in 
Mental Health and Addiction Treatment Expansion Act of 2021 (S. 2069/
H.R. 4323); and

      Bolstering vital crisis response systems by passing the Crisis 
Assistance Helping Out On The Streets (CAHOOTS) Act (S. 764/H.R. 1914) 
to expand mobile response and the bipartisan Behavioral Health Crisis 
Services Expansion Act (S. 1902) to provide comprehensive support for 
developing and sustaining crisis services.

As necessary as these proposals are, however, many of these actions are 
long-term. The current crisis also requires a more immediate response. 
To act expeditiously in addressing the current mental health needs of 
young people and meet the call to action in the Surgeon General's 
advisory, Congress must also pass an FY 2022 Appropriations package, as 
quickly as possible. This would be the most immediate way to increase 
resources for a variety of already authorized Substance Abuse and 
Mental Health Services Administration (SAMHSA) and Department of 
Education programs that provide mental health services for young 
people. This includes Project AWARE, the National Child Traumatic 
Stress Initiative, the Student Support and Academic Enrichment Grant 
Program, Safe Schools National Activities, and the Community Mental 
Health Services Block Grant, which provides care for children with 
serious emotional disturbances and would include a set aside for 
prevention and early intervention. MHLG calls on Congress to fund these 
programs at the highest levels possible in a final FY 2022 omnibus 
bill.

Once again, we applaud you for convening this crucial hearing, which 
recognizes the challenges facing the mental health of our youth and the 
potential damage that lack of action can have on an entire generation. 
We thank you for your continued bipartisan leadership on issues related 
to mental health and substance use disorders. MHLG and its members 
stand ready and willing to work with you in your efforts to advance 
policies that support the mental and behavioral health of individuals, 
families, and communities.

Sincerely,

2020 Mom
American Academy of Child and Adolescent Psychiatry
American Art Therapy Association
American Association for Psychoanalysis in Clinical Social Work
American Counseling Association
American Dance Therapy Association
American Mental Health Counselors Association
American Occupational Therapy Association
American Psychological Association
American Foundation for Suicide Prevention
Anxiety and Depression Association of America
Association for Ambulatory Behavioral
Healthcare
Centerstone
Children and Adults with Attention-Deficit/Hyperactivity Disorder
Children's Hospital Association
CLASP
Clinical Social Work Association
Depression and Bipolar Support Alliance
Eating Disorders Coalition
Eating Disorders Coalition for Research, Policy and Action
Education Development Center
Global Alliance for Behavioral Health and Social Justice
International OCD Foundation
The Jed Foundation
The Jewish Federations of North America
Maternal Mental Health Leadership Alliance
Mental Health America
NAADAC, the Association for Addiction Professionals
National Alliance on Mental Illness
National Association for Behavioral Healthcare
National Association for Children's Behavioral Health
National Association of Counties
National Association of Pediatric Nurse Practitioners
National Association of School Psychologists
National Association of Social Workers
National Federation of Families
National League for Nursing
National Register of Health Service Psychologists
Nemours Children's Health
Network of Jewish Human Service Agencies
PsiAN
Psychotherapy Action Network
REDC Consortium
RI International, Inc.
Sandy Hook Promise
SMART Recovery
The Kennedy Forum
The National Alliance to Advance Adolescent Health
The Trevor Project

                                 ______
                                 
   National Advocacy on Serious Neurobehavioral Illness (NASNIcares)

                             P.O. Box 99501

                          Pittsburgh, PA 15233

                 National Shattering Silence Coalition

                              P.O. Box 563

                        Shapleigh, ME 04076-0563

February 12, 2022

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

RE: Hearing on ``Protecting Youth Mental Health: Part II--Identifying 
and Addressing Barriers to Care,'' Tuesday, February 15, 2022

Dear Chairman Wyden and Ranking Member Crapo:

We thank the Senate Finance Committee for the opportunity to share our 
perspectives on the topic of mental health. We appreciate that in 
holding these hearings, the Senators on this committee are 
demonstrating that the mental well-being of Americans and particularly 
America's youth is a matter of importance.

We must not belabor getting to the pivotal questions that underlie this 
communication:

        What is Mental Health?
        What is Mental Illness?

What are the implications of the definitions and meanings attached to 
these terms as it relates to medical care, healthcare, social services, 
and the construct of parity?

The concept of parity is that mental health is as important to overall 
well-being as physical health. The term mental health is a metaphor 
that refers to non-medical psychosocial issues--the problems of 
everyday living . . . from the relatively benign to the very serious. 
Yet, in societal discourse, the term ``mental health,'' specifically 
poor mental health, is conflated with ``mental illness.''

According to content on the CDC's website:

        Although the terms are often used interchangeably, poor mental 
        health and mental illness are not the same.

We agree with this statement although we do not subscribe to other 
statements on the site, such as what causes ``mental illness''--yet, 
this pivots on what someone means when they use the term ``mental 
illness.'' Inasmuch as the term ``mental illness'' is also a metaphor, 
there is no distinction between the terms.

That is why, although we must still use the term ``mental illness'' for 
the sake of clarity, stakeholders in this network of advocates strongly 
object to the use of the term ``mental illness' to classify and 
describe what are truly medical disorders. Segments of this advocacy 
network are calling on the medical establishment to reclassify 
illnesses such as ``Bipolar,'' ``Schizophrenia'' and Neurogenic 
``Depression'' as the neurological conditions that they truly are, and 
moreover, are calling for these medical disorders to be renamed.

There is a federal definition of Serious Mental Illness (SMI) for 
administrative and regulatory purposes, but we do not subscribe to it. 
It was forged by the same influences that gave rise to what NASNIcares 
refers to as the crisis of conflation. The most serious ``mental 
illnesses'' are in fact brain function disorders--they are medical, 
they are physical in that they can involve physical anomalies of brain 
structure and/or systemic bodily functions that disorder the brain's 
semblance of mind. NASNIcares refers to these medical conditions as 
Cerebral Illness and across our network of advocacy we refer to these 
medical conditions as Serious Brain Disorders (SBD) or Brain Function 
Disorders (indicating that the brain's semblance of mind can be 
disordered due to systemic factors arising outside of the brain organ, 
such as in an encephalopathy).

        NASNIcares describes Cerebral Illness or SBDs as:

        Disorders of the brain's semblance of mind and consciousness 
        that can involve structural anomalies of the brain organ, and 
        or dysfunctions of neurocircuitry involving metabolic, 
        hormonal, and other systemic factors that affect cognition, 
        metacognition, motor behaviors, volition and actualization, 
        perceptual processing, identity of self (ipseity) and others, 
        the sense of one's habitus, and other faculties and 
        functionalities. These disorders are predominantly hereditary, 
        neurodevelopmental, organic and not caused by childhood 
        adversity, trauma (except for physical injury--such as 
        traumatic brain injury--TBI), or poor mental health.

In the context of parity, we need to consider that it is not logical or 
just to require one class of medical disorders to have access to 
healthcare under the construct of parity while other medical disorders 
are covered under regular medical benefits.

In in a 1996 Senate Hearing, Dr. E. Fuller Torrey spoke to this matter 
of the illogic of parity within this context and the relevance of how 
these illness are classified to the IMD Exclusion (the misguided and 
tragic policy premised on the fallacious notion of ``diseases of the 
mind''). Excerpting from the full text of this hearing which is 
available online: https://archive.org/stream/deinstitutionali00unit/
deinstitutionali00unit_djvu.txt.

        My fourth and final point is that the Senate Finance Committee 
        today has the opportunity to correct both of these errors. 
        Number one, you should ensure that health care reform covers 
        brain diseases such as schizophrenia and manic depressive 
        illness in exactly the same way it covers brain diseases such 
        as multiple sclerosis and Parkinsons disease and Alzheimers 
        disease. The brain is a single organ and it is both illogical 
        and discriminating to provide full coverage for some diseases 
        of the brain and not for other diseases of the brain. . . . It 
        would be exactly like covering some diseases of the heart but 
        not covering other diseases of the heart.

Excerpting from an article in jscimedcentral.com:

        Advances in neuropsychiatry are increasing our understanding of 
        brain-
        behavior relationships. With this knowledge, the classification 
        of illnesses as psychiatric and neurologic appears increasingly 
        outdated.

There are historical reasons for the conflation of Mental Health with 
``Mental Illness'' and the demedicalization (psychologization) of 
neurologic illnesses that afflict consciousness, cognition, and 
mentation. These historical influences are the origin of the acute 
attentions that are being paid in the present to mental health--
reaching back to the divergence of psychiatry from neurology, the rise 
of psychosocial psychiatry stemming from that separation, the 
subjugation of what can be called biological psychiatry, and the Mental 
Hygiene Movement of the early 20th century.

 Prioritization of Funding--Mental Health Versus Serious Brain Function 
                    Disorders

On the matter of how we allocate what can be, in some circumstances, 
scarce resources in terms of funding and the infrastructure of 
healthcare systems as a whole, we feel that it is important to give 
careful consideration to priorities when crafting programmatic 
solutions under the rubric of ``mental health.'' Mental Health relates 
to non-medical interventions, such as psychotherapy or CBT, peer 
support programs, and other complimentary services delivered by mental 
health providers.

Cerebral Illnesses or Serious Brain Function Disorders (which are not 
mental health issues) relate to inpatient and outpatient medical 
services--specifically pharmacological treatment, intensive case 
management, and supported housing with 24/7 onsite staff for the most 
severely ill individuals that cannot benefit from AOT or who cannot 
live safely in the family home or independently with social service 
supports. There is a paucity of these services, especially supported 
housing and ideologically-driven state recovery models and the IMD 
exclusion curtail services for most seriously ill.

We do not mean to devalue the importance of mental health and we 
certainly do not align with dismissive judgements that tag people 
struggling with mental health issues as the ``worried well.'' We do 
recognize that mental health problems can be serious enough to lead to 
suicide. But it is also important for policy makers to be aware that 
there is what a Bipolar expert within our network describes as ``a 
different type of suicide.'' This is a neurobehavioral/neurological 
phenomenon that can be deemed accidental suicide in a sense because the 
individual's state of consciousness is severely disordered. This is a 
type of suicide that society generally does not understand. Suicide is 
generally conceptualized as an act of psychological and emotional 
distress. Someone in the throes of neurogenic dysmentation within a 
disordered state of consciousness (psychosis) may be in a state of 
repose rather than distress and unaware that they are dangerously ill 
(anosognosia). Despite what professionals with a psychosocial 
orientation to psychiatry believe, anosognosia is not denial.

However, we do not describe ourselves as mental health advocates and we 
are aware that what underlies the intense focus on mental health in 
part are ideas that informed the mental hygiene movement--the belief 
that poor mental health leads to ``mental illness'' and that we must 
funnel the resources of government into the cultivation of good mental 
health and in doing so, work assiduously to stave off ``mental 
illness.''

Excerpting from a paper published in ncbi.nln.nih.gov titled ``The 
roots of the concept of mental health'':

        What today is broadly understood by ``mental health'' can have 
        its origins tracked back to developments in public health, in 
        clinical psychiatry and in other branches of knowledge.

        . . . more than a scientific discipline, mental health is a 
        political and ideological movement. . . .

Most of America's youth will be okay as mental health is concerned 
despite some of the alarmist messaging that is promulgated by today's 
mental health movement, unless by this intense focus on mental health 
more harm is done to them than good. We want to protect children and 
young people by promoting mental wellness and resilience, but we need 
to be circumspect that serious brain function disorders typically 
encroach upon people during adolescence when the brain is undergoing 
dramatic changes. The needs of people afflicted by these 
neurodevelopmental conditions are dire. Failure to identify and treat 
these grave medical conditions can have catastrophic consequences. We 
recommend Dr. Henry A. Nasrallah as a preeminent resource to consult on 
this topic.

Sincerely,

Jennifer Bailey
Project Director
NASNIcares

Jeanne Gore
Coordinator and Co-Chair, Steering Committee
National Shattering Silence Coalition

                                 ______
                                 
         National Association for Children's Behavioral Health

                      201 E. Main St., Suite 1405

                          Lexington, KY 40507

                           Tel: 859-402-9768

                      Website: https://nacbh.org/

February 22, 2022

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

Dear Chairman Wyden and Ranking Member Crapo:

The National Association for Children's Behavioral Health (NACBH) 
appreciates the opportunity to provide a written statement for the 
record, following up on the two excellent Finance Committee hearings on 
youth mental health held on February 8 and 15.

First, we congratulate the committee for organizing such a huge topic 
into five areas of inquiry and action. Focusing input from the field, 
the public, and hearing witnesses in this way will allow a lot to be 
accomplished in a relatively short time frame.

Hearing witnesses were particularly well-chosen, and NACBH supports the 
many concrete suggestions they offered, especially around school-based 
services, crisis intervention, other community-based services, and 
examples of best practices that could be replicated. In addition, we 
appreciate the attention called to the pending implementation of the 
988 suicide prevention hotline and the need to competently respond to 
young people who dial in, which includes ensuring that treatment 
services are actually available and accessible to youth reaching out 
for help. That is a looming challenge as the July 2022 hotline 
implementation approaches, and we link it with the longstanding issue 
of boarding in emergency departments to reiterate NACBH's response to 
the committee's September 2021 request for information:

Please provide Medicaid funding for the full range of necessary mental 
health and substance use treatment services by passing H.R. 2611, the 
Increasing Behavioral Health Treatment Act. This would remove the 
antiquated and discriminatory IMD exclusion for states that establish: 
a full array of community-based services; assessment and oversight to 
ensure treatment placements at the clinically indicated level; 
engagement strategies for specific populations such as youth and young 
adults; particular attention to transitions from institutional 
treatment settings; and annual reporting of demographic and utilization 
data for system accountability.

