improving mental health care for children.

the senate finance committee holds the hearing. live coverage on c-span 3. >> the beginning of treatment is actually 11 years. those are in the surgeon general's words 11 long, confusing, isolating and painful years. this obviously is a number worth a thousand words. and more than anything it says that america's approach to mental health care is way out of whack. it starts failing america's young people early on. so several priorities for today. let's focus on how mental health care for young people starts

much earlier. earlier screenings, earlier interventions, earlier discussions with primary care doctors. there's also a need to step up mental health efforts in schools and in our communities. those are also places where trained professionals can get the symptoms right from the outset and refer young people the skilled practitioners when necessary. at present we have called again and again the school counsellors are overwhelmed. community-based programs are too few, and referrals are inconsistent. mental health care doesn't simply start rl enough and it's not reaching young people.

second, our country must have better crisis care. the 11-year treatment gap is a sign that young people are struggling, going without the treatment they need and heading on a path to crisis. in addition, america's mental health system too often fails the young when they are in crisis as well. the evidence shows there's a shocking increase among young people. suicide attempts among young teen girls resulting in hospitalizations recently jumped more than 50%. far too many of these young people in distress are spending days or even weeks boarded in emergency departments for the bulk of the time they are probably alone. imagine colleagues feeling a sense of extreme isolation,

clashing with chaos and commotion of the emergency department buzzing outside your door. just yesterday i spoke with the group of health care practitioners who told me they were concerned in many of these crisis situations, young people who end up in the hospital emergency rooms aren't even seeing practitioners with those who have training in mental health. emergency room is no place for a child in crisis to spend day after day, but it's all too common. young people simply deserve better. third and finally, solving these problems is going to require creativity from the public and the private sector. the children's health insurance program and medicaid, which is the largest simple payer of mental health care for young people can play a key role in sparking new solutions. these efforts will be essential

to make sure that mental health is treated with the same consistency and focus given to physical health. the bottom line is no more mental health business as usual. because business as usual is failing too many young people at every single point. from the first sign of symptoms to the most critical moments of crisis. that's a lot for the committee to discuss today. we're going to have a great panel that i'm going to introduce shortly. s i want to thank senators carper and cassidy, and i also want to commend senator stabenow for her years and years of work on behavioral health issues that are so important. now we'll turn to senator krai poe and then we'll have introductions and where is my friend? there he is.

>> thank you, mr. chairman. and thank you to our witnesses for joining us today as we discuss ways to respond to mental health challenges impacting children anded a let acceptabilities across the country. according to recent reports from the cdc, the number of young people dealing with depression, anxiety and suicidal thoughts has unfortunately risen during the pandemic. as social isolation has taken its toll on far too many children and adolescents. although it appears the pandemic is subsiding and our return to normalcy may be be eminent, we cannot ignore the lasting events of the last two years on the social and emotional well being of children. we should do all we can to increase access to mental health services and reduce the causes of delayed treatment. while mental health issues affect people of all ages, children's needs are often

different from those of adults. necessitating carefully tailored solutions. as this committee works in a bipartisan way to advance the conversation on medicine tall health, we must not only identify the complexity and scope of the problems at hand, but also explore innovative, sustainable and concrete policy solutions. i'll look forward to working with my colleagues on both sides of the aisle to develop meaningful measures to combat these challenges including by expanding access to telehealth service, supporting our workforce and better integrating physical and mental health care services. children can and often do benefit from services dlifred by it'll health. wile we often focus our discussions on medicare, this committee should also prioritize clarifying and expanding care

delivery options for children covered by medicaid regardless of geographic location. additionally, we should work to maintain a strong mental health workforce with the capacity to care for all who need services. these will prove crucial as health care professionals burn out. and other strains jeopardize long-term provider retention and capacity. we have clear opportunities for improvement at every level. i regularly hear from front line providers as well as state policymakers, seeking the flexibility to innovate and craft targeted local solutions to the challenges facing their communities. their ideas and input will play a critical role in this process. especially as we look to bridge gaps in care, better integrate physical and behavioral health services and promote value-payment models that put patients first.

