Youth Mental Health: Promoting access and affordability of quality treatment and care

NGA Chair New Jersey Governor Phil Murphy and Michigan Governor Gretchen Whitmer hosted the third convening of the NGA Chair’s Initiative: Strengthening Youth Mental Health, in Detroit, Michigan, from April 20-21, 2023. The Governors were joined by New Jersey First Lady Tammy Snyder Murphy, North Carolina First Lady Kristin Cooper, and North Dakota First Lady Kathryn Burgum. Strong state contingents from Michigan, New Jersey, North Carolina, North Dakota, Ohio, and Utah were joined by over 60 diverse policy and subject matter experts and private sector leaders to discuss state solutions for the third pillar of the Chair’s Initiative: Access and affordability of quality treatment and care.

Continuing challenges to access and affordability

Challenges in accessing and affording youth mental health and substance use care are an everyday reality for young people, their families, and communities. “Care deserts” persist, especially in rural states, where the nearest source of specialized treatment and care could be hundreds of miles away. Access can also be impeded by a high cost of care. States vary in their enforcement processes of insurance coverage parity for physical and mental health needs resulting in gaps in covered care.

States also vary in their enforcement of the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) mandate and the scope of mental health services covered under Medicaid, which is the largest insurer for children, and covers intersectional populations with complex needs, such as children in the foster care system or juvenile justice system. Additionally, Medicaid reimbursement rates are generally significantly below rates for their commercial counterparts, perpetuating a disincentive for providers to accept, limiting access for many children, youth, and families with lower incomes.

General discontent for the current reimbursement rates in both Medicaid and private insurance and increasing administrative burden have contributed to the provider shortage. The coverage landscape is challenging as cost is a major barrier for families, and as more providers refuse to contract with insurers or accept private and public insurance, this dynamic exacerbates affordability challenges and creates additional obstacles for families, employers, and schools providing mental health services.

One of the biggest drivers of access challenges is the continuing provider shortage, worsened by the COVID-19 pandemic. Most US counties lack a psychiatrist specializing in children or adolescent services, and the US Department of Health and Human Services has estimated that the country will have a shortage of 10,000 mental health professionals–including psychologists, marriage and family counselors, social workers and substance use behavior experts–by 2025. There is a severe lack of culturally representative care: For example, 2020 data from the American Psychiatric Association shows that only 5% of psychologists and 2% of psychiatrists are Black.

State licensing board processes and administrative challenges can further contribute to the logjam, slowing provision of licenses and further straining the provider landscape. State leaders can lean in to create a diverse pipeline of youth mental health professionals, support their attainment of qualifications and licenses, support teams-based approaches, and reduce barriers for them to use their skillsets and take steps to retain professionals once they are qualified.

Roundtable Panels

Strategies to Assess and Advance Access to Affordable Care

  • Natalie Kasiborski, Community Health Alliance of Michigan
  • David Lloyd, The Kennedy Forum
  • Dr. Amy McKenzie, Blue Cross Blue Shield of Michigan
  • Marisa Weisel, Ohio Department of Medicaid
  • Moderator: Colleen Desmond, Boston Consulting Group

Mental Health Workforce Solutions in the Short-and Long- Term

  • Dr. Tami Benton, Children’s Hospital of Philadelphia
  • Dr. Brittany Barber Garcia, Helen DeVos Children’s Hospital, Michigan
  • Dr. Bill Hazel, Claude Moore Foundation
  • Dr. Charmain Jackman, lnnopsych
  • Moderator: Dave Anderson, Child Mind Institute

Strategies to Align State Systems to Innovate Care and Treatment

  • Commissioner Christine Norburt Beyer, New Jersey Department of Children and Families
  • Malaak Elhage, CLASP
  • Dr. Deepti Rao, Elevance Health
  • Pawel Walczuk, Accenture
  • Moderator: Doug Howard, Maximus

Lastly, taking a systems-level lens to the overall youth mental health landscape, services are often provided in silos, with insufficient coordination. There is a lack of integration and data-sharing amongst different mental health services, which leads to a disjointed and frustrating experience for young people and their families trying to navigate complex patient journeys.

These challenges are difficult to overcome, but states have generated significant alignment and momentum to drive advances for their constituents. Many Governors and state policy leaders are responding with unprecedented support through legislative changes and funding allocation. At the NGA Chair’s Initiative convening, discussion highlighted solutions to address three key themes: strategies to assess and advance access to affordable care, mental health workforce solutions in the short and long term, and approaches to align state systems to innovate care and treatment. Ultimately, states need to ensure that young people can access services where, when, and how they need them.