With the additional requirements of H.R. 2611, this approach would 
bring Medicaid mental health and substance use disorder treatment into 
the 21st century with guardrails to prevent unnecessary 
institutionalization, and allow low-income and disabled beneficiaries 
to enjoy the promise of parity offered to most privately insured 
Americans. The nearly 50-year-old Institutions for Mental Diseases 
exclusion is the largest violation of parity principles allowed to 
stand in this country, and truly inexplicable in light of Congressional 
champions' many passionate and eloquent statements on parity in the 
private sector.

As Chairman Wyden said on the recent release of the tri-department 
parity report, ``If given the right tools,'' he is ``confident that 
true mental health parity can become a reality in the American health 
care system.'' For child and adolescent services in Medicaid, those 
tools could include the provisions of H.R. 2611 to fund a comprehensive 
array of services, use of validated assessment instruments such as 
CASII and ECSII to guide appropriate placement decisions, and federal 
definitions of additional 24-hour settings (in Medicaid) and congregate 
care settings (in child welfare) to ensure federal oversight of safety 
and quality.

This would be a great opportunity to tackle some of the unfinished 
business of the Children's Health Act of 2000 and the Family First 
Prevention Services Act (FFPSA) which is also under this committee's 
jurisdiction. Part I of the Children's Act has never been implemented, 
leaving the use of seclusion and restraint in ``certain non-medical, 
community-based facilities for children and youth'' entirely 
unregulated at the federal level. Under FFPSA, four types of child 
caring institutions are eligible for Title IV-E federal matching funds, 
but only one is defined: Qualified Residential Treatment Programs. At a 
minimum, federal definitions should be established for the other three 
IV-E-eligible child caring institutions--settings specializing in 
providing prenatal, post-partum, or parenting supports for youth; 
supervised independent living settings; and settings providing high-
quality residential care and support services to children who have been 
or are at risk of becoming sex trafficking victims--and Part I 
regulations promulgated for all four. Clearly, these are all programs 
serving children and youth with unique vulnerabilities and mental 
health needs, and not only should there be appropriate federal 
oversight of safety and quality, the Medicaid IMD exclusion should not 
continue as a barrier for health services reimbursement.

Thank you again for the opportunity to provide a written statement for 
the record. We will follow up with the staff identified for the five 
work groups, including additional information on the IMD exclusion and 
proposed cost offsets for NACBH's policy recommendations.

Sincerely,

Patricia Johnston
Director of Public Policy
[email protected]

                                 ______
                                 
                     Nationwide Children's Hospital

Statement of David Axelson, M.D., Medical Director of Behavioral Health 
         Services and Chief of Psychiatry and Behavioral Health

The crisis in pediatric behavioral health has become increasingly clear 
over the last decade, and it has only been exacerbated by the COVID-19 
pandemic. Before the pandemic, approximately 1 in 5 children had a 
mental illness, but less than half of the estimated 7.7 million 
children who needed services received them from a mental health 
provider.

Physical distancing, isolation, stressful home environments, and the 
loss of nutrition and other supports that youth access in schools 
contribute to the growing crisis. Nationwide, mental health emergencies 
among children have significantly increased during the pandemic, 
including:

      A 25% increase in overall mental health-related emergency 
department visits for 5- to 11-year-olds from 2019 to 2020.
      A 31% increase in overall mental health-related emergency 
department visits for 12- to 17-year-olds from 2019 to 2020.
      A 14% increase in mental health emergencies for 5- to 17-year-
olds seen at children's hospitals in the first two quarters of 2021 
compared to the same time period in 2019.

Prior to the pandemic, Nationwide Children's Hospital expanded capacity 
to serve children with mental and behavioral health concerns. In March 
2020, at nearly the exact same time as the pandemic was closing 
schools, triggering stay-at-home orders and delaying certain kinds of 
medical treatment, we opened the Big Lots Behavioral Health Pavilion--a 
behavioral health hospital within Nationwide Children's.

It is the largest pediatric mental health care and research facility of 
its kind in the United States and a model for integrated care through 
every level of acuity. The Big Lots Behavioral Health Pavilion enabled 
an extraordinary expansion of our services and staff. In 2014, we had 
418 staff members; today, we have more than 1,100 staff members 
providing or supporting behavioral health services. With expanded 
infrastructure and an incredibly dedicated team of providers, allied 
health care professionals, and support staff, we have dramatically 
increased the number of patients served. In 2014, Nationwide Children's 
provided 128,000 outpatient visits. By 2021, this number had grown to 
more than 257,000.

The Big Lots Behavioral Health Pavilion expanded services and capacity 
to include a state-of-the-art Psychiatric Crisis Department for 
children experiencing a mental health crisis; created a 10-bed Extended 
Observation Unit, allowing for more time to observe and treat patients; 
expanded from six to 16 the number of beds at the Youth Crisis 
Stabilization Unit; launched a new inpatient program, which now has 36 
beds; and added a Partial Hospitalization Program and two intensive 
outpatient therapy programs.

Just as importantly, our Pavilion functions as a hub for a community-
wide system of pediatric behavioral health care, created with the help 
of many partners. Our system ranges from prevention services in schools 
through inpatient services in our Pavilion. The expertise and resources 
at Nationwide Children's, working in collaboration with community 
organizations and providers, serve to expand the capacity for child 
behavioral health in our region.

Despite the significant expansion in infrastructure and workforce, 
Nationwide Children's is struggling to serve children given the surging 
demand for services. Referrals to Nationwide Children's Behavioral 
Health services have continued to climb, reaching 63,000 in 2021, up 
nearly 20% from 2018. Those referrals have driven growth in ambulatory 
services, which have expanded significantly over the past five years, 
often increasing more than 10% annually. In 2021, Nationwide Children's 
experienced nearly 260,000 visits in the ambulatory setting, serving 
38,751 unique children.

Additionally, patients are continuing to present to the Psychiatric 
Crisis Department at record numbers, nearing 50 patients in a 24-hour 
period during peak times. The Psychiatric Crisis Department topped 
8,100 visits in 2021, up 35% from the prior year and more than double 
the number in 2016, when Nationwide Children's Hospital began directly 
seeing patients in the emergency setting with behavioral health 
clinicians.

Over the last year, Nationwide Children's has experienced record 
volumes and high levels of acuity, driving demand for more intensive 
care, including inpatient services. That, in turn, has had an impact on 
the number of patients with acute mental health needs who must be 
``boarded'' at our hospital. A boarder is a person in immediate need of 
inpatient-level psychiatric care, but who must be kept in a medical or 
observation bed because no behavioral health-specific inpatient beds 
are available. The boarder census indicates the demand for high acuity 
behavioral health services in excess of capacity. In 2021, Nationwide 
Children's Behavioral Health Pavilion, a facility with 56 mental health 
beds, experienced a daily average of 12 boarders. During peak periods 
the number was as high as 35.

Recruiting and hiring mental health providers has always been a 
challenge, and Nationwide Children's continues to struggle to secure 
the highly specialized workforce needed to serve our patients. In Ohio, 
52 of 88 counties don't have a single practicing child and adolescent 
psychiatrist, and 33 counties are in extreme shortage. That is, only 
three of Ohio's 88 counties have anything approaching an appropriate 
number of child and adolescent psychiatrists. Hiring psychiatric 
nursing and mental health clinicians is also a challenge. For the year 
ending 2021, Nationwide Children's had 209 budgeted positions unfilled, 
with the largest percentage of vacancies among therapists/clinicians 
(66%) and mental health technicians (21%).

Nationwide Children's is a health system committed to youth mental 
health and that has made historic investments in facilities, mental 
health promotion programing, and its workforce. Despite these 
investments, Nationwide Children's, like children's hospitals across 
the country, struggles to meet the needs of the kids we serve.

In an effort to address the challenges, Nationwide Children's 
collaborated with peer hospitals in the Children's Hospital Association 
to develop the Strengthening Kids' Mental Health Now proposal, a set of 
recommendations focused on mitigating the negative trends in pediatric 
mental health.

As the Senate Finance Committee examines the youth mental health 
crisis, I respectfully request the consideration of the Strengthening 
Kids' Mental Health Now proposal that addresses the needs of children, 
adolescents, young adults and providers by:

      Increasing investments to support the recruitment, training, 
mentorship, retention and professional development of a diverse 
clinical and non-clinical pediatric workforce.
      Expanding pediatric mental health care infrastructure to ensure 
sufficient capacity to meet the needs of children in crisis who require 
higher intensity care, such as inpatient services, partial 
hospitalization or step-down programs.
      Ensuring payment models and reimbursement support for clinical 
and non-
clinical pediatric mental health providers and workers and eliminating 
implementation barriers hindering coordinated or integrated care.
      Addressing existing inequities within the pediatric mental 
health care system that contribute to mental health disparities in 
racial and ethnic minority populations and underserved communities.

Beyond the Strengthening Kid's Mental Health Now proposal, Congress 
should examine the unfulfilled promise of congressional efforts to 
ensure mental health parity. Since the enactment of the Mental Health 
Parity Act of 1996, Congress has pursued the policy goal that coverage 
for mental health services should be equal to medical and surgical 
coverage. Legal protections and oversight of mental health parity 
requirements were strengthened in 2008 with the passage of the Paul 
Wellstone and Pete Domenici Mental Health Parity and Addiction Equity 
Act (MHPAEA), and in 2021 with the passage of the Consolidated 
Appropriation Act.

The 2022 MHPAEA Report to Congress, titled Realizing Parity, Reducing 
Stigma and Raising Awareness: Increasing Access to Mental Health and 
Substance Use Disorder Coverage, highlights the current enforcement 
challenges. With the passage of the Consolidated Appropriations Act of 
2021, the Department of Labor, Department of Health and Human Services 
and the Department of the Treasury for the first time are proactively 
reviewing non-quantifiable treatment limitations (NQTLs).

The report indicates that very few health plans are required to 
document that NQTLs comply with MHPAEA requirements. For example, of 
the 2 million self-
insured health plans regulated by the Employee Benefits Service 
Administration (EBSA), only 156 plans were required to submit 
documentation to ESBA justifying compliance: ``ESBA concluded that many 
plans and issuers were deficient in their statutory obligation to 
perform and document the necessary analyses.''

Further, the report states that ``a significant number of plans sought 
extensions on the grounds that the requested analyses either were not 
complete, or in some cases not yet begun.'' ESBA documents systemic 
insufficiency in the comparative analyses submitted by many plans and 
issuers. During a seven-month period in 2021, all comparative analyses 
submitted to ESBA were initially insufficient in terms of information 
provided, plan details, and demonstration of parity compliance among 
other factors.

While Congress has enacted multiple bills in pursuit of mental health 
parity, regulation of plans and issuers as described in the 2022 report 
remains a challenge. Variation in the state-by-state enforcement of 
fully insured commercial health plans presents another variable in 
considering why parity remains elusive. These parity issues have an 
effect on access to mental health services. Anecdotally, we know that 
children wait months for access to mental health services, or as 
previously mentioned, children in need of inpatient level mental health 
care must board in a medical bed until an inpatient psychiatric bed is 
available. Most frequently, families and youth are waiting 3 months for 
outpatient services, but in some specialty areas the wait can be 8-12 
months before services begin.

Providers observe commercial reimbursement for mental health services 
at significantly lower levels than reimbursement for medical and 
surgical health services. Private practice youth mental health 
providers often accept cash pay only, due to low reimbursement rates 
and extremely high demand for services.

According to a 2019 Milliman Report titled Addiction and Mental Health 
vs. Physical Health: Widening Disparities in Network Use and Provider 
Reimbursement, there are significant disparities between medical/
surgical and mental health services in terms of both out-of-network 
utilization levels and provider in-network reimbursement rates. The 
report utilized a robust claims data analysis to explore the impact of 
two non-qualitative treatment limitations (network adequacy and 
reimbursement rates) on access to mental health services.

Among the key findings about network adequacy:

      In 2017, a youth mental health office visit was 10.1 times more 
likely to be out-of-network when compared to medical/surgical claims.
      In 2017, patients in behavioral health inpatient facilities were 
5.2 times more likely to be out of network when compared to similar 
medical/surgical claims.
      In 2017, patients seeking outpatient behavioral health services 
were 5.7 times more likely to be out-of-network when compared to 
similar medical/surgical claims.
      In 2017, 17.2% of behavioral health office visits were out-of-
network, compared to 3.2% for primary care providers and 4.3% for 
medical/surgical specialists.

Comparing average reimbursement as a percentage of Medicare-allowed 
amounts in 2017:

      Primary care provider reimbursement was 23.8% higher than 
behavioral health reimbursement.
      Low complexity evaluation and management codes for primary care 
providers were 22.3% higher than behavioral health reimbursement.
      Moderate complexity E & M codes for primary care providers were 
19.7% higher than behavioral health reimbursement.

The Milliman quantitative analysis of claims data from years 2013-2017 
demonstrate that in the domains of network adequacy and reimbursement 
rates, disparities between mental health and medical/surgical health 
services remain. A claims data analysis alone does not indicate 
systemic violations of MHPAEA, but it informs our understanding of the 
current mental health crisis and encourages additional review of the 
marketplace.

I am grateful to the Senate Finance Committee for taking the time to 
explore the ongoing youth mental health crisis and public policy aimed 
at promotion of mental health and expanding access to high quality 
mental health services for our nation's youth.

