American Hospital Association
Committee on Finance
United States Senate
“Protecting Youth Mental Health: Part II - Identifying and Addressing Barriers to Care”
February 15, 2022
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.
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 Sens. Chris Murphy (D-CT) and Bill Cassidy (R-LA), legislation whose provisions were incorporated into the Consolidated Appropriations Act, 2021 (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.
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.
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.
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.