State policy solutions discussed at the convening include:

Access and affordability

  • Conduct a fiscal mapping of the sources and allocation mechanisms of funding streams for youth mental health to understand gaps and opportunities for improvement
  • Identify additional sources of funding, such as private and philanthropic funds, to support upstream community services that support prevention and resilience-building
  • Develop innovative payment models and policies that allow for a greater integration of services among primary, pediatric, and behavioral health care providers, and drive high-quality, evidence-based, equitable outcomes for children
  • Invest in integrated care and wraparound models such as coordinated specialty care for early psychosis
  • Reevaluate Medicaid reimbursement rates compared to service costs for local providers
  • Ensure compliance with the EPSDT mandate and expand preventative mental health services to all Medicaid-eligible students
  • Identify solutions to provide patients with the right level of care for their needs, including digital tools and non-clinical support
  • Appoint state insurance regulators to collect and review commercial insurance plans’ parity analyses and data reporting, including youth-specific parity compliance, to assess the equivalence of medical/surgical and mental health and substance use disorder coverage
  • Continue post-pandemic support for telehealth and digital technology services, including supporting legislation and guidance, encouraging appropriate reimbursement, and exploring waivers for continuous enrollment and wraparound supports for youth and their families
  • Leverage lived experience perspectives to help identify policies and regulations that create barriers to care for consumers, or unnecessary burdens for providers
  • Explore care or compensation models for non-clinical professionals, like peer mentors and community health workers or home-visiting workers.

Workforce development

  • Explore incentivizing upskilling for primary health care providers and pediatricians on youth mental health, and formalize connections between these providers and psychiatrists and psychologists to enable advice-sharing and easier referrals
  • Train early childhood professionals and school-based or community health workers to support prevention and screening activities, and manage the early signs of mental health challenges
  • Increase high school and college student awareness of career paths in the youth mental health care workforce and pathways into these occupations, to develop a long-term pipeline of diverse talent
  • Explore new or increased tuition subsidies and loan forgiveness programs for mental health professionals, potentially in exchange for work in specific communities or in private or public networks
  • Promote a team-based and integrated approach to care in general medical education and by engaging multi-disciplinary providers to expand capacity of highly credentialed or severe-acuity providers, like psychiatrists 
  • Review licensing and scope of practice regulations requirements for mental health professionals to maximize the ability of mental health professional to work to their license, while maintaining education and training standards that align with high-quality care
  • Examine telehealth and cross-state state licensing flexibility and agreements, including multi-state compacts, as a means of supplementing pediatric network capacity and maximizing the scope of practice for providers across states
  • Eliminate culturally or otherwise outdated questions from the licensing testing process that could discourage potential applicants
  • Bolster administrative support for under-staffed licensing offices and modernize application processes
  • Encourage the composition of licensing boards to reflect demographics, and comprise multiple areas of expertise required in a team-based approach to youth mental health

System alignment and Innovation

  • Meet children and adolescents where they are through the provision and reimbursement of mental health services in schools, community locations, and primary care settings
  • Compel and formalize collaboration to reduce silos between youth-focused government agencies that oversee mental health and other services to address the social determinants of health, such as food security and housing
  • Convene community stakeholders–including providers, payers, caregivers and others along the care continuum–to discuss challenges and to promote collaboration
  • Map capacity standards across youth mental health patient journeys to understand supply, demand, and gaps 
  • Enable data sharing amongst youth-facing state agencies, including law enforcement, to ensure accurate and up-to-date information can be employed to treat individuals’ mental health challenges
  • Identify the different points of entry into the system, and develop infrastructure to ensure there is “no wrong door” to accessing help
  • Invest in upstream prevention and intervention, including addressing social factors and services to reduce pressure on downstream crisis services and in-patient capacity
  • Integrate youth-specific crisis response services (including services accessed through 988, mobile crisis, crisis receiving and stabilization, community programming, warm lines, peer supports) into the broader youth mental health landscape, to enable connection to the continuum of care

The Michigan roundtable follows successful convenings hosted in California in January 2023, and Utah in October 2022. The fourth and final roundtable of the Initiative will be hosted in Philadelphia by Pennsylvania Governor Josh Shapiro on May 18, 2023. Focused on the Chair’s Initiative’s fourth pillar – Caregiver and Educator Training and Support – discussions will center on the important role of families and youth-facing adults in school and beyond, and how Governors and state leaders can better equip them with the tools and supports to identify youth mental health needs and connect young people to care. If your state or territory is interested in becoming more involved in the Chair’s Initiative, please contact Jordan Hynes, NGA Program Director for Children and Families.