                                 ______
                                 
                       Nemours Children's Health

                     10140 Centurion Parkway North

                         Jacksonville, FL 32256

February 22, 2022

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

Dear Chairman Wyden and Ranking Member Crapo:

On behalf of Nemours Children's Health, thank you for holding this 
important hearing, Protecting Youth Mental Health: Part II--Identifying 
and Addressing Barriers to Care, on February 15, 2022. We are pleased 
to submit this letter as written testimony for your consideration as 
you develop a mental health legislative package. We urge you to include 
the policies outlined below that support the health and well-being of 
children and families, as well as the mental health infrastructure 
needed to provide them with accessible, high-quality care.

Nemours Children's Health is one of the nation's largest multistate 
pediatric health systems, including two free-standing children's 
hospitals and a network of nearly 75 primary and specialty care 
practices. Nemours Children's seeks to transform the health of children 
by adopting a holistic health model that utilizes innovative, safe, and 
high-quality care, while also caring for the health of the whole child 
beyond medicine. Nemours Children's also powers the world's most-
visited website for information on the health of children and teens, 
KidsHealth.org.

The Nemours Foundation, established through the legacy and philanthropy 
of Alfred I. duPont, provides pediatric clinical care, research, 
education, advocacy, and prevention programs to the children, families 
and communities it serves.

Background

The COVID-19 pandemic has exacerbated a host of stressors for children 
and families and contributed to the pediatric mental health crisis we 
are currently facing. Children have experienced more stress from 
changes in their routines, breaks in the continuity of learning and 
health care, missed life events, and an overall loss of security and 
safety.\1\ In addition, sentinel agencies are reporting declines in 
referrals as fewer child-serving professionals are making reports of 
concern for child safety, such as the decline in referrals for concerns 
about maltreatment and neglect to child welfare agencies since March 
2020.\2\
---------------------------------------------------------------------------
    \1\ Centers for Disease Control and Prevention. (2020). COVID-19 
parental resources kit. Retrieved 2021, May 11th from: https://
www.cdc.gov/coronavirus/2019-ncov/daily-life-coping/parental-resource-
kit/index.html.
    \2\ Brown, S.M., Orsi, R., Chen, P.C.B., Everson, C.L., and Fluke, 
J. (2021). The impact of the COVID-19 pandemic on child protection 
system referrals and responses in Colorado, USA. Child maltreatment, 
10775595211012476.

Nationally, mental health-related emergency department visits increased 
by nearly 25% for children age 5-11 and by over 30% for those 12-17 
years during April through October 2020, compared to the same period in 
2019.\3\ Many children are requiring more immediate and intensive 
treatments, have a higher probability of admission, and are staying in 
the hospital longer.\4\ These challenges may result in lasting impacts 
on children if they do not receive appropriate supports. Unfortunately, 
it is estimated that more than 45% of children diagnosed with a 
behavioral health disorder do not receive treatment.\5\
---------------------------------------------------------------------------
    \3\ Leeb, R.T., Bitsko, R.H., Radhakrishnan, L., Martinez, P., 
Njai, R., and Holland, K.M. (2020). Mental health-related emergency 
department visits among children aged <18 years during the COVID-19 
Pandemic--United States, January 1-October 17, 2020. MMWR. Morbidity 
and mortality weekly report, 69(45), 1675-1680, https://doi.org/
10.15585/mmwr.mm6945a3.
    \4\ Krass, P., Dalton, E., Doupnik, S.K., and Esposito, J. (2021). 
US pediatric emergency department visits for mental health conditions 
during the COVID-19 Pandemic. JAMA Network Open, 4(4), e218533-e218533, 
https://doi.org/10.1001/jamanetworkopen.2021.8533.
    \5\ Centers for Disease Control and Prevention. (2021, March 22). 
Data and statistics on children's mental health. Retrieved 2021, May 
27th from: https://www.cdc.gov/childrensmental
health/data.html.

At Nemours Children's Hospital, Delaware, our emergency department saw 
an increase of more than 80% in visits for suicidality or intentional 
harm in 2021 compared to 2020. Nemours Children's Hospital, Florida 
from 2020 to 2021, saw a 55% increase in patients in our emergency 
department with chief concerns of suicidality or intentional harm. Our 
behavioral health providers across our system have shared that our 
patients are increasingly experiencing higher levels of anxiety and 
depression, and grief from deaths of caregivers or family members. In 
outpatient and ambulatory care across our Florida operations, 85% of 
children screened had anxiety, depression, or another form of a 
---------------------------------------------------------------------------
behavioral health symptom.

We applaud the Surgeon General for raising the youth mental health 
crisis as a priority public health challenge. As the Surgeon General 
notes in his advisory, it will take time to resolve the many mental, 
emotional and behavioral (MEB) health challenges that children and 
youth are facing. However, the time to begin is now. We urge Congress 
to consider these five priorities to address barriers to providing high 
quality pediatric and youth mental health preventive services, supports 
and care:

      Address the social factors that contribute to poor mental 
health.
      Support the pediatric MEB health workforce.
      Strengthen reimbursement for MEB health services.
      Sustain and expand access to telehealth.
      Invest in pediatric MEB health infrastructure.

Address the Social Factors that Contribute to Poor Mental Health

We urge Congress to center its approach to addressing MEB health issues 
for children and youth in prevention. With a healthy start in life and 
appropriate care and developmental supports, a child's health 
trajectory can be significantly improved.

There is great opportunity through the Centers for Medicare and 
Medicaid Services (CMS) to go well beyond medicine to advance 
innovative, multi-sector, integrated care models that address the 
unique providers, settings and needs of children, with a focus on 
prevention and optimal development. The Medicaid program is an 
important lever because it covers 27 million children and 42% of births 
nationally.\6\
---------------------------------------------------------------------------
    \6\ MACPAC states that Medicaid covers 43% of births: https://
www.macpac.gov/wp-content/uploads/2020/01/Medicaid%E2%80%99s-Role-in-
Financing-Maternity-Care.pdf.

Over the past few years, CMS and the Department of Health and Human 
Services (HHS) have taken significant strides to test new models as 
well as improve interoperability and exchange of health data, which is 
critical to promoting holistic approaches. Additionally, CMS has 
promoted options for states, providers and payers to address social 
determinants of health (SDOH) and advance value-based care through 
guidance, waivers and new models. For the most part, these efforts have 
been limited to a few vanguard states. To help support a broader 
segment of the pediatric population while focusing on prevention and 
early identification of MEB health needs, we need to incentivize 
holistic pediatric payment and delivery models that address physical 
health, MEB health and SDOH. CMS can help catalyze these models that 
---------------------------------------------------------------------------
have great potential for long-term impact.

We suggest that Congress authorize and fund a Whole Child Health 
demonstration model within the Centers for Medicaid and CHIP Services 
(CMCS). The demonstration would support and test integrated, community 
based pediatric collaborations that align financial incentives and 
resources across Medicaid and other public and private programs to 
address SDOH, improve MEB health and well-being, and reduce health 
disparities among pediatric populations. Models would be designed with 
input and engagement from community residents, Medicaid beneficiaries, 
and organizations, and be informed by a comprehensive needs and assets 
assessment in target communities.

Additionally, we encourage Congress to direct CMS to review the early 
and periodic, screening, diagnostic and treatment (EPSDT) requirements 
and how they are being implemented across the states to support access 
to needed mental health services and early intervention services 
critical to children's well-being. CMS should provide guidance to 
ensure consistent application across states on what is required to 
ensure children are better supported at the community and family 
levels, addressing the social challenges contributing to health 
disparities and a lack of healthy early development and prevention 
services.

Finally, we support enactment of the LINC to Address Social Needs Act 
(S. 509, https://www.congress.gov/bill/117th-congress/senate-bill/
509?r=1), which would provide states with up to $150M for public-
private partnerships to develop or enhance integrated, cross-sector 
solutions to better coordinate health and social services.

Support the Pediatric MEB Health Workforce

MEB health provider shortages are persistent and severe in pediatric 
health care, and these shortages are projected to worsen over time. 
There is an opportunity to ensure that workforce development programs 
support a broad base of provider types, including MEB health 
specialists, primary care physicians, developmental and behavioral 
pediatricians, nurses, social workers, community health workers, and 
others. Developing this capacity and integrating more providers into 
the MEB health care model would help address the provider shortage by 
promoting identification of concerns and referrals from a variety of 
providers. To ensure children have care options that meet their needs, 
resources must support a range of child and 
adolescent-centered, community-based prevention and treatment services.

We support the Helping Kids Cope Act of 2021 (H.R. 4944, https://www.
congress.gov/bill/117th-congress/house-bill/
4944?q=%7B%22search%22%3A%5B%
22hr+4944%22%5D%7D&s=1&r=1). This bill would provide funding for 
pediatric behavioral health care integration and coordination, allowing 
flexibility to fund a range of community-based activities such as 
recruitment and retention of community health workers or navigators to 
coordinate care, pediatric practice integration, supporting pediatric 
crisis intervention, community-based initiatives such as school-based 
partnerships, and initiatives to decompress emergency departments.

The high cost of education is another contributing factor to current 
provider shortages. Students who graduate with psychology doctorates, 
for example, have a median student loan debt of $82,000.\7\ We support 
pediatric mental health workforce training and loan repayment programs 
such as the Health Resources and Services Administration's (HRSA) 
Pediatric Subspecialty Loan Repayment Program, and recommend that funds 
are made available for MEB health providers across adult and pediatric 
specialties. Additionally, we support loan repayment incentives, such 
as those offered through the Minority Fellowship Program, to increase 
workforce diversity across child-serving behavioral health providers.
---------------------------------------------------------------------------
    \7\ Stamm, K., Doran, J., Kraha, A., Marks, L.R., Ameen, E., El-
Ghoroury, N., Lin, L., and Christidis, P. (2015). How much debt do 
recent doctoral graduates carry? American Psychological Association's 
Center for Workforce Studies, 46(6): https://www.apa.org/monitor/2015/
06/datapoint.
---------------------------------------------------------------------------

Strengthen Reimbursement for MEB Health Services

Provider shortages are compounded by low reimbursement, discouraging 
individuals from entering the profession. Commercial health insurers, 
Medicaid, the Children's Health Insurance Program (CHIP) and other 
payers have historically provided insufficient coverage and payment for 
MEB health services.\8\ Payment rates for behavioral health providers 
are typically based on a fee schedule that is considerably lower than 
that of a medical/surgical provider. Lower rates based on these fee 
schedules has spillover effects on contract negotiation with payers, 
challenging children's hospitals to successfully contract with payers 
in a way that appropriately reimburses for MEB health services. When 
such negotiations are not successful, access to services becomes even 
more limited in a patient's covered provider network.
---------------------------------------------------------------------------
    \8\ Melek, S., Davenport, S., and Gray, T.J. (2019, November 19th). 
Addiction and mental health vs physical health: Widening disparities in 
network use and provider reimbursement. Milliman, Inc.: https://
assets.milliman.com/ektron/
Addiction_and_mental_health_vs_physical_health_Wid
ening_disparities_in_network_use_and_provider_reimbursement.pdf.

Sustainable reimbursement that supports Medicaid providers is needed to 
enhance children's access to the full continuum of care. We urge 
Congress to increase Medicaid reimbursement rates for pediatric MEB 
health services to Medicare levels, or to increase the Federal Medical 
Assistance Percentage (FMAP) for pediatric MEB health services to 100%. 
We also support inclusion of an increased FMAP for a High Performing 
Child Medical Home. A High Performing Child Medical Home would include 
components that promote prevention, child development, parenting 
supports, behavioral health, and referrals to various service providers 
that can address social needs, risk factors and determinants of health. 
Such an approach--which includes coordinated, team-based, whole-person 
care models--could help to promote positive social and emotional 
---------------------------------------------------------------------------
development and potentially prevent MEB health issues from arising.

Finally, we support expanded utilization of family and youth peer 
support specialists through enhanced Medicaid reimbursement, funding to 
train and certify peer support specialists, and technical assistance 
for state Medicaid programs interested in expanding the model. Peer 
specialists can extend the existing provider workforce by using their 
lived experience with MEB health needs to support others. In bright 
spots across the country, peer support specialists are integrated into 
care teams or into schools, and peer-led organizations as valued 
community partners. Grief counseling, rising to new importance during 
COVID-19, has long found benefits of peer support in normalizing 
experiences for children, youth, and caregivers.\9\ Unfortunately, 
youth and family peer support is not systematic, and few children have 
access, while many peer supporters do not receive the reimbursement and 
support they need. The same is true for many other professionals and 
paraprofessionals in supporting roles, such as community health workers 
(CHWs).
---------------------------------------------------------------------------
    \9\ McClatchey, I.S., Vonk, M.E., and Palardy, G. Efficacy of a 
camp-based intervention for childhood traumatic grief. Res Soc Work 
Pract. 2009;19(1):19-30.
---------------------------------------------------------------------------

Sustain and Expand Access to Telehealth

Throughout the COVID-19 pandemic, greater state and federal regulatory 
flexibilities have increased the availability and convenience of 
telehealth services for children and families. Nationwide, psychiatry 
continues to rely on telehealth at a far greater rate than any other 
physician specialty. Between January 2021 to February 2022, nearly 65% 
of all Nemours Children's telehealth visits were psychology and 
psychiatry visits.

Extending and expanding telehealth for children and families also helps 
address regional shortages with respect to the availability of mental 
health care generally (e.g., in underserved rural areas), and specific 
competencies (e.g., evidence-based approaches to grief counseling) that 
are not widely available. This is a pathway to increase access and 
address inequity, though additional barriers including access to 
technology and broadband Internet will remain for some families. These 
infrastructure deficiencies must also be addressed.

