Pandemic Has Taken Unprecedented Toll on Mental Health of Children, More Support Needed

A study released last month by the Centers for Disease Control and Prevention (CDC) adds to the mounting evidence that the COVID-19 pandemic has taken an unprecedented toll on children’s mental health.

CDC Study Findings

According to the findings of the study, emergency department visits by children ages 12 to 17 for suspected suicide attempts were significantly higher during much of the pandemic when compared to the same periods in 2019. These findings were especially true for adolescent girls with the CDC study finding that such emergency department visits were over 50% higher during the winter of 2021 when compared to 2019 for girls in this age group.

Last month’s report comes after another CDC study released late last year raised similar concerns. That study found that between April 2020 and October 2020, the overall proportion of reported children’s emergency room visits for mental-health-related concerns increased and remained elevated relative to the same period in 2019. The CDC findings, coupled with data recently released in a fact sheet by the Centers for Medicare & Medicaid Services (CMS)—concluding that despite an overall rebound for most services, there remains a “notable gap” in services for mental health conditions compared to pre-pandemic rates—highlight the ongoing impact the pandemic has had on children’s mental health and access to needed care.

While there is good reason to be hopeful as more individuals, including adolescents, gain access to the COVID-19 vaccine and the country begins to emerge from the pandemic, it is clear that there is still a long way to go to meet the longstanding unmet mental health needs of children in the United States.

MACPAC Weighs In

Medicaid and the Children’s Health Insurance Program (CHIP) play a significant role in serving children with mental health conditions providing coverage to more than 38 million children across the country with Medicaid serving as the nation’s largest payer for mental health services.

In a recent report to Congress, the Medicaid and CHIP Payment and Access Commission (MACPAC) included a chapter dedicated to the issue of access to mental and behavioral health services for children covered by Medicaid and CHIP. The chapter acknowledges that children in the United States have faced longstanding unmet mental health needs citing that in 2018—well before the start of the COVID-19 pandemic—only about half of all non-institutionalized youth enrolled in Medicaid or CHIP who experienced a major depressive episode received any mental health treatment. An issue that has undoubtedly been exacerbated by the COVID-19 crisis.

The report goes on to touch on a number of key issue areas as it relates to access to mental health services for children in Medicaid and CHIP such as prevalence, disparities, and treatment rates, availability of providers, and the unique needs of children with significant mental health conditions. The report also highlights the complexities of coordinating among the various federal and state agencies involved in addressing the mental health needs of children. Focusing on this issue, the report concludes with two unanimous recommendations.

  • The first recommendation calls on the Secretary of the U.S. Department of Health and Human Services (HHS) to direct agencies including CMS, the Substance Abuse and Mental Health Services Administration (SAMHSA), and the Administration for Children and Families (ACF) to issue joint subregulatory guidance that addresses the design and implementation of benefits for children and adolescents with significant mental health conditions covered by Medicaid and CHIP.
  • The second recommendation calls on the Secretary of HHS to direct a coordinated effort by CMS, SAMHSA, and ACF to provide education and technical assistance to states on improving access to home and community-based behavioral health services for children and adolescents with significant mental health conditions covered by Medicaid and CHIP and also calls on the Secretary to examine options to use existing federal funding to support state-level activities to improve the availability of these services.

MACPAC also issued a separate chapter as part of its June report to Congress focused on access to mental health services for adults covered by Medicaid making similar recommendations focused on additional guidance as well as educational and technical assistance to states to improve the continuum of care. It also included a chapter focused on integrating electronic health records and behavioral health care.

Signals from the Administration and Congress

MACPAC’s formal recommendations for more coordinated efforts and guidance from agencies across HHS come on the heels of an announcement in May that Secretary Bacerra is establishing a new “Behavioral Health Coordinating Council.” According to the announcement, the Behavioral Health Coordinating Council will be comprised of senior leadership from across HHS to “facilitate collaborative, innovative, transparent, equitable, and action-oriented approaches to addressing the HHS’ behavioral health agenda.” The announcement was silent on what role agencies such as CMS will play in the new Behavioral Health Coordinating Council or what next steps look like for the Council. We will be watching closely and are hopeful that the needs of children will be front and center as the Council commences its work.

Congress has also recently signaled the need to do more to address the ongoing mental health crisis. This past month, the Senate Finance Committee led by Chairman Ron Wyden held a hearing focused on improving mental health and substance use disorder services during the COVID-19 pandemic and beyond. The hearing, which was largely bipartisan in nature, touched on a number of topics including the unique needs of children and the need for better coordination of payers and care. Similar hearings have been held over the past year by a number of Committees in the House of Representatives with Congress including provisions to strengthen compliance with mental health and substance use disorder parity in the end of year spending package signed into law in December.

However, it is important to note such provisions were largely focused on private insurers with separate CMS regulations generally applying to Medicaid and CHIP managed care plans. A recent issue brief by MACPAC examining implementation of such parity laws and regulations in Medicaid and CHIP calls to attention the need to do more to ensure meaningful access to behavioral health services for individuals covered by these programs.

In addition to hearings focused on the issue of mental health, a number of bills have been introduced in Congress to improve access to behavioral health services including the “Better Care Better Jobs Act.” The bill comes as a follow up to President Biden’s American Job’s Plan, which called to expand access to and quality of home and community-based services and better support the caregiving workforce. Among other provisions, the bill would build off the additional support provided in the American Rescue Plan for Medicaid home and community-based services by providing a permanent 10 percentage point increase for federal Medicaid matching funds for home and community-based services for states that meet a number of requirements including “[e]xpanding access to behavioral health services and coordination with employment, housing, and transportation supports.”

[Read Part 2 of this blog series to learn more about American Rescue Plan funding opportunities for states to improve access to mental health services.]

Free and confidential support for those in distress is available 24/7 at the National Suicide Prevention Lifeline at 1-800-273-8255 (en Español: 1-888-628-9454; for the deaf and hard of hearing: Dial 711 then 1-800-273-8255) or the Crisis Text Line by texting HOME to 741741. 

Anne Dwyer is an Associate Research Professor at the Georgetown University McCourt School of Public Policy’s Center for Children and Families.