US Surgeon General Vivek Murthy issued a stark warning in December: America’s youth are in the midst of a “devastating” mental health crisis, suffering from skyrocketing rates of depression and anxiety. Our health care system, which for too long has slighted mental health care, is woefully unprepared for the heartbreaking surge in troubled kids arriving in emergency rooms and psychiatric facilities: Lower insurance reimbursement rates for mental health care providers and hospitals has translated into fewer providers and less access. And as weak as the mental health care system is for adults, for children and adolescents it’s even worse.
Decades of overlooking mental health care can’t be overcome quickly. But the surgeon general’s warning ought to be a wake-up call to regulators and insurance companies that higher payments for mental health providers can’t wait any longer.
The statistics are grim. Average wait times for initial assessment, ongoing therapy, and medication services are all longer for children than for adults. While an adult may typically wait 12.7 weeks for therapy, a child may be delayed by more than 15 weeks.
Meanwhile, suicidal ideation in young people has been rising steadily since 2009; suicide is the second-leading cause of death in children between 10 and 14 years of age. The mental health of young Americans has been deteriorating for years, but the COVID-19 pandemic greatly worsened the crisis. Millions of children have suffered through social isolation caused by school closures and the loss of loved ones from the disease, worsening the gap between the demand and supply for mental health services.
The most visually arresting issue within child and adolescent mental health care is the lack of inpatient beds. On one Monday in March, there were 503 adults and 247 children awaiting beds in psychiatric facilities across Massachusetts. More beds in psychiatric facilities would mean vulnerable children won’t have to spend another night boarding in an emergency room.
But additional beds won’t get to the root of the problem unless the number of people entering the field for child and adolescent behavioral health — including but not limited to psychiatrists, nurses, counselors, social workers, and psychologists — matches the ever-increasing number of children who need care.
Even as hospitals struggle to recruit doctors and practitioners, more are leaving. For every 10 outpatient clinicians who enter mental health clinics, 13 outpatient clinicians leave. Serving children in outpatient clinics is crucial: Meeting their mental health needs early can prevent them ever having to endure boarding later.
The primary reason for providers leaving is low salaries and benefits for an increased workload. Adolescent mental health care involves entire systems of care, starting with the child and extending to their school, family, teacher, therapist, and community.
“Because our culture does not value mental health care, and reimbursements are set up in a way that reflects our culture, we are looking at people burning out and leaving,” said Dr. Patricia Ibeziako of the Boston Children’s Hospital. The failure of insurers to adequately value outpatient mental health services drives clinicians either to leave the field or work privately, thereby making themselves less accessible.
Another concern of psychiatrists in Boston is that insurance companies, which hold the ultimate power to authorize different models of care for children, are not well versed in children’s mental health needs.
As cumbersome as authorization for a routine medical procedure is, it is significantly more complicated to prove the importance of different methods of behavioral care such as intensive outpatient therapy, virtual group therapy, or dialectical behavioral therapists to insurance companies.
Mental health, especially in children, was ignored for centuries as stigma against mental illness festered. Now that politicians are catching up, they would also do well to consider that children of color and LGBTQ youth suffer at even higher rates, and that the number of mental health care providers of color is also not growing fast enough.
There has been progress on Beacon Hill, but it may not be enough and it is certainly not fast enough.
The Legislature has put some money from the federal COVID stimulus program into mental health, and last year the Massachusetts Senate passed its Mental Health ABC Act 2.0. The act puts more teeth into the requirement that mental health and primary care providers be reimbursed at the same rates for the same service; eliminates prior authorization requirements for acute treatment; and mandates that insurance coverage for mental health care be equal to insurance coverage for other medical conditions. The House of Representatives should urgently take up this legislation.
Then there’s the Thrive Act, the school-based behavioral health legislation that requires public schools to mandate age-appropriate physical and mental health education for all students. This is also pending approval in the House.
Lastly, there is Governor Charlie Baker’s push to improve access to health care — this bill requires providers and insurers to increase spending on primary care and behavioral health by 30 percent over the next three years.
All the proposals have some overlapping policies. But any legislation that emerges from the various plans floated on Beacon Hill would be an improvement over a health care system that has left too many kids in crisis.
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