We strongly recommend permanent extension of the telehealth 
flexibilities provided during the pandemic, particularly those that 
allow providers to care for patients across state lines. One 
intermediate step would be to pass the Temporary Reciprocity to Ensure 
Access to Treatment (TREAT) Act (S. 168/H.R. 708, https://www.
congress.gov/bill/117th-congress/senate-bill/168/
text?q=%7B%22search%22%3A%5
B%22TREAT+Act%22%2C%22TREAT%22%2C%22Act%22%5D%7D&r=4&s=3), which would 
provide temporary licensing reciprocity for health care professionals 
for any type of services provided, within their scope of practice, to a 
patient located in another state during the COVID-19 pandemic.

Additionally, we support the Enhance Access to Support Essential 
Behavioral Health Services (EASE) Act (S. 2112/H.R. 4036, https://
www.congress.gov/bill/117th-congress/senate-bill/2112/
text?q=%7B%22search%22%3A%5B%22EASE+Be
havioral+Health+Act%22%2C%22EASE%22%2C%22Behavioral%22%2C%22Health%
22%2C%22Act%22%5D%7D&r=1&s=1) to expand the scope of required guidance, 
studies, and reports that address the provision of telehealth services 
under Medicaid, including in schools. Another important bill is the 
Telehealth Improvement for Kids' Essential Services Act (TIKES) Act (S. 
1798/H.R. 1397, https://www.congress.
gov/bill/117th-congress/senate-bill/1798/
text?q=%7B%22search%22%3A%5B%22TI
KES+Act%22%2C%22TIKES%22%2C%22Act%22%5D%7D&r=1&s=2), which would 
promote access to telehealth services for children through Medicaid and 
CHIP, as well as study children's utilization of telehealth to identify 
barriers and evaluate outcomes.

Invest in Pediatric MEB Health Infrastructure

Finally, investments in pediatric mental health infrastructure are 
critical and urgently needed to prevent children in crisis from 
boarding in emergency departments and to enable their swift placement 
in appropriate care. There is also a vital need to increase access to 
alternatives to inpatient and emergency department care including step-
down, partial hospitalization, intensive outpatient services and day 
programs. These types of programs ensure that children and adolescents 
continue to receive intensive services and supports they need while 
alleviating pressure on acute care settings. We support the Children's 
Mental Health Infrastructure Act (H.R. 4943, https://www.congress.gov/
bill/117th-congress/house-bill/4943?q=%7B
%22search%22%3A%5B%22hr+4943%22%5D%7D&s=5&r=1) to support additional 
pediatric care capacity for behavioral and mental health services.

CONCLUSION

Nemours stands ready to leverage our expertise and relevant experiences 
to assist the Committee as it works to develop a comprehensive mental 
health legislative package. Thank you for your consideration of our 
recommendations, and we look forward to continued collaboration. Please 
do not hesitate to reach out to me at [email protected] or 
to Katie Boyer at [email protected] with questions or requests 
for additional information.

Sincerely,

Kara Odom Walker, M.D., MPH, MSHS   Daniella Gratale, MA
Executive Vice President            Director,
Chief Population Health Officer     Office of Child Health Policy and 
                                    Advocacy

                                 ______
                                 
                      Partnership to End Addiction

                      711 Third Avenue, Suite 500

                           New York, NY 10017

                             t 212-841-5200

                             f 212-956-8020

                         https://drugfree.org/

February 24, 2022

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

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

Dear Chairman Wyden and Ranking Member Crapo,

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

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

We greatly appreciate the Committee dedicating two hearings to the 
issue of youth mental health. We are also concerned by this growing 
crisis, as untreated mental illness is a significant risk factor for 
substance use, and mental illness and substance use disorder frequently 
co-occur. As highlighted by many witnesses and committee members, 
school-based mental health services are critically needed to reach more 
youth. We urge the Senate to advance the Mental Health Services for 
Students Act (S. 1841), the Pursuing Equity in Mental Health Act (S. 
1795), and the Suicide Training and Awareness Nationally Delivered for 
Universal Prevention (STANDUP) Act (S. 1543). We encourage Congress to 
facilitate an earlier and broader approach to substance use prevention 
\1\ that includes mental health, as well as other fields that promote 
child health and resilience and structural changes that facilitate 
healthy and stable families. As described in our blog \2\ published by 
Health Affairs, there are a number of policy initiatives to improve 
family stability and security and child health and resilience that 
Congress has recently undertaken in COVID-19-related legislation or is 
currently exploring in the Build Back Better Act. While these policy 
changes are seemingly outside the realm of substance use, they are 
critically important for prevention and will also reduce the risk for 
other negative mental and behavioral health outcomes that have the same 
risk and protective factors as substance use. As explained by the 
Surgeon General in response to questions from Sen. Warren, increasing 
access to affordable child care, for example, is important for 
improving children's mental health, along with other early investments 
in health and well-being. Sen. Casey and the Surgeon General similarly 
highlighted that children's mental health does not exist in a vacuum, 
and that broader family, community, and societal circumstances must 
also be addressed in order to protect youth. We encourage the Committee 
to consider such policies for inclusion in a legislative package.
---------------------------------------------------------------------------
    \1\ https://drugfree.org/reports/rethinking-substance-use-
prevention-an-earlier-and-broader-approach/.
    \2\ https://www.healthaffairs.org/do/10.1377/
forefront.20210607.239986/full/.

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

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

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

Sincerely,

Partnership to End Addiction

                                 ______
                                 
                       Primary Care Collaborative

                      601 13th St., NW, Suite 430N

                          Washington, DC 20005

                         https://www.pcpcc.org/

February 15, 2022

The Honorable Ron Wyden             The Honorable Mike Crapo
Chairman                            Ranking Member
U.S. Senate                         U.S. Senate
Committee on Finance                Committee on Finance
Washington, DC 25510                Washington, DC 25510

Dear Chairman Wyden and Senator Crapo,

I write today to submit this letter as the Primary Care Collaborative's 
statement for the record regarding the Committee on Finance's hearing, 
``Protecting Youth Mental Health: Part II--Identifying and Addressing 
Barriers to Care,'' held February 15, 2022. PCC commends the 
Committee's ongoing work to develop a bipartisan response to the mental 
health and substance abuse crises in the United States, including the 
emergency in children's mental health and well-being. This letter 
describes the Primary Care Collaborative's (PCC) recommendations as 
this work proceeds.

PCC is a nonprofit, nonpartisan, multi-stakeholder coalition of 60+ 
organizational Executive Members (https://www.pcpcc.org/executive-
membership) ranging from clinicians and patient advocates to employer 
groups and health plans. PCC's members share a commitment to an 
equitable, high value health care system with primary care at its base: 
care that emphasizes comprehensiveness, longitudinal relationships, and 
``upstream'' determinants for better patient experience and better 
health outcomes. (See the Shared Principles of Primary Care, https://
www.pcpcc.org/about/shared-principles#Continuous.)

America's specialty behavioral health delivery system is overwhelmed by 
increasing suicide rates,\1\ accelerating rates of substance use 
disorder deaths,\2\ and a tripling in the prevalence of depressive 
symptoms since the beginning of the pandemic.\3\ Moreover, noted 
disparities in mental health by rurality and economic circumstances 
exist, and for the first time in several years, there are 
proportionally more drug-induced deaths among Blacks than whites.\4\ 
Your public, bipartisan commitments to meaningful legislation are an 
important step toward a national response to these crises. However, 
your legislation and the United States can only successfully meet this 
challenge by leveraging team-based primary care that includes 
behavioral health integration and is available in all communities.
---------------------------------------------------------------------------
    \1\ Hedegaard, H., Curtin, S.C., and Warner, M. Suicide mortality 
in the United States, 1999-2019. NCHS Data Brief, no 398. Hyattsville, 
MD: National Center for Health Statistics. 2021. DOI: https://
dx.doi.org/10.15620/cdc:101761.
    \2\ Hedegaard, H., Minino, A.M., and Warner, M. Drug overdose 
deaths in the United States, 1999-2019. NCHS Data Brief, no 394. 
Hyattsville, MD: National Center for Health Statistics. 2020.
    \3\ Ettman, C.K., Abdalla, S.M., Cohen, G.H., Sampson, L., Vivier, 
P.M., and Galea, S. Prevalence of Depression Symptoms in US Adults 
Before and During the COVID-19 Pandemic. JAMA Network Open. 
2020;3(9):e2019686. doi:10.1001/jamanetworkopen.2020.19686
    \4\ Pain in the Nation: Alcohol, Drug and Suicide Epidemics. Trust 
for America's Health and Well-Being Trust. May 2021. https://
www.tfah.org/wp-content/uploads/2021/05/2021_PainIn
TheNation_Fnl.pdf.

Primary care teams with strong, ongoing patient-relationships are 
uniquely able to identify behavioral health concerns, triage 
challenges, and help patients find the right level and setting of care. 
More mental health care is rendered in the primary care setting than 
anywhere else, including the mental health care sector where this has 
been the case for at least the past four decades.\5\ An adequate 
response to the multiple current behavioral health crises demands 
recognizing that reality. It also requires recognizing that primary 
care clinicians, particularly those that serve populations who have 
been historically marginalized, are overextended and desperately in 
need of enhanced support. Team-based integrated behavioral health can 
improve outcomes and decrease costs. By leveraging the full healthcare 
team, the U.S. can most appropriately leverage behavioral health 
professionals to help those in need of care.
---------------------------------------------------------------------------
    \5\ Regier et al., JAMA 1978; Jetty et al., Journal of Primary Care 
and Community Health, 2021.
---------------------------------------------------------------------------

 The Foundation for Progress: Payment Reform and Investment in Primary 
                    Care

Efforts to scale behavioral health-primary care integration are 
hampered by the overall chronic underinvestment in the primary care 
sector. To assure a strong foundation for comprehensive, integrated 
advanced primary care, it will be necessary to change both how the U.S. 
pays and how much the U.S. invests in primary care. The U.S. currently 
devotes just 5-7 percent of health spending to primary care, a 
proportion lower than other nations.\6\ Primary care practices need 
pathways to rapidly transition from a predominantly fee-for-service 
(FFS) model, to a predominantly population-based prospective payment 
models that would include adjustments for health status, risk, social 
drivers, and other factors. The National Academies of Science 
Engineering and Medicine has recommended making hybrid models (part 
FFS, part per member per month payment) \7\ as the default for Medicare 
and Medicaid, rather than the fee-based system that consistently and 
systematically undervalues the cognitive work reflected in primary care 
and behavioral health services.
---------------------------------------------------------------------------
    \6\ Investing in Primary Care: A State-Level Analysis. Primary Care 
Collaborative. July 2019. https://www.pcpcc.org/sites/default/files/
resources/pcmh_evidence_report_2019_0.pdf.
    \7\ National Academies of Sciences, Engineering, and Medicine. 
2021. Implementing high-
quality primary care: Rebuilding the foundation of health care. 
Washington, DC: The National Academies Press. https://doi.org/10.17226/
25983.

Over the medium and long term, broader change in how we pay and how 
much we pay for primary care is vital. PCC is working with our 
Executive Members and other stakeholders to identify bold steps to 
strengthen the primary care foundation needed for a health system that 
achieves equitable outcomes through high-quality, affordable, patient-
---------------------------------------------------------------------------
centered care.

However, in the interim, primary care teams and many of their patients 
live daily with a national crisis of poor mental well-being and 
substance use. Exacerbated by COVID-19 and associated economic 
disruptions, this crisis hits hardest in communities already grappling 
with health inequities. Because improvements in overall physical health 
can be more difficult to achieve when individuals face behavioral 
health comorbidities, this crisis also threatens to derail the fight 
against other chronic health challenges including heart disease, 
diabetes, and cancer.

The Finance Committee's legislative work must both respond to the 
urgency of the immediate behavioral health crisis and lay the 
groundwork for transformed and integrated whole-person primary care.

 Paying for Behavioral Health Integration in Medicare and Medicaid

When provided adequate resources, primary care has the capacity to be 
flexible. It can effectively provide what patients need and/or connect 
those patients to other care or resources. At present, evidence 
supports multiple integrated behavioral health delivery models in 
primary care, including the collaborative care model and the primary 
care behavioral health model.\8\, \9\ To maximize the number 
of patients that can benefit from integrated care across diverse 
practice settings and communities, primary care payment options must be 
available to support a variety of evidence-based models of integration. 
Payment policy that supports multiple care integration models has two 
additional merits; it can support the development of real-world 
implementation evidence across diverse populations, and spur further 
innovation in behavioral health integration at the practice level and 
in practice/payer collaboration.
---------------------------------------------------------------------------
    \8\ Dissemination of Integrated Care Within Adult Primary Care 
Settings: The Collaborative Care Model. American Psychiatric 
Association. 2016. https://www.psychiatry.org/psychiatrists/practice/
professional-interests/integrated-care/learn.
    \9\ Kearney, L.K., Post, E.P., Pomerantz, A.S., and Zeiss, A.M. 
(2014). Applying the interprofessional patient aligned care team in the 
Department of Veterans Affairs: Transforming primary care. American 
Psychologist, 69, 399-408. http://dx.doi.org/10.1037/a0035909.

For these reasons, PCC supports a multi-component policy approach to 
behavioral health integration. This approach would provide immediate 
support for scaling integration through the fee-based payment 
methodologies most broadly in use today while testing new ways to 
integrate behavioral health into comprehensive advanced primary care 
payment models.
 Promote Medicare's Existing Collaborative Care and Behavioral Health 
        Integration Codes
Existing behavioral health integration codes, currently available in 
the Medicare Physician Fee Schedule, are underutilized in Medicare 
relative to the prevalence of behavioral health conditions among 
beneficiaries. Existing Medicare payment values for behavioral health 
integration should be reassessed to determine whether they are 
sufficient to expand utilization and meet the exigencies of the present 
crisis.