a structured effectively, these reforms could prove game-changing populations of all ages, including young people. finally, no conversation on mental health care reforms for children and young adults would be complete without uninput from those whom the policies intend to empower and support. to that end, thank you for your willingness to join us today to share your perspective. we have the opportunity to better support children, their families and their providers by enhancing mental health outcomes across the united states. moreover we can and must do so while honoring this committee's strong tradition of member-driven, bipartisan and fiscally responsible legislative solutions. thank you to our witnesses for agreeing to share their expertise from across the continuum of care. they have provided invaluable service during these

unprecedented times and i look forward to hearing their testimony. thank you. >> senator, thank you for a very helpful opening statement. we're going to do this in a bipartisan way. there's an awful lot of common ground here, and i especially appreciative that you zeroed in held health because the finance compete is proud of the telehealth contribution we made at the beginning of the pandemic during those early days, the services headed by was trying to figure out how to proceed and to a great extent, they took the telehealth provisions of the chronic care law that was written in a bipartisan way in our committee. so i appreciate your zeroing in on telehealth issues and we are certainly going to build on them in our work this year.

and also thank you for giving a little bit of a sendoff as we move to troogss to trace because he is one of our own. a student from dpon, a mental health leader anded a go vat in his community. he's volunteered with youth line, a peer to peer crisis service based in our state that receives 27,000 contacts each year from young people across the country. youth line is provided by lines for life, a nonprofit dedicated to suicide prevention and mental health support and oregon's home for the national suicide prevention lifeline. yopd looun youth line, he has advocated for youth mental health through a number of other organizations including the national mental health advisory board supported by well being and active lines. a high school senior because i'm on the intelligence committee,

people sometimes tell me important little items a about our guests and i recently learned that he has been accepted to johns hpkins university. and we a all want to extend a congratulations for that great achievement. with that i'm going to turn it over to my colleagues to introduce witnessed that they have worked with and are proud of. senator casey will introduce dr. benton from the children's hospital of philadelphia. dr.en will introduce from new hampshire and then senator carr don will introduce dr. hoover from the maryland school of medicine national center for mental health. and then we will hear their testimony. senator casey? >> mr. chairman, thank you for this opportunity. i'm pleased to introduce dr. benton, and i appreciate dr. benton's expertise at this

hearing today. in addition to her lifelong commitment to serving both children and families, dr. benton is a psychiatrist in chief, an executive director and chair of the department of child and adolescent psychiatry and behavioral sciences. she's clinical director of child and adolescent psychiatry and a psychiatrist in the 22 q and u center at the children's hospital of philadelphia, which we often refer to by the acronym. she also serves as president of the american academy of child and adolescent psychiatry and an associate professor of industry at the maryland school of medicine at the university of pennsylvania. dr. benton also serves on the board of the juvenile law center, which a advocates for children and child welfare and the juvenile justice systems.

her expertise spans pediatric depression, suicide and anxiety, particularly for minority youth and those with chronic diseases. so dr. benton, thank you for being with us today. and thank you for all you have done to support families long before and throughout this pandemic. i look forward to your insights today. >> we look forward to hearing from dr. benton. senator hasten is here. >> thank you so much, chairman. for holding today's hearing on protecting youth mental health. it is essentialen we get our children the support and resources they need. i would like to welcome someone to serve as an expert for

today's hearing. jodi is the vice president for clinical operations, youth and family services at the mental health center in portssmith, new hampshire. she has a master of arts and is a licensed clinical mental health counsellor. at the community mental health center where she works, she oversees the treatment services for children and their families. these services include psychiatry, community-based behavioral supports, targeted case management, substance use disorder treatment, 24/7 cisis intervention and post intervention services to schools and communities affected by suicide and loss. to say she is at the front lines of some of the toughest battles our children face, would be an understatement. in her role as vice president and mental health counsellor, she provides support to young people who are experiencing mental health challenges.

and she has seen firsthand how the pandemic and a shortage of mental health services has increased the number of patients in her center. in fiscal year '20, the youth and family services team at seacoast mental health srnlt provided more than 33,000 services. in fiscal year '21 alone, it provided more than 41,000 services to children and families, a 25% increase. the number of patients seen was almost 13% higher than in the previous year. in response to the wave of children and young adults, she has worked on innovative programs in new hampshire that have been integrated into places like our school asks our summer camps. given her extensive experience and expertise, she will be a able to speak about the challenges facing our children, the critical programs that she has helped to develop and the persistent barriers that limit access to mental health care.

