New Pathways to Behavioral Health Services Will Boost the Wellness of Children in Philadelphia and Across the Nation
Date: October 25, 2021
To: Committee on Finance, State Senate, email@example.com
From: Children First
Re: Improving Behavioral Health Access for Children and Young People RFI
Thank you for this opportunity to play a role in shaping bipartisan legislation aimed at improving behavioral health access for children and youth. We share the Committee on Finance’s belief that every American should absolutely have access to timely, high-quality behavioral health care. Access is most critical for children and youth who typically rely on their parent or guardian to access the care they need. We have three over-arching recommendations that will lead to significant advancements in improving behavioral health access for children and youth nationwide.
Based on our collective years of experience and study, we strongly agree with the Senate Finance Committee that developing strategies to increase behavioral health access for children and youth is the top priority. We urge Congress to pass legislation to expand the use of Medicaid funds to support preventive and early behavioral health care for children and youth, including the three key areas as described below:
#1: Fund Behavioral Health Screening in Schools
Providing behavioral health screening of students in school is a critical first step to identifying unmet behavioral health needs. Comprehensive school-based behavioral health that includes early identification and treatment is associated with improved outcomes for students including enhanced academic performance, decreased need for special education, fewer disciplinary encounters, improved school attendance, and higher rates of graduation. Given that half of all lifetime cases of mental illnesses begin by age 14, the earlier students are identified and access critical behavioral health support, the better off they tend to be.
Literature indicates that early behavioral health identification and intervention is associated with increased educational attainment and work productivity, thereby reducing the economic burden of each patient. While early intervention might be costly, researchers estimate a two-to-one return on investment compared to the high cost of intervention.
Children First recommends that Congress designate adequate funding support for school districts to conduct behavioral health screenings of students. Schools are experiencing a staffing crisis that has been severely exacerbated by the pandemic. Funding should be allocated so that schools can hire dedicated staff who have the time and resources to build, enhance and sustain a process for behavioral health screening, data collection, reporting, dissemination, and continuous quality improvement. Investing in early screening, identification, and intervention will reduce the cost of more intensive treatment later. The bipartisan Every Student Succeeds Act (ESSA) includes a flexible block grant program, Student Support and Academic Enrichment (SSAE), under Title IV, Part A, which is authorized at $1.6 billion through FY-2021. Many states, including PA, have prioritized the use of ESSA funds to begin to support the behavioral health needs of students, but these funds are insufficient in building a comprehensive system of behavioral health care in schools, including behavioral health screening. Since SSAE is one of the largest authorized programs in ESSA, failing to adequately fund it will undermine the bipartisan Congressional intent in passing this critical law.
#2: Create a National Center on School-Based Behavioral Health Care
Screening alone does not improve access to behavioral health care. Once a child has an identified need, they often face tremendous obstacles to accessing care in the community including long waits for treatment, issues with geographical accessibility, and fear of stigma. As a result, only an estimated 20% of children access the care they need. About 70-80% who do access behavioral health care do so in their school (Center for School and Health Care in Schools). Children are also six times more likely to complete treatment in schools than in community settings. Schools offer a more accessible, less stigmatizing environment than other community behavioral health settings do, which makes schools the most effective point of entry for students to receive behavioral health services they would otherwise fail to access. The federal government must invest in school-based behavioral health services, so children can have the best chance at accessing the care that they need. Children First recommends that Congress create and fund a national center on school-based behavioral health care to provide support to Departments of Education and Behavioral Health Administrators. States should be required to take the following steps to support student access to comprehensive School Based Behavioral Health nationwide: 1) develop statewide training and implementation support; 2) promote cross-sector engagement, goal setting, and decision-making; 3) align planning and funding by Medicaid, private insurance, and managed care organizations at the state level to support school behavioral health; 4) convene a coordinated school behavioral health council. To accomplish these state-wide initiatives, there will need to be funding to support a national center to provide technical assistance that can support states in developing multi-tiered approaches to school behavioral health; engage in cross-agency collaboration with concrete actions, outcomes and accountability related to comprehensive school behavioral health systems; and execute research and innovation to advance school behavioral health strategies.
#3: Permit Medicaid and CHIP Coverage for Preventive Behavioral Health
To access most forms of behavioral health services, major insurances including Medicaid and CHIP, require that children have a mental health diagnosis, which carries a tremendous amount of stigma. This results in children with low level behavioral health needs either being prematurely diagnosed or ineligible to access early care altogether. This lack of early behavioral health care can lead to an unnecessary escalation in the child’s symptoms that is more harmful to the child (and possibly their family and community) and is far more costly to treat. While some families can afford to pay costly out of pocket fees so that their child may receive early behavioral health care, many simply cannot afford to do this. As a nation, we need to make it a priority to create equity in behavioral health care. Every child wanting to speak to a therapist should have access, regardless of their parent or guardian’s ability to pay.
Children First recommends that Medicaid and CHIP pay for early care for children with low level behavioral health needs who do not yet have a clinical diagnosis. Some states including CA have used alternative referral criteria including a recent loss or trauma, other adverse childhood experiences, or social determinants of health to justify ‘medical necessity’ for treatment. The latest literature found that targeted behavioral health prevention including behavioral health screening plus evidence-based treatment interventions such as Cognitive Behavioral Therapy (CBT) in school were the most cost-effective interventions in the prevention of behavioral disorders in children and adolescents. Early behavioral health care needs to be accessible across other community settings including outpatient as well.