 Waive the Medicare Fee Schedule Budget Neutrality Requirements for 
        Primary Care--Behavioral Health Integration
The Medicare Physician Fee Schedule's budget neutrality requirements 
are a barrier to increased payment and new payment codes for primary 
care-behavioral health integration. When new codes are adopted, these 
neutrality requirements can result in across-the-board cuts that affect 
other primary care services. Insofar as Medicare depends on fee-based 
payment to expand access to integrated behavioral health care in the 
current behavioral health crisis, the Congress should exempt new 
investments in behavioral health integration codes from the current fee 
schedule budget neutrality requirements.

One approach would be to establish a new code available as an add-on 
code for all Evaluation and Management claims when a practice can 
demonstrate the capacity for integrated behavioral care. Such a code 
would complement and support broader utilization of the existing 
behavioral health codes, rather than replacing them. Practices would be 
required to attest to certain core functionalities, such as the ability 
to screen for behavioral health challenges, offer care management, 
medication management, participate in measurement-based care through a 
registry, deliver short-term psychosocial therapy in the practice, and 
integrate evidence-based treatment for behavioral health conditions, 
either in person or virtually.
 Test Behavioral Health Integration Strategies as Part of a Per Member 
        Per Month Approach to Primary Care Payment
Moving more of the American health care financing system to a value-
based model is key to supporting care integration. When payers place 
emphasis on outcomes rather than services, primary care practices are 
put in a better situation to focus on the health of their patients 
rather than the volume of their service. Policymakers should pursue the 
development and testing of prospective primary care payment models, 
such as per-member per-month approaches, that adequately support 
integrated advanced primary care addressing both physical and 
behavioral health care needs. However, work may be needed to optimize 
the balance between external referrals and services delivered in the 
primary care practice itself. Various integration thresholds, 
standards, and performance measures should be tested using CMS 
Innovation Center authorities, Medicaid 1115 demonstrations, other CMS 
demonstration authorities, and/or Congressionally authorized 
demonstrations. PCC encourages the Committee to work with CMS to ensure 
that primary care integration remains a priority.
 Address Low Medicaid Payment Rates in Some States for Pediatric Mental 
        Health Services and Access to Services in Schools
The American Academy of Pediatrics, American Academy of Child and 
Adolescent Psychiatry and the Children's Hospital Association declared 
a national emergency in child and adolescent mental health last fall, 
an assessment endorsed by several of PCC's Executive Member 
organizations including the American Academy of Family Physicians, 
American Psychiatric Association, American Psychological Association, 
and Mental Health America.\10\ Low payment rates, common in many state 
Medicaid programs, weaken provider engagement and participation in 
Medicaid and directly relate to the mental health access challenges for 
children. Additionally, children's behavioral health needs should be 
identified and access to services should be provided where they are. 
Better assistance and technical guidance to schools regarding 
appropriate reimbursement can help support service delivery to 
Medicaid-
eligible and enrolled students, in coordination and collaboration with 
their behavioral health providers.
---------------------------------------------------------------------------
    \10\ See https://www.soundthealarmforkids.org/partners/.
---------------------------------------------------------------------------

 Addressing Other Barriers to Behavioral Health Integration

Investing in and paying for integrated care, as described above, is 
fundamental. But these changes alone may not be sufficient without 
addressing certain specific barriers to broader integration of primary 
care and behavioral health.
 Remove In-person Requirements for Tele-mental Health Services
Once the current COVID-19 Public Health Emergency expires, current 
Medicare statute and regulation bar reimbursement for tele-mental 
health services unless a patient has had an in-person encounter with a 
member of the same provider group in the previous six months and 
require an in-person visit every twelve months. This limits the ability 
of primary care practices to leverage tele-mental health services to 
deliver comprehensive and integrated care. The CY 2022 Medicare Part B 
Physician Fee Schedule Final Rule promulgated these in-person visit 
requirements for Medicare reimbursement of tele-mental health services, 
both prior to the initial telehealth service and every twelve months 
thereafter. The Committee's legislation should remove the requirement 
for in-person visit for tele-mental health visits enacted by the 
Consolidated Appropriations Act of 2021, repeal the promulgated 
requirements and leave the decision of the appropriate modality of 
tele-mental health care to the care team and the patient.
 Assure Access to Upfront Resources to Support Transition to Integrated 
        Care
For any primary care practice, the transition to new integrated models 
of care delivery can involve significant expense, training, technology 
upgrades and workflow changes. It may involve retraining or expanding 
the primary care team, including, but not limited to, nurse case 
managers, psychiatrists, nurse practitioners, psychologists, social 
workers, counselors and peer support workers.

To support these changes, practices pursuing integration typically must 
rely on time-limited grants or partnerships with larger entities, like 
health plans or health systems. Others have depended on limited 
duration demonstrations or CMS Innovation Center Models to resource 
these changes. Yet this limited, ad-hoc approach has failed to enable 
widespread, sustained implementation of behavioral health integration 
in primary care.

HHS should work with Congress to develop and enact a broadly available 
program of forgivable loans to finance costs associated with 
transformation. Practice support for these transitional costs is 
particularly crucial for primary care practices which are smaller in 
size, operate independently, and/or serve lower-income communities. To 
support rapid scaling, transitional support should be available on a 
nationwide basis, not confined to a limited-scope demonstration.
Ensure Resources for Ongoing Practice Transformation
The reality is that practice transformation is not a one-time expense. 
The best models of behavioral health integration may evolve based on 
experience and new medical and implementation science. Moreover, the 
challenge of practice transformation extends beyond behavioral health 
integration. Some primary care practices are shifting to more 
comprehensive models of care that integrate across more domains of care 
including those that address health-related social needs and oral 
health.\11\, \12\ Permanent, long-term sources of training 
and technical assistance for comprehensive, integrated care models are 
necessary to assure access to the best evidence-based approaches over 
time.
---------------------------------------------------------------------------
    \11\ The Primary Care Collaborative. (January 2021). Innovations in 
Oral Health and Primary Care Integration: Alignment with the Shared 
Principles of Primary Care. https://www.
pcpcc.org/resource/innovations-oral-health-and-primary-care-
integration-alignment-shared-principles, National Academies of Science, 
Engineering and Medicine. (2019). Integrating Social Care into the 
Delivery of Health Care: Moving Upstream to Improve the Nation's 
Health. https://www.nap.edu/read/25467.
    \12\ Kreuter, M.W., Thompson, T., McQueen, A., and Garg, R. 
Addressing Social Needs in Health Care Settings: Evidence, Challenges, 
and Opportunities for Public Health. Annu Rev Public Health. 
2021;42:329-344. doi:10.1146/annurev-publhealth-090419-102204.
    The Primary Care Collaborative. (January 2021). Innovations in Oral 
Health and Primary Care Integration: Alignment with the Shared 
Principles of Primary Care, https://www.
pcpcc.org/resource/innovations-oral-health-and-primary-care-
integration-alignment-shared-principles.

One potential policy vehicle to encourage practice transformation over 
the long term--the Primary Care Extension Program (PCEP)--has already 
been statutorily authorized.\13\ As the U.S. Agricultural Extension 
service has promoted evidence-based practices in agriculture and 
community development, the PCEP could assist primary care through 
practice facilitation and community-based collaborations. Yet Congress 
has so far failed to appropriate resources for this important work. PCC 
urges the Committee to explore whether this program could provide the 
technical assistance and support that primary care practices need or 
whether other programs should be established.
---------------------------------------------------------------------------
    \13\ 42 U.S.C. Sec. 280g-12.
---------------------------------------------------------------------------

Promoting Behavioral Health Integration Across Payers

Convene Stakeholders to Align Integration Efforts
Payers that work together to align documentation, measurement and model 
design related to integrated care face potential anti-trust action. 
However, state and/or federal bodies can convene payers and clinician 
representatives with the goal of aligning documentation, measurement, 
and payment innovations associated with behavioral health integration.

The Committee should seek to ascertain whether all states have the 
resources necessary and whether CMS has the capacity to support the 
states in this vital work.
 Incorporate Behavioral Health Coding and Billing as Standard Features 
        in Electronic Health Records
Vendors require practices to pay extra for the module that supports 
billing for existing integrated care codes. PCC has asked CMS, working 
with the Office of the National Coordinator for Health Information 
Technology, to adjust the definition of CEHRT technology to address 
this challenge. PCC encourages the Committee to work with CMS to 
realize this important policy goal.

Even as the COVID-19 pandemic continues to sweep American communities, 
the depth of the mental and behavioral health crisis is difficult to 
understate. The inequities in well-being that underlie that crisis are 
glaring. The time is now for bold action to support behavioral health 
integration in primary care. PCC urges you to work on a bipartisan 
basis to enact strong legislation this year. Please contact PCC's 
Director of Policy, Larry McNeely ([email protected]) with any 
questions.

Sincerely,

Ann Greiner
President and CEO

                                 ______
                                 
                Statement Submitted by Ethan J.S.H. Reed
Honorable Chairman Wyden, Ranking Member Crapo, and members of the 
Finance Committee, thank you for giving me this opportunity and 
platform as a young person in this country to express my concerns in 
regards to the youth mental health crisis the young people are facing 
across this country.

Currently, I am beginning work with congressional leadership and other 
members of Congress--including several committees with jurisdiction on 
mental health, to ensure Congress passes critical funding and 
investments towards mental health services and professionals to provide 
adequate support to the thousands of young people across this country 
who are suffering from a mental health issue.

One of the most important things Congress can do right now to take 
action on combating the current youth mental health crisis is to pass 
immediate federal funding to mental health professionals and services. 
Right now, there are multiple funding investments towards mental health 
in the original Build Back Better Act, and so I am urging congressional 
leadership to transfer the funding provisions into another form of 
legislation to further expedite the funding. It is something I've 
constantly heard as concerns from associates of Mental Health America, 
experts in the field, and even members of Congress. It is with my best 
hope that the honorable committee will support this effort on getting 
much needed funding immediately passed.

As I understand, mental health telehealth capabilities are of major 
concern to this Committee, and I share this concern for thousands, if 
not millions of Americans across this country who do not have easier 
access to facilitate mental health services and professionals. A few 
years ago when I served on a state youth advisory council for the 
Colorado legislature, I had the opportunity to speak with other young 
people across the state--and more specifically, those in the rural 
parts of Colorado such as the Eastern plains. Some of the youth 
expressed the troubles of having readily access to mental health 
services and professionals due to their area. I am proud to stand with 
Congressman Joe Neguse of Colorado on his bill, H.R. 6076, the CARE for 
Mental Health Professionals Act, which would allow providers to enter 
into interstate compacts that would expand the workforce of 
credentialed mental health professionals to serve patients whom may not 
be in the same state as they are. This will help close the gap between 
rural and urban communities across this country to be able to get the 
services and support they need whenever, and wherever they may reside.

While those are some of the only pieces of legislation I've focused on 
in regards to mental health, I am proud to support dozens of mental 
health pieces of legislation that I believe as a young person will 
truly provide adequate services and support to my generation as we 
continue to face the mental health crisis. I thank each and every 
member of Congress (including those in leadership) who have been 
fighting the good fight with me, and I appreciate the efforts made by 
so many--especially including Congressman Tony Cardenas of California.

Let's get to work for the young people of this country who are 
struggling.

I welcome any and all comments, concerns, or questions about the work 
or legislation I am proud to advocate and support. Thank you again for 
giving me this opportunity to speak today.

                                 ______
                                 
                           The Trevor Project

                             P.O. Box 69232

                        West Hollywood, CA 90069

                       [email protected]

                   https://www.thetrevorproject.org/

                             March 1, 2022

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

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

Re: The Trevor Project Statement for the Record, Senate Committee on 
Finance's Hearing on Protecting Youth Mental Health: Part II--
Identifying and Addressing Barriers to Care

Dear Chairman Wyden and Ranking Member Crapo,

The Trevor Project (Trevor) submits the following statement for the 
February 15, 2022 Full Committee hearing, ``Protecting Youth Mental 
Health: Part II--Identifying and Addressing Barriers to Care.'' We 
respectfully request that this statement be entered into the hearing 
record.

There is a mental health crisis in our nation, and it is having 
particularly harmful impacts on marginalized communities such as LGBTQ 
youth. These youth already confront a range of barriers to quality 
mental health care, and it is more important than ever to open doors to 
essential mental health services for these youth by ensuring that when 
the 9-8-8 number for the National Suicide Prevention Lifeline (NSPL or 
Lifeline) is activated in July, the Lifeline is equipped with the 
specialized services that these young people need. It is also important 
to ensure that access to quality mental health services is not impeded 
by the marketing of dangerous practices that masquerade as mental 
health care for LGBTQ youth. Thank you for your attention to this issue 
and we look forward to working with you to address this crisis.

Founded in 1998, The Trevor Project is the world's largest suicide 
prevention and crisis intervention organization for LGBTQ youth, and it 
is the only accredited national organization providing crisis 
intervention and suicide prevention programs, as well as a peer-to-peer 
social network support for LGBTQ youth. Specifically, The Trevor 
Project offers life-saving, life-affirming programs and services that 
create safe, accepting, and inclusive environments over the phone, 
online, and through text. With operations in all 50 states and 
approximately 440 trained counselors, The Trevor Project is able to 
reach thousands of youth with its services every week.