jodi, thank you for being here and for your work on behalf of new hampshire's children and families. i look forward to hearing from you today. thank you. >> and thank you for all your help for this hearing and for making sure we could have her and we're working forward to working closely with you every step of the way. senator karden is here. >> thank you, mr. chairman. lelt me thank the senators for their leadership on this issue and so many others bring us together to deal with a critical problem. congratulations on your accept stance. she is a licenseed clinical psychologist and professor at university of maryland school of

medicine division of child and adolescent psychiatry. she's also director for school and mental health and director of the center for safe support i have schools within the national traumatic stress network. dr. hoover has lead and collaborated on multiple grants and co-leading two large randomized trials of school mental health efforts. since 2004, she has worked with the national traumatic stress network, treatment services adaptation center, trains school district and school leaders and educators and supports staff in a multitiered system of support for psychological trauma. dr. hoover is a certified national trainer for the cognitive behavioral intervention for trauma in schools program and the support for students exposed to trauma program. last year she was kind enough to

join the event i hosted concerning youth and covid-19, and i know that dr. hoover's input was extremely helpful to my constituents, and i know she will add to our discussion today. >> thank you, senator cardin, and for your years of advocacy in the area of health care for vulnerable folks in maryland and our country. so thank you, all. mr. tar relate, we're glad to have your voice coming from lapine and please proceed. >> thank you, chairman, ranking member and the other members of the committee for the opportunity to represent the perspective as it pertains to mental health. i'm a 1-year-old from oregon. before i share more about myself, i would like to tell you some things i have heard from teens across the country. 407, i just need someone to talk

to. 4:37 p.m., my dad hit me, but you can't call the cops. 5:23 p.m., i need therapy, put my family can't afford it. 8:07 p.m. i just lost my dad, and i can't stop crying. 6:42 p.m., i want to kill myself. these are just some examples of the many conversations that i respond to as a volunteer. a free confidential teen to teen crisis help online located in oregon. whether helping someone navigate complicated feelings about their sexuality orring with others to develop safety plans, i spend three and a half hours every week responding to a variety of mental health challenges experienced by teens across the country. with an emphasis on the fact no problem is ever too big or too small. i became involved during my freshman year of high school. as someone who struggled with depression, eating disorder behavior and anxiety throughout middle and early high school, i, for the longest time, believed

that no one could troelt my experiences. however, as i became more involved, i realized my challenges were a microkozment of issues that affected hundreds of thousands of teens across the country. as more and more teens start to have conversations about mental health and engage in help-seeking behaviors, the expansion has never been so needed. so what can we do to address the youth mental health crisis? we must centralize our efforts in schools. from my experience and many of my peers, schools are lacking. day after day, i hear my friends due to being overworked and overloaded. this is a difficult challenge for the many teens who rely on professionals for crisis. we have to address the staffing crisis. we must also create a streamlined approach. my school 4 of 5 every girls are not carried out.

80% of referrals go nowhere. last, we need a comprehensive and standardized mental health curriculum. all students to learn about engaging behaviors, developing systems of self-care because statistics show we turn to each other before anyone else. two, we need to address the pressing challenges that young people continue to face about mental health care. while no policy solutions, i am someone with lived experience. i know what it's like to be a teen today struggling with mental health. i know what it's like to offer support. the most common in regards to accessing mental health care are financial broadband barriers. and the stigma around mental health. these issues are incredibly real. my friends have struggled to receive mental health services because it's too expensive for

their families, too far away or inaccessible with internet access. we need to bring care to where people are. and for teens, that's in schools or at home. in addition, we know that the lack of mental health professionals in the united states prevents teens from receiving the help they need. it's by funding a national line. youth need to call in and have the opportunity to be connected with another trained team. we must invite youth to the table. i am just 1 of 165 youth volunteers. fpz what did us this tangherlini you? youth respect afraid to talk about mental health. if anything, adults are. across the country, young people are mobilized for mental health like never before. i have been involved with the organizations for whom i and millions of my peers hope to change the narrative for how we

take care of our mental health. we believe we deserve a seat at the table. it starts by entering the meaningful contribute to and be involved with legislative work on the local, state and federal level. if there's anything i want to leave you with today, it's this. teens are talking. and we need you to listen. we foe the work we do makes a difference in the lives of young people across the country. and we know that because of what we hear from teens after. after we have connected them to help, after we talked self-care and helped them find a path forward. i feel so much better talking. 8:34 p.m. if it wornt for this conversation, i wouldn't be here today. thank you. >> thank you for getting us off to such a powerful start. and what i want you to know you said that young people were mobilizing. those are very welcome words.