Children First’s Health Policy Team would be pleased to discuss these recommendations with you in more detail and serve as a resource for information and strategizing. We would also be happy to connect you with the variety of stakeholder groups we work with locally. Background on the Problem Growing up in Philadelphia is far too difficult for too many children. Extrapolations from national data suggest that 34,000 children in Philadelphia are likely to have a behavioral health issue. Two in five have witnessed violence, lived in foster care, been bullied, experienced discrimination, or felt unsafe in their neighborhood (see attached research data). With the additional stress of COVID, survey data collected by the U.S. Census Bureau show that rates of depression and anxiety have more than tripled, with people of color disproportionately affected.
The most compelling evidence of the system failure is the more than 3,000 Philadelphia youth removed from their homes and placed in the dependency or delinquency systems because they have acted out and can’t stabilize or they’ve committed a low-level offense. Tragically, the earlier children are placed in residential facilities, the more likely they will end up incarcerated as adults. In Philadelphia, this burden is disproportionately borne by Black children, mostly boys, who comprise 75% of all youth removed from their homes and sent to institutions, while Black children represent only 47% of all children in the city. Meanwhile, Philadelphia has an impressive array of behavioral health assets and partnerships that with Children First’s prodding and pushing have evolved to ensure robust behavioral health services are available to children. But the utilization of these assets is depressingly low and far too many children are still not eligible to use these assets. This story is all too familiar. The CDC and SAMHSA cite the latest literature, which indicates that 80% of children nationwide with a behavioral health condition fail to access the care they need. Even fewer are estimated to get effective treatment. Even fewer children of color access the care that they need.
In 2019, SAMHSA and CMS issued a Joint Informational Bulletin urging states and school systems to take steps to address mental health and substance use issues for students in schools, where children can more easily access the care they need. Despite the clear need for comprehensive school-based behavioral health services, many school and behavioral health systems across the nation continue to operate in silos, with limited behavioral health care built into the school structure. Children First is using our skills as successful advocates to gather key players in Philadelphia to work together to enable thousands of children who need preventative and traditional behavioral health care to access it.
About Children First
The mission of Children First (formerly Public Citizens for Children and Youth) is to improve the lives and life chances of the region’s children through thoughtful and informed advocacy. Fueled by a 40+ year record of success, Children First fights for kids from a place of optimism. We lead the charge to ensure that vulnerable children have the building blocks they need to thrive, including access to quality schools, reliable health care services, and safe and healthy homes. We push for change by publishing original research, building powerful coalitions, informing citizens, organizing effective education campaigns, and providing high quality direct services. Through these strategies and a relentless optimism, Children First has earned a reputation as the region’s champion for children.
Our child health policy team tackles key areas including behavioral health, public health insurance, and lead poisoning. Children First has published behavioral health resource guides for preschool and school age children in Philadelphia and the surrounding four counties with information on how to access behavioral health services that accept Medicaid and CHIP, as well as agencies that can treat regardless of health coverage. A dozen years ago, Children First convened a broad coalition around school-based behavioral health to help the system achieve its goals. In collaboration with Community Behavioral Health (CBH, the behavioral health payor for Medicaid recipients in Philadelphia), the Philadelphia School District (PSD), and a number of behavioral health, parent, and educator stakeholders, we published a report on the group’s findings and recommendations, Behavioral Health Goes to School. In partnership with PSD, Children First worked closely with CBH to include data on which students were using care, the types of care used, and key demographic data.
Philadelphia Takes Steps Toward a More Comprehensive, Healing- Centered Continuum of Behavioral Health Support in Schools
The Philadelphia School District, along with other schools nationwide, have shifted to a Multi-Tiered System of Support (MTSS) framework. This evidence-based framework provides a multi-level prevention system to maximize student achievement by supporting social, emotional, and behavior needs, utilizing a strengths-based perspective. Embedded within each tier of MTSS, the National Center for School Mental Health (NCSMH) recommends that schools move toward a comprehensive continuum of behavioral health support that incorporate a healing-centered approach, which moves beyond “traumainformed care” to include the following: 1) acknowledges the collective experience of the individual; 2) considers the environmental context that caused the harm in the first place; and 3) fosters possibility (well-being) versus pathology (trauma). Recently, the Philadelphia School District (PSD), in partnership with Community Behavioral Health (CBH) and the City, have made tremendous strides toward strengthening the array of behavioral health services available to students within the MTSS framework by expanding existing Tier 1, 2, and 3 services that students ca n access as illustrated in the following:
Although Philadelphia has taken initial steps toward a more comprehensive school-based behavioral health system, we continue to experience the following challenges : 1) insufficient staffing to initiate behavioral health screening of students; 2) weak referral systems, 3) inadequate capacity to provide care once behavioral health needs have been identified, 4) access to the majority of services are limited to children enrolled in Medicaid, and 5) bureaucratic requirements for major insurances inhibit access to treatment where a child’s mental fragility is not yet severe enough to warrant a diagnosis.
Without significant federal support, critical services will languish and the promise of dramatic expansion in school-based access in Philadelphia and nationwide could collapse.
Thank you for your consideration.
Kathryn S. Miller, LCSW, RPT-S (she/her)
Associate Director of Health Policy