 What is The Trevor Project's perspective on the current youth mental 
                    health crisis?

There is no question that our nation is in the midst of a serious and 
troubling mental health crisis. Unfortunately, for LGBTQ youth the 
current crisis has only compounded the existing barriers that these 
young people face to receiving the type of mental health care they need 
and deserve. We are on the front lines of the national mental health 
crisis, and our counselors hear from young people every day whose 
mental health has been negatively impacted by the COVID-19 pandemic, 
recent politics, and a wide range of instances of anti-LGBTQ 
victimization.

The national mental health crisis is hitting our young people 
especially hard. And for marginalized young people, such as those who 
are LGBTQ and/or people of color, the crisis is hitting even harder. 
U.S. Surgeon General Vivek Murthy recently explained in his Advisory on 
the youth mental health crisis that LGBTQ youth often lost access to 
key services during the pandemic, were sometimes confined to homes 
where they were not supported or accepted, and face discrimination in 
the health care system that makes them more hesitant to seek help.\1\
---------------------------------------------------------------------------
    \1\ HHS, ``Protecting Youth Mental Health: The U.S. Surgeon 
General's Advisory,'' available at https://www.hhs.gov/sites/default/
files/surgeon-general-youth-mental-health-advisory.pdf.

At The Trevor Project, we have seen firsthand how these factors have 
converged to put LGBTQ youth at tremendous risk. Suicide is the second 
leading cause of death among young people,\2\ and CDC data \3\ shows 
that LGBTQ youth are more than four times as likely to attempt suicide 
compared to their straight and cisgender peers. The Trevor Project 
estimates that more than 1.8 million LGBTQ youth (13-24) seriously 
consider suicide each year in the United States, and at least one 
attempts suicide every 45 seconds.\4\
---------------------------------------------------------------------------
    \2\ Hedegaard, H., Curtin, S.C., and Warner, M. (2018). Suicide 
mortality in the United States, 1999-2017. National Center for Health 
Statistics Data Brief, 330, Hyattsville, MD: National Center for Health 
Statistics.
    \3\ Johns, M.M., Lowry, R., Haderxhanaj, L.T., et al. (2020). 
Trends in violence victimization and suicide risk by sexual identity 
among high school students--Youth Risk Behavior Survey, United States, 
2015-2019. Morbidity and Mortality Weekly Report, 69 (Suppl-1):19-27. 
See also Johns, M.M., Lowry, R., Haderxhanaj, L.T., et al. (2020). 
Trends in violence victimization and suicide risk by sexual identity 
among high school students--Youth Risk Behavior Survey, United States, 
2015-2019. Morbidity and Mortality Weekly Report, 69,(Suppl-1):19-27.
    \4\ The Trevor Project, ``Estimate of How Often LGBTQ Youth Attempt 
Suicide in the U.S.,'' available at https://www.thetrevorproject.org/
research-briefs/estimate-of-how-often-lgbtq-youth-attempt-suicide-in-
the-u-s/.

The Trevor Project's annual National Survey on LGBTQ Youth Mental 
Health (National Survey), which includes some of the largest and most 
diverse samples of LGBTQ youth ever conducted, seeks to amplify the 
unique stressors, challenges, and disparities that place LGBTQ youth at 
elevated risk for poor mental health and suicide. It is important to 
remember that LGBTQ youth are not inherently prone to suicide because 
of their sexual orientation or gender identity. Rather, they are placed 
at significantly increased risk because of how they are mistreated and 
stigmatized by society. Some of the most noteworthy findings from our 
2021 National Survey, which captured the experiences of nearly 35,000 
---------------------------------------------------------------------------
LGBTQ youth across the country, include:

      42% of LGBTQ youth seriously considered attempting suicide in 
the past year, including more than half of transgender and nonbinary 
youth. Yet, nearly half (48%) of LGBTQ youth reported wanting mental 
health care in the past year but were not able to get it;
      75% of LGBTQ youth reported that they had experienced 
discrimination based on their sexual orientation or gender identity at 
least once in their lifetime, and those who experienced discrimination 
in the past year attempted suicide at more than twice the rate of those 
who did not;
      12% of white youth attempted suicide compared to 31% of Native/
Indigenous youth, 21% of Black youth, 21% of multiracial youth, 18% of 
Latinx youth, and 12% of Asian/Pacific Islander youth.
      Half of all LGBTQ youth of color reported discrimination based 
on their race/ethnicity in the past year, including 67% of Black LGBTQ 
youth and 60% of Asian/Pacific Islander LGBTQ youth;
      13% of LGBTQ youth reported being subjected to conversion 
therapy, with 83% reporting it occurred when they were under age 18; 
and
      Transgender and nonbinary youth who reported having pronouns 
respected by all of the people they lived with attempted suicide at 
half the rate of those who did not have their pronouns respected by 
anyone with whom they lived. However, more than 60% of transgender and 
nonbinary youth under the age of 18 said that none of the people they 
lived with respected their pronouns.

The Trevor Project has also examined the impacts of the pandemic and 
recent politics and public debates on the mental health and well-being 
of LGBTQ young people and found:

      70% of LGBTQ youth stated their mental health was ``poor'' most 
of the time or always during COVID-19;
      More than 80% of LGBTQ youth stated that COVID-19 made their 
living situation more stressful--and only 1 in 3 LGBTQ youth found 
their home to be LGBTQ-affirming;
      Nearly 60% of transgender and nonbinary youth said that COVID-19 
impacted their ability to express their gender identity; and
      85% of transgender and nonbinary youth--and 66% of all LGBTQ 
youth--say recent debates about state laws restricting the rights of 
transgender people have negatively impacted their mental health.

Youth, and in particular LGBTQ young people, face significant barriers 
to accessing mental health services. The Trevor Project has conducted 
research that found that marginalized groups such as Black and Latinx 
LGBTQ communities don't have access to healthcare resources, and when 
they are available, they do not have the ability to address LGBTQ 
issues or understanding of the experiences of minorities or the LGBTQ 
community. Help when you are struggling is hard to ask for, and 
financial and cultural barriers shouldn't exist to make that brave 
action harder to take.

The crisis in front of us is clear to see. It should be a cause for 
concern to everyone, regardless of political party. Our young people 
are suffering, and LGBTQ young people are among those suffering the 
most. What we do to help our young people matters, and countless young 
lives are at stake. Fortunately, there are concrete steps Congress can 
take to lower barriers to accessing essential mental health services 
and help our young people now, including ensuring the Lifeline will be 
ready to serve the country and specifically LGBTQ youth when 9-8-8 goes 
live in July 2022 and that our LGBTQ youth are being protected from 
forms of health care fraud so-called ``conversion therapy,'' sometimes 
referred to as ``reparative therapy'' or ``sexual orientation or gender 
identity change efforts.''

 How can we ensure 9-8-8 ready is ready to serve youth in crisis?

The designation of 9-8-8 as the new dialing code for the NSPL in 2020 
was an important step towards lowering barriers to care and addressing 
the mental health crisis, particularly for LGBTQ youth. 9-8-8 is 
scheduled to become the new dialing code for the NSPL in July 2022, and 
the American public will only fully benefit from the implementation of 
9-8-8 if the Lifeline is appropriately funded, and specialized services 
are provided for LGBTQ youth as an acutely at-risk community.

The Substance Abuse and Mental Health Services Administration (SAMHSA) 
has previously reported that they expect call volumes to nearly double 
as a result of the new dialing code and that 9-8-8 will receive 
approximately 7.6 million calls in FY23. We estimate that NSPL could 
receive more than 400,000 contacts from LGBTQ youth in 2023. 
Alarmingly, this call volume will substantially increase wait times for 
youth in crisis, operators are not specially trained to handle these 
emergency calls and there is no standard of care for LGBTQ callers. 
These wait times and lack of training serve as operational barriers for 
LGBTQ youth seeking mental health services.

Ensuring that 9-8-8 is equipped with appropriate specialized services 
for LGBTQ youth is a matter of life and death. The absence of 
specialized mental health resources for LGBTQ youth will mean that 
young people will not get critical, lifesaving services. This is the 
very reason The Trevor Project exists, and according to a formal, 
external evaluation of Trevor's services, almost three-quarters of 
youth stated that they either would not or were unsure if they would 
have contacted another service if The Trevor Project did not exist. 
More than 80% of LGBTQ youth said it was important that a crisis line 
include a focus on LGBTQ youth, should they need it.

Specialized services for LGBTQ youth must include the training of 
existing counselors in LGBTQ cultural competency and the establishment 
of an Integrated Voice Response (IVR) option for LGBTQ youth to receive 
more specialized care. The implementation of an IVR option can transfer 
LGBTQ youth callers to specialized groups like The Trevor Project, 
where we have additional trained counselors, who are part of a pre-
existing nationwide response infrastructure and can take some of the 
increased burden from existing NSPL call centers. Importantly, use of 
IVR would facilitate efficient access to specialized care without the 
delays and miscommunication that come with efforts to make ``warm 
transfers'' between the Lifeline and specialized service providers.

Minimizing the barriers that allow LGBTQ youth to access services from 
group such as The Trevor Project is essential because it allows these 
young people to speak to counselors who can best help them. A multi-
year evaluation conducted by third party researchers found that over 
90% of youth in crisis who reach out to The Trevor Project are 
successfully de-escalated (meaning they are moved out of a state of 
crisis) and that de-escalation is sustained even weeks later. It is 
through these same proven training methods that the Lifeline will be 
able to provide the highest quality of services to its contacts.

The inclusion of specialized services, and specifically an IVR option, 
can play an important role in reducing barriers to mental health care 
because it would both increase the capacity of the Lifeline to handle 
calls, reducing wait times, and would ensure that LGBTQ youth can 
access counselors that have knowledge of their experiences and are 
specially trained to interact with individuals like them.

Fortunately, the need for 9-8-8 to include specialized services for 
LGBTQ youth is a matter of bipartisan agreement. Congress has 
repeatedly recognized the need for specialized services for LGBTQ 
youth. When Senator Orrin Hatch argued for the enactment of the 9-8-8 
legislation in 2018, he explained that:

        The prevalence of suicide, especially among LGBT teens, is a 
        serious problem that requires national attention. No one should 
        feel less because of their gender identity or because of their 
        orientation. They deserve our unwavering love and support. They 
        deserve our validation and the assurance that not only is there 
        a place for them in this society but that it is far better off 
        because of them. These young people need us, and we desperately 
        need them.\5\
---------------------------------------------------------------------------
    \5\ https://www.govinfo.gov/content/pkg/CREC-2018-06-13/html/CREC-
2018-06-13-pt1-PgS3866-3.htm.

Leaders from both parties, including the former Republican FCC Chair, 
have recognized the vital role that specialized services play in saving 
lives. The Act, passed with widespread bipartisan support, built on 
this promise and highlighted the need for specialized services for 
LGBTQ youth. The FY20 and FY21 Labor, Health and Human Services 
Appropriations Act Explanatory Statements directed SAMHSA to pursue the 
implementation of specialized services for LGBTQ youth, including both 
counselor training and the establishment of an IVR. Additionally, FY22 
appropriations language currently under consideration by Congress would 
---------------------------------------------------------------------------
allocate $7.2 million for specialized services, including IVR.

However, right now it is not clear if 9-8-8 will be ready for action in 
July. There are positive signs. SAMHSA has stated that more than $560 
million will be required to strengthen local crisis call capacity, 
including their ability to address the needs of high-risk populations. 
The agency has also announced that $282 million are being invested in 
efforts to ``shore up, scale up and staff up'' the NSPL,\6\ and 
recently reported to Congress that the agency ``has begun collaborating 
with the Trevor Project'' in the effort to provide specialized services 
to LGBTQ youth.\7\ However, time is running short, formal agreements 
and funding have yet to be finalized, and it is not clear that 
essential specialized services will be ready for LGBTQ youth in July.
---------------------------------------------------------------------------
    \6\ SAMHSA, HHS Announces Critical Investments to Implement 
Upcoming 988 Dialing Code for National Suicide Prevention Lifeline, 
December 20, 2021, available at https://www.
samhsa.gov/newsroom/press-announcements/202112201100.
    \7\ SAMHSA, 988 Appropriations Report, December. 2021, available at 
https://www.
samhsa.gov/sites/default/files/988-appropriations-report.pdf.

Overall, a properly functioning Lifeline is an essential tool to 
reducing barriers to mental care, particularly for LGBTQ youth. As the 
July activation date approaches, Congress should fully fund the NSPL 
and specialized services. This includes the training of counselors in 
LGBTQ cultural competency, the establishment of an IVR option for LGBTQ 
youth to receive specialized care, and the use of text and chat 
services. Taking these steps would help ensure that LGBTQ young people 
can get access to mental health resources and crisis intervention 
services that can be the difference between life and death. In the 
midst of a mental health crisis, no response is more important. The 
Trevor Project is ready, willing, and able to help make sure that 9-8-8 
succeeds.

 How can we protect LGBTQ youth from conversion therapy?

One of the barriers that LGBTQ youth and their families face when 
seeking appropriate mental health care is the continue prevalence of 
dangerous and fraudulent practices that seek to exploit the mental 
health challenges faced by these families. LGBTQ youth, already placed 
at increased risk for mental health challenges is because they face 
unique stressors and the threat of anti-LGBTQ victimization, should not 
also have to worry about being the victims of conversion therapy.