we're going to see the democrats and republicans in the united states senate, the finance committee are going to start mobilizing to move real reform and make no mistake about it. you and young people are going to have a seat at that table when we're working on these reforms. so thanks for getting us off to such a strong and powerful start. dr. benton, let's see where you are. >> thank you, chairman. ranking member and members of the committee, thank you for this opportunity to testify. i wish there were no need for me to appear today, but children are experiencing mental distress

at higher rates and with more dire consequences than ever before. in the first half of 2021 alone, we reported cases of behavior and suicide in children ages 5 to 17 and 45% higher rates during the same period in 2019. and for children under 13, the suicide rates for black children have increased twice the rate for white children. the pandemic has highlighted and worsened disparities. there are barriers to access, underrecognition and undertreatment of mental health disorders. the burden of illnesses worsen for children of color who often have greater exposure to environmental traumas. it's also true that children with mental health challenges are overrepresented in the juvenile justice and child welfare system where higher rates of mental health disorders are often unrecognized. you have heard many of these statistics before, but i like to

share with you how these situations show up in my day-to-day life as a physician. a 5-year-old in the emergency department who disclosed suicidal feelings and plans to run into traffic in reaction to her parent's job loss, financial stresses and her mother's depression. a 6-year-old boy suspended from first grade for kicking a desk after witnessing a shooting 20 feet away while walking home from school. too terriied to disclose the experience for fear he would be the next victim. a 16-year-old honor student becoming depressed after a romantic break up making a serious suicide attempt while waiting six weeks and hospitalized for two weeks in the medical facility where he waited for in-patient care. and when it was available, financial barriers interviewed with a smooth transition. it's situations like these that led the american academy of industry, the american academy and the children's hospitals

sorks to sound the alarm for kids and to declare a national emergency for mental health. but there are things that we know. children and adolescents recover best when care is targeted to their needs, evidence-based, no more restrictive than it must be for safety and close to home. and while i can speak more directly to the shortage of child psychiatrists, there are also severe shortages of mental health providers, which all must be addressed. these shortages lead to increased emergency visits for things that are preventable. a at my home institution in philadelphia, we have 20 to 30 patients awaiting acute care and this is true on any given day. we typically operate at full capacity, so occupied beds for children with complex medical needs receiving care i remain optimistic. effective strategies exist for

preventing and treating mental and behavioral conditions while supporting the natural resilience of children and families. but success will require response to two urgent tasks pfr us. first, addressing the immediate crisis we are facing right now. and second reframing our mental health system with a goal of preventing disrupted development and facilitating a successful transition to adulthood. expansion of the workforce will take time. even if we start today. i'll focus on immediate options to address the crisis. one of the best things we can do is to support those on the front lines now by providing them with effective training. should extend beyond primary care. caregivers and educators can be empowered to better manage the situations they face. and we must act now to pivot mental health services from care to prevention and make sure that needed the treatments are available where families are likely to be such as

pediatricians offices, day care, after-school programs. the pandemic has also taught us important lessons. telehealth has been an important tool for providing care across state lines and underserved areas, rural areas, local and distant communities and for working families. it has had therapeutic advantages such as seeing the whole family and seeing them in their natural environment. this tool must continue as to our current continuum of treatment. i can cannot conclude that both coverage of the range of services kids need and the appropriate reimbursement for these services are essential. the continuum of services need for children from mental health are absent at every level. children need to get the right treatment at the right time at the right place. and finally, i want to end by sharing an experience that reflects my hope for the future. just last week i interviewed two fifth graders. they asked me, when can normal

feelings like depression become bad for you? these are questions all americans should be asking at this time and able to answer. i want to thank you for allowing me to provide this testimony. i'm confident you'll take this opportunity to support our children through the crisis. thank you. >> thank you very much. i noted you talked about access to coverage and reimbursement. that will be intertwined with some of these big insurance companies not following through on parenting, which is so essential for mental health patients. so you gave us a lot of valuable input, and we look forward to working with you. now we go to jodi. >> good morning, chairman, ranking member, and members of the committee on finance. i want to thank you for the

opportunity to testify today as a witness regarding pediatric medicine tall health. i'm humble and grateful for this opportunity. i serve as the vice president of clinical operations for youth and family services. we are one of ten centers in the state of new hampshire. i'm also a licensed clinical mental health counsellor still actively seeing patients, a youth swim coach and a parent. in march of 2020, life for all of us changed as we once knew it. we made many quick pivots to respond and daft to the covid-19 pandemic. as we made many adaptations in our personal and pfl lives, we had our past experiences to reflect upon. we faced the challenges, we pulled from our tool box of coping strategies. we knew who we could turn to for the extra support we might have needed. but for most of the youth in our country, they were left feeling paralyzed, hopeless and scared.

for many youth, this was their first experience with grief, trauma, depression or anxiety. life for them had completely changed and their worlds were turned side down. the uncertainty and stressors have left many kids unable to cope or understand the depth of this experience. and for some, there is no trusted adult to support them during this critical period and their only means of relief is contemplating death. we're learning teenage girls have begun to demonstrate an increase in their symptom presentation. data from the centers for disease control indicates a 51% increase in suicide rates by teenage girls age 12 to 1. lgbtq youth continue to have higher rates of suicide than their heterosexual peers. the percentage of emergency department visits for mental health emergencies rose by 24% for children between the ages of 5 and 11 and 31% for those ages