Conversion therapy is not ``therapy'' at all--it is a dangerous and 
discredited practice that harms both LGBTQ young people and their 
families. The American Psychiatric Association (APA) has stated that 
``The potential risks of reparative therapy are great, including 
depression, anxiety, and self-destructive behavior.'' The Trevor 
Project's 2021 National Survey found that:

      LGBTQ youth who were subjected to conversion therapy reported 
more than twice the rate of attempting suicide in the past year 
compared to those who were not; and
      13% of LGBTQ youth reported being subjected to conversion 
therapy, including 21% of Native/Indigenous LGBTQ youth and 14% of 
Latinx LGBTQ youth.

That's why twenty states and more than 100 localities have prohibited 
licensed mental health providers from subjecting LGBTQ youth to 
conversion therapy--but gaps in federal and state prohibitions persist, 
and medical billing procedure makes it difficult to track the 
occurrence and frequency of conversion therapy.

In order to effectively respond to the current mental health crisis, it 
is time for this dangerous practice to end once and for all. While we 
wait for Congress and states to close gaps in prohibitions against 
providing or funding conversion therapy, Congress should encourage 
agencies such as the Federal Trade Commission (FTC) to rigorously 
investigate and prosecute instances of deceptive or fraudulent 
advertising in connection with conversion therapy.

The mental health crisis has put more families with children in need of 
effective mental health services, strained the ability for effective 
provision and regulation of those services, and created an environment 
that makes it easier anti-LGBTQ practitioners to prey on marginalized 
families and children. For this reason, an effective response to the 
current mental health crisis should include efforts to ensure both that 
LGBTQ youth have access to the quality mental health care services they 
need, and that they are not victimized by fraudulent conversion therapy 
practices. These steps are an essential part of the necessary response 
to the current mental health crisis, to ensure that we are protecting 
LGBTQ youth in every corner of our country. They would reduce barriers 
to care by helping effective and reputable mental health care providers 
respond to families seeking help during the mental health crisis, 
saving the lives of some of the most marginalized young people, and 
assisting groups such as The Trevor Project in ending the harmful 
practice of conversion therapy.

Conclusion

Reducing barriers to care in order to address the mental health crisis 
facing our country requires a comprehensive, dynamic, and urgent 
response. Making sure that 9-8-8 is ready to serve all who need it when 
the number goes active in July--including providing specialized 
services to LGBTQ youth--and helping end conversion therapy are 
necessary components of any effective response to the unique mental 
health challenges facing LGBTQ youth.

Too many young lives are at stake, and I urge you to take action--
through your position of power and in your personal life. Our research 
has found that having at least one accepting adult can reduce the risk 
of a suicide attempt among LGBTQ young people by 40 percent. Isn't that 
profound--the impact that just one adult can make in the life of a 
young person? When having these conversations, we must always remember 
that suicide is preventable, and each and every one of us has the power 
to help end this public health crisis.

Thank you again for your attention to and action on this issue. The 
Trevor Project appreciates the opportunity to submit this statement and 
looks forward to continuing to work with Congress and the 
administration in addressing the mental health crisis and supporting 
our most marginalized young people.

For any questions, please contact Preston Mitchum (he/him), The Trevor 
Project's Director of Advocacy and Government Affairs at 
Preston.Mitchum@TheTrevor
Project.org.

                                 ______
                                 
                           Voice for Adoption

                      3919 National Dr., Suite 200

                         Burtonsville, MD 20866

                              202-210-8118

                       [email protected]

                    https://voice-for-adoption.org/

                Statement of Joe Kroll, Interim Director

Voice for Adoption (VFA) was established in 1996 to shape the public 
debate on permanency for children in the U.S. foster care system and 
the families who care for them. We advocate, educate, and collaborate 
with members of Congress, policymakers, partner organizations, 
agencies, and individuals to advance federal policies that promote and 
sustain permanence for children and youth in foster care. We envision a 
day when all children and youth in the U.S. foster care system will 
have a safe, loving, and supported permanent family through 
reunification, adoption, or guardianship.

In the federal fiscal year 2019, according to the Adoption and Foster 
Care Analysis and Reporting System (AFCARS), more than 66,000 children 
and teens were adopted from foster care in the U.S.--the highest number 
ever reported. The number of children waiting to be adopted has trended 
upward over the past five years, with 122,216 children in 2019 waiting 
to be adopted. Sadly, approximately 20,000 youth (ages 18 to 21) age 
out of the foster care system each year without a family.

The physical and mental health needs of children who have experienced 
abuse, neglect, trauma, and losses are significant. The State Policy 
Advocacy and Reform Center, in Medicaid to 26 for Former Foster Youth: 
An Update on the State Option and State Efforts to Ensure Coverage for 
All Young People Irrespective of Where They Aged Out of Care, explains 
it: ``Children who have been abused or neglected often experience a 
range of physical and mental health needs, physical disabilities and 
developmental delays, far greater than other high-risk populations. For 
example, foster children are more likely than other children who 
receive health coverage through Medicaid to experience emotional and 
psychological disorders and have more chronic medical problems.''

Nearly 70 percent of children in foster care exhibit moderate to severe 
mental health problems and 40 to 60 percent are diagnosed with at least 
one psychiatric disorder. Lewis et al. explain, ``Depression, reactive 
attachment disorders, acute stress responses, and post-traumatic stress 
disorders are some of the common mental health diagnoses of children in 
foster care.'' Researchers Kerker and Dore note that being taken into 
foster care compounds existing problems, ``Although children frequently 
enter foster care with preexisting conditions that put them at high 
risk for mental health problems, . . . the very act of separating 
children from their biological family may affect children's mental 
health as well.''

For many years, the conventional wisdom was that once children were 
adopted, any previous trauma a child experienced would be eliminated by 
joining a permanent family. Thus, it was generally assumed that once a 
child achieved legal permanence, their families would not need to seek 
services or support from the child welfare system. However, research 
has revealed that the trauma, abuse, and neglect children experience 
has serious, often lifelong repercussions. Childhood trauma and abuse 
affect brain development and have consequences throughout an 
individual's life. Among other things, complex trauma can affect 
children's ability to express and control emotions, concentrate, handle 
conflict, form healthy relationships, interpret social cues, and 
distinguish safe from threatening situations.

As a result, many children and families need help and support long 
after permanence has been obtained, including when children reach 
different milestones and experience transitions. In a longitudinal 
study of adopted children, Rosenthal found difficulties several years 
after adoption, particularly in adolescence: ``The study's core 
finding--one that those in the special-needs adoption field know from 
their everyday practice experience--is that `problems' in special needs 
adoption do not dissipate in a steady, predictable fashion. Instead, 
children and families continue to present complex challenges throughout 
the adoption. In particular, behavioral problems are quite persistent 
and may even intensify.''

The challenges for young people who leave care without permanency are 
even more significant since they don't always have supportive, caring 
adults in their lives. Youth who leave foster care due to age continue 
to experience poor health outcomes into adulthood, including high rates 
of drug and alcohol use, unplanned pregnancies, and poor mental health 
outcomes. More than half of those who aged out of foster care report 
being uninsured. More than one-fifth report unmet needs for medical 
care--research findings from Chapin Hall at the University of Chicago 
highlight additional troubling statistics. One-third of youth aging out 
reported two or more emergency room visits in the past year, 22 percent 
were hospitalized at least once, three-quarters of young women had been 
pregnant, and 19 percent received mental or behavioral healthcare in 
the past year.

At this time, there is no single access point for children, youth, and 
parents dealing with serious mental health and substance abuse issues 
to access services, treatments, and support. Foster care, juvenile 
justice, and education appear to be the primary points of access for 
the child welfare community, frequently exacerbating or creating much 
more significant issues such as specific populations being 
disproportionately over represented. In contrast, others may be denied 
services and experience discrimination. This fragmented model of mental 
health care provides no room for accountability. Instead of addressing 
the failure to provide services, blame is often pushed to systems not 
designed to provide these services, like the three above. In the end, 
that accountability has to be placed on a mental health system whose 
responsibility it is to ensure access, quality, and oversight are 
provided.

Regardless of which agency has the responsibility to provide access and 
ensure treatment effectiveness, no child or family involved with the 
child welfare system, especially those taken into foster care and 
promised our government's protections, should experience any form of 
abuse or neglect, including discrimination based on race, religion, 
sexual orientation, gender identity, or gender expression. The well-
being of our children, especially the well-being of their mental and 
behavioral health, demand that we improve access and provide children 
and families with trauma-informed, evidence-based, mental and 
behavioral health systems with a single point of entry--creating a 
mental health system that can be held accountable for failures in 
treatment, but also responsible for ensuring that all services 
providers and treatment options promote racial equity, strive to block 
discrimination, and dismantle system racism--ensure that mental health 
of those impacted by the System is preserved and nurtured and reduce 
trauma rather than inflict it.

Given the body of scientific evidence regarding the long-term effects 
of trauma on child development, child welfare, and behavioral health, 
systems must ensure they offer children and families a robust array of 
mental health and other post-permanency support and services.

VFA is pleased to provide recommendations to the Senate Finance 
Committee and welcomes opportunities to meet with committee members to 
discuss our requests further.

                 Fund Post-Permanency Support Services

      Congress should require and fund a core set of support services 
for children and families exiting foster care to a permanent family, 
with such services to include trauma-informed and permanency-competent 
mental and behavioral health services.

As noted above, research on the short- and long-term impact of trauma 
has revealed that many children and families need support long after 
legal adoption or guardianship has been obtained, including when 
children reach different milestones and experience transitions. As a 
result, child welfare systems must make a comprehensive array of 
services available to adoptive and guardianship families, including 
critical mental health services. These services must be available when 
needed and without waiting times and responsive to the needs of each 
family; a ``one size fits all'' approach is not acceptable. 
Importantly, professionals must deliver them with the expertise and 
training to meet adoptive and guardianship families' unique needs. 
Delay of services and inadequately trained mental health providers can 
exacerbate family problems and ultimately disrupt a child's adoption or 
guardianship placement.

State, local, and tribal child welfare systems need to have federal 
guidance and funding so they can fully develop and maintain 
comprehensive and responsive post-permanency services. Several states, 
including Tennessee, Alabama, and Illinois, provide a model of 
providing comprehensive, in-home mental health services to adoptive or 
guardian families.

             Improving Access for Children and Young People

      Congress should maintain access to Medicaid for youth who age 
out of foster care up until age 26 and assure this coverage extends 
across state lines when a young person moves to a new state. This 
requirement should take effect immediately rather than in 2023 as 
currently written.

      Congress should protect this Medicaid benefit in every state by 
precluding work requirements for youth who have experienced foster 
care.

      Congress should extend access to Medicaid to children who leave 
foster care to adoption and guardianship, just as it extends the 
benefit to those who emancipate from care.

More than 20,000 youth age out of the foster care system every year. 
Statistics about their uncertain futures are dire, and the lifetime 
societal costs are astronomical. The Affordable Care Act (ACA) is a 
critical lifeline for these youth. As a result of the ACA, young people 
who aged out of care without a permanent family can remain on Medicaid 
until age 26, just as other young people can stay on their parent's 
health care plans. The Congressional Research Service reported that in 
2015, 70 percent of 21-year-olds who had aged out of care were on 
Medicaid, showing how necessary this provision is to this population.

For those who age out of care or who exit to adoption or guardianship, 
access to Medicaid is a critically important way to meet the lifelong, 
significant mental health, substance use, and behavioral health care 
needs of young people who have experienced abuse and neglect and the 
challenges of separation from their birth parents. Losing coverage at 
age 18, when so many other transitions and changes are happening, is 
particularly risky for this population with a much higher rate of 
mental and behavioral health challenges.

                        Strengthening Workforce

Congress should:

      Support the expansion of adoption-competency training for mental 
health providers and caseworkers and encourage their participation by 
providing ongoing funding to the National Adoption Competency Mental 
Health Training Initiative and other similar adoption-competency 
programs.

      Provide federal incentives to recruit and train more master's-
level clinicians. There is a shortage of well-trained mental health 
specialists who can meet the complex and unique needs of the child 
welfare and adoption community.

      Provide funding for targeted recruitment and retention 
initiatives to recruit, train, and support BIPOC and LGBTQ+ clinicians 
to address the unique needs of BIPOC and LGBTQ+ children and families 
in foster care and adoption.

Although funding is critically important to ensure access to post-
placement support services, it is equally essential that services be 
permanency and adoption competent--reflecting the impact of trauma, 
grief, loss, and other critical issues in adoption and permanency. 
Children, youth, and families must have workers and other service 
providers who understand and respond to these issues and build their 
skills to serve children with their specific experiences. Families must 
have professionals who understand adoption and provide mental health 
services designed to respond to clinical issues and build parenting 
skills for families parenting children who have experienced trauma and 
broken attachments.

But more than training is needed. We have an urgent need to recruit 
additional highly skilled, diverse providers into the field. BIPOC and 
LGBTQ+ children and youth are over-represented in the foster care 
population. Having a workforce and service providers who reflect their 
background and understand their experiences will improve outcomes for 
children.

Services provided by highly trained staff who reflect the population of 
children and families in adoption and guardianship will be more 
effective at ensuring that families thrive and remain together, 
preventing foster care re-entry.

                       Increasing Access to Care

      Congress should increase Medicaid rates to align with private 
insurance.

The vast majority of children in and exiting foster care have Medicaid 
as their insurance provider. But these children and their families face 
significant obstacles accessing services due to low reimbursement rates 
and too few providers who accept Medicaid (often due to low rates), 
particularly in non-urban communities. Clinicians must be reimbursed at 
fair rates through Medicaid, which authorizes just a fraction of the 
rates clinicians get privately or through some other insurance 
providers. Reasonable reimbursement rates will ensure that skilled 
clinicians are willing to see our children and families.

      Congress should ensure that Medicaid includes coverage for 
family therapy, not just services to individuals, as well as 
nontraditional treatments that effectively help those affected by 
trauma.

Too often, Medicaid (and other insurance policies) covers only services 
to the insured individual, when the issues facing those in adoption, 
guardianship, and foster care are often related to the family system. 
Medicaid should explicitly cover therapeutic services provided to the 
entire family of children, including the children, their siblings, and 
birth, foster, and adoptive parents and guardians.

Youth and families must also have access to Medicaid coverage for 
nontraditional forms of therapy (such as neurofeedback, mind-body-
sensory trauma interventions, and other alternative innovations).

      Congress should support the development and advancement of 
services sensitive to racial and cultural and other needs of LGBTQ+ and 
BIPOC individuals, including ensuring that Medicaid and other insurers 
cover them.

In addition to recruiting and retaining diverse providers as 
recommended above, we must do more to ensure that the various children 
and families served by the child welfare system have access to mental 
health and behavioral health services designed to address their unique 
needs, including the impact of racism, homophobia, transphobia, and 
other discrimination. Funding should support ongoing development and 
research on new or adapted interventions sensitive to the racial, 
cultural, and different needs of LGBTQ+ and BIPOC children and 
families. In addition, Congress should ensure that these services are 
supported by Medicaid and other insurers and are accessible to those 
who need them.

      Congress should require Medicaid and other insurers to cover the 
subspecialty of therapists to include competence in child welfare and 
adoption.

There currently is no recognized ``subspecialty'' of adoption/
permanency competence despite the wide recognition of the unique needs 
of children in adoption and other permanent families. Congress should 
support and incentivize the creation of such a subspecialty whereby 
therapists complete either accredited adoption competency training or 
trainings that have an evidence base to show a positive change in 
practice and child and family outcomes. This is consistent with 
Medicaid managed-care companies' needs to ensure they spend their 
capped dollars on effective treatments specific to the audience.

      Congress should amend the Dosha Joi Immediate Coverage for 
Former Foster Youth Act (S. 712) and the Expanded Coverage for Former 
Foster Youth Act (S. 709) to include explicit language stating that 
Medicaid covers individual therapy and telehealth therapy services for 
young people who are or were in foster care.

Currently, young people who have Medicaid coverage may not have access 
to a full range of services that they need to meet their well-
documented needs. Congress should ensure that those covered by Medicaid 
can access the type of services they specifically need, including 
individual therapy rather than simply group care and telehealth 
services.

      Congress should also support expanded telehealth options, 
including allowing reimbursement to providers in other states, 
maintaining equal reimbursement rates for telehealth and in-person 
visits, and setting national standards for telehealth services.

Expanding telehealth services is vital to supporting many children, 
youth, and families, including, but not limited to, those residing in 
more remote locations. These individuals have limited access to 
providers and a reduced selection of treatment options. This may 
prevent access to services at all or, at a minimum, result in delays in 
access. Such limitations can cause additional problems as untreated 
mental and behavioral health problems worsen untreated.

By lifting geographic barriers to telehealth, children and families 
would have access to services from providers who can best meet their 
needs, with reduced wait times and choices for more adoption- or 
permanency-competent providers.

National standards for telehealth services would ensure that the 
provided services are of high quality and are most likely to serve each 
client effectively.

      Congress should increase the Federal Match Assistance Percentage 
(FMAP) rate for all children's mental health and supportive services 
provided under the Early and Periodic Screening, Diagnostic, and 
Treatment (EPSDT) entitlement, covering all children under the age of 
21 in all states and territories. In addition, Congress should expand 
access to these services for children and youth in foster care and who 
have exited care to adoption and guardianship while ensuring that such 
services are adoption/permanency-competent for this population.

Increasing the FMAP would encourage states to use this vital, underused 
resource for children covered by Medicaid. According to MACPAC, more 
than 40 million children were eligible for EPSDT services in 2014, but 
less than 60 percent of children who should have received at least one 
screening received one. Such screenings are essential concerning 
psychiatric care, which typically requires a determination of the 
medical necessity for future coverage. As noted above, children in and 
exiting foster care to permanency have significantly higher mental and 
behavioral health needs rates. They would particularly benefit from 
such screenings and the coverage that the screening results may make 
available to them. But for the screening and services to be effective 
for this population, they must consider specific issues common in 
foster care, including the impact of trauma, grief and loss, and broken 
attachments.

      Congress should refine language in the Timely Mental Health for 
Foster Youth Act (S. 3625) to mandate all jurisdictions to participate 
and require an additional mental health screening by trauma-informed 
professionals conducted 60 days before youth exit care to permanency or 
due to emancipation. Ensure that professionals work with families or 
young people to arrange for services to address any needs identified.

In many cases, children receive mental health assessments soon after 
entering foster care to determine their needs and identify services to 
be provided. Because needs change over time, such screening must also 
be done before children exit the system--and thus lose access to some 
services and supports--so that their current state of health is 
determined. The assessment process must include identifying and 
connecting to access services that address the child or youth's 
identified needs.

      Congress should mandate that the National Youth in Transition 
Database (NYTD) measure outcomes for healing and trauma through a 
qualitative question that addresses how to best support youth with 
their mental health and healing needs.

The NYTD current data collection falls short of identifying the needs 
of youth who have exited care and what is helping them heal. Additional 
questions, developed with the input of young people who have been in 
care, will help assess needs and identify which services and supports 
are successfully meeting those needs. The reported data would also hold 
states accountable for assisting young people in their healing process.

                            Ensuring Parity

      Congress should ensure that all health insurance provides true 
parity for mental and behavioral health services in all health 
insurance plans. Congress should hold more hearings, issue state report 
cards, and direct HHS to craft model state laws to reach parity.

In 2020, the Psychiatric Times noted that we had not achieved mental 
health parity despite previous legislation and other action. Citing a 
report card based on 2017 data, the Times reported on ``continued and 
increased disparities between behavioral health care and physical 
health care coverage, indicating possible evidence of non-compliant 
insurance practices.'' Data showed more out-of-network visits and 
higher co-pays for behavioral health than physical health in many 
states. Many of these disparities can be attributed to managed care 
rules.

There should not be limits on the number of visits and other mental and 
behavioral health services if such limits are not put on physical 
health needs. Services should be provided based on the individual's 
needs and the professional opinion of the service provider.

The mental health needs of children and young people who have been in 
foster care are significant. Their experiences and their families as 
they struggle to access appropriate services show us how fractured this 
country's mental health system is. We need a robust, comprehensive 
mental and behavioral health system that serves all Americans while 
also providing targeted investments and support for those children for 
whom the government accepted responsibility when it removed the 
children from their families and placed them in foster care.

                                 ______
                                 
                             Youth Villages

                          3320 Brothers Blvd.

                           Memphis, TN 38133

March 1, 2022

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

Chairman Wyden, Ranking Member Crapo, and Members of the U.S. Senate 
Committee on Finance, I want to thank you for the opportunity to submit 
a written statement regarding the Committee's continued support and 
interest in youth mental health in the United States as evidenced by 
your recent hearings on February 8, 2022: ``Protecting Youth Mental 
Health: Part I--An Advisory and Call to Action'' and February 15, 2022: 
``Protecting Youth Mental Health: Part II--Identifying and Addressing 
Barriers to Care.''

As you may know, Youth Villages \1\ is a national leader in children's 
mental and behavioral health committed to building strong families, 
delivering effective services, and significantly improving outcomes for 
children, families and young people involved in child welfare and 
juvenile justice systems across the country. Founded in 1986, the 
organization's 3,300 employees help more than 30,000 children annually 
in 23 states and the District of Columbia.\2\
---------------------------------------------------------------------------
    \1\ https://youthvillages.org/.
    \2\ https://youthvillages.org/about-us/locations/.

We full-heartedly agree with the members of the Senate Finance 
Committee and Surgeon General Dr. Murthy that there is a youth mental 
health crisis and that as a nation we must do more. We are extremely 
grateful for the Committee's leadership on the issue and your desire to 
work with young people and organizations that serve them to craft and 
implement solutions to the challenges this unique population faces. The 
challenges as mentioned in the hearings span beyond kids in crisis, but 
to parents, caregivers, and the workforce dealing with a range of 
---------------------------------------------------------------------------
challenges from access to services to burnout.

We know that when youth and families have the services and support that 
they need, they will be successful even when dealing with the most 
severe mental health challenges. Prevention is key to combatting the 
mental health crisis through investment in effective high-quality 
services and supports that offer timely support and flexibility for 
children, youth, and family's needs. I want to tell you about a young 
person who overcame difficulties with mental health that we served 
through our Intercept \3\ program, which is designated as ``Well-
Supported'' by the title IV-E Prevention Clearinghouse.
---------------------------------------------------------------------------
    \3\ https://youthvillages.org/services/intensive-in-home-treatment/
intercept/.

Cassidy was 16 years old and had multiple stays in in-patient mental 
health centers. She struggled with depression, anxiety, and suicidal 
ideation. In just one year, Cassidy was hospitalized for her mental 
health nine times. Approximately five million children across the 
country have a serious mental health condition, and hospital stays can 
---------------------------------------------------------------------------
cause significant trauma to a young person.

Youth Villages helps keep kids at home and in their communities while 
receiving mental health treatment by working with the whole family to 
provide intensive support, new parenting and communication skills, and 
evidence and strengths-based mental health intervention services.

As part of the Intercept program, Cassidy and her mother, Ellen had the 
ability to call the 24/7 Youth Villages crisis line to help de-escalate 
crisis situations when they arose as well as meeting with their family 
intervention specialist three times every week, sometimes at home, 
sometimes in the community--even at Cassidy's favorite coffee shop. 
They would work on coping skills and grounding techniques, 
affirmations, communication, and Cassidy's self-esteem. Her specialist 
would conduct safety sweeps at home and would work with them to create 
safety plans. Thanks to her time and success in Intercept, it has been 
more than a year since Cassidy's last hospitalization. She is enrolled 
in a therapeutic school and is on the honor roll. Ellen and Cassidy 
both feel comfortable and safe leaving Cassidy at home alone now--
something Ellen never thought she would be able to do again. Cassidy 
sometimes still struggles with self-image and negative thoughts; 
however, her specialist created a personalized affirmation book for her 
to use as a tool when she is having a tough time. For the first time, 
Cassidy is looking forward to what is next. She now envisions a future 
for herself and dreams big. She has started visiting colleges and wants 
to pursue a career in art.

Cassidy should not be the exception for youth with mental health 
issues. She should be the norm. We share this story because Youth 
Villages knows what is at stake as the Committee continues to work on 
solutions for the youth mental health crisis America is facing. Without 
the proper services and supports, especially those that are intensive, 
trauma informed, community based, and family oriented, young people's 
lives could be in jeopardy. Youth Villages stands with you, ready and 
committed to doing our part to help end this crisis and ensure that 
children, youth, and families can live successfully.

We would like to thank the Committee for including youth voice in the 
conversation on mental health reform. Youth Villages agrees with Trace 
Terrell that young people should not get lost in the system(s) and 
should be able to obtain the level of care they need and where it is 
developmentally appropriate. Youth Villages LifeSet program, which was 
designed to help young people ages 17 to 23 who are aging out of child 
welfare, juvenile justice or children's mental health systems get a 
good start on independent adulthood, shows a positive impact with 
meeting the needs of multi-systemic young people. For young people 
transitioning from the foster care system, there is a need for 
increased coordination and targeted case management that focuses on a 
youth's mental health care and all their needs outside of clinical 
support.

Young people who experience foster care are resilient and capable. 
Still, they need support as they move toward adulthood. Nathe'anna's 
journey--overcoming health issues, the COVID-19 shutdown and a natural 
disaster--proves that point. Nathe'anna, the youngest of four children, 
came into foster care around 7 years old. When she turned 18 in a group 
home, COVID-19 hit. Then, she had to have gall bladder surgery, alone 
because of visitor restrictions. Her LifeSet specialist Kelly Adams was 
there, through phone calls, offering support and encouragement.

After her recovery, Nathe'anna returned to school virtually. Soon 
after, her community was struck by Hurricane Ida. There were weeks with 
no electricity and roads closed. Kelly stayed connected. LifeSet turned 
into a lifeline. Today, Nathe'anna is working toward becoming an 
emergency medical technician.

``I watched every one of my brothers and sisters age out of foster 
care. This program wasn't around for them, and they had negative 
outcomes,'' she said. ``LifeSet is a program that gives you a chance, 
that gives you hope.''

Thank you again for the Committee's interest and commitment to 
addressing the youth mental health crisis and the opportunity to submit 
Cassidy's story for the record. Last October, Youth Villages submitted 
a letter to the Senate Finance Committee addressing numerous concerns 
surrounding the mental health crisis and its impact on youth and 
families. We offered some of the following policy solutions, if 
included in the bipartisan legislation, will help improve mental and 
behavioral health outcomes for children, youth, and families:

      We would like to reiterate that to address the high turnover and 
burnout among behavioral health practitioners, the Committee should 
find ways to increase payment rates to providers and provide 
educational incentives for mental health professionals.
      Prior to the pandemic, many children and youth with complex 
needs faced barriers in accessing high-quality services, especially 
young people in foster care. The Committee should provide additional 
funding for research and evidence-based programs to expand high quality 
services for young people, specifically those with foster care or 
juvenile justice experiences.

If you have any questions about our Intercept program, how we address 
youth mental health, or the solutions we see to this crisis, please 
contact Director of Federal Policy, Shaquita Ogletree at 
[email protected].

Respectfully submitted,

Pat Lawler
CEO

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