12 to 17 compared to 2019. youth mental health has become the secondary pandemic to covid. as mental health needs rose for pediatric patients, the availability of servicesen continues to become more scarce. youth are presenting in emergency rooms in a state of crisis. many who are assessed and meet the criteria for psychiatric care will be faced with boarding in an emergency room for days, weeks and sometimes months before a bed becomes available. emergency room boarding often crete creates stress and increased exoat sure while receiving no mental health care until the bed becomes available. staffing shortages and both outpatient and inpatient settings due to an exhausted, depleted and underpaid workforce has only prolonged access to care for pediatric parents. without funding and reimbursement structures from medicaid, mental health providers are left with the

difficult decision to leave the nonprofit world and enter a for profit world to make a livable wage. during the pandemic, there were 2 or 3% increases to medicaid rates. prior to those increase, there had not been meaningful increases in over 20 years. without a realistic structure based on the cost of living, centers are losing staff who can noer afford to work in mental health centers. they are recording a 40% rolling 12-month turnover rate in staffing during the pandemic leaving no workforce available to attend to the critical and fragile needs of pediatric patients. the workforce are left supporting higher case loads with limited time while attending to administrative tasks that private mental health providers are not expected to complete. the community hen tall health workforce treat some of the complex cases the complexity of cases, severity of needs and

demands placed upon this workforce during the pandemic have left many professionals questioning their longevity in the mental health field. a field many entered with an good spirit now left broken and tired. ideal care settings, none of this can be provided without a robust, well-trained and sustainable mental health workforce from all professional disciplines and degree levels. simply put, we need to be able to reimburse mental health providers to compensate the mental health work tors. adequate reimbursement will sustain a workforce to provide high quality care to our pediatric population. i thank you for your time today. >> thank you very much. you finished so powerfully with the workforce. i just wanted to come back for a moment and say thank you for mentioning at the outset that in

those first days of the pandemic, you reached for requester mental health tool box pause that's really what this is all about. it's about making sure practitioners, not somebody micromanaging in washington, d.c., can have an adequate array of tools. as you know so well from your outstanding work, too often the tool box is pretty barren in much of the country and that's what dr. murphy told us. i know you're going to get some questions in a moment. dr. hoover next please. >> thank you. thank you for the invitation to speak with the committee today and for your leadership on the issue of mental health in our nation including the impact on youth. thank you to the ranking member and to all of the committee members for your vision to improve the well being of our young people and for the opportunity to be with you here today to talk about these important issues.

i'm speaking to you from my perspective as codirector of the national center for school mental health, which is funded by the u.s. department of health and human services. and as a professor of psychiatry. but i also speak to you through my lens as a parent to three teenagers, all of whom had their learning land skap altered during covid with almost a year of virtual education. they along with most children had significant disruption to their learning and to their well being. i'm fortunate my kwids kids are going to school and doing well, but we know many are suffering. even before the pandemic, youth mental health challenges were rising with suicide being the second loading cause of death for young people ages 10 to 24. as noted by the surgeon general during last week's hearing, one of the most central tenants in creating accessible equitable systems is to meet people where they are. for most this is in schools. i often think back to a story

that my dad told me about his first day of school. he grew up in a rural town in west texas. and on that first day, he recalled that his peers and he received toothbrushes from his first grade teacher. it was the first toothbrush he had ever owned. i remember asking him, you didn't have toothbrushes, to which he replied no. my family wouldn't have spent the money on toothbrushes back then. my dad went on too a long career in computer science and helped create coding to put astronauts on the moon, but he credits those teachers who cared about him with setting him on that path. when i consider that moment when he had received his first toothbrush on that first day of school, think of it really as a classic example of how our schools are a vital place to promote our children's health and well being. we simply can't rely on our

health care system alone to support the mental health and well being of our young people. we know on average that people don't get into a care for over a decade after the onset of symptoms and illnesses begin in the school-aged years. our traditional approach has not leveraged the natural venues where our young people access support. it's really akin to waiting for tooth aches until a child gets proper dental care. with should do the equivalent of passing out toothbrushes and providing care by offering every child in every school the social, emotional, behavioral, and mental health supports they need to be successful. increasingly, schools have comprehensive mental health systems that reflect partnerships to support a full continuum of mental health and substance use services and promotes. when treatment is delivered, youth are more likely to be identified early and to initiate and complete care.

schools that have systems in place and positive mental health promotes academic and life success. there are many policy and funding opportunities, including strengthening medicaid programs that can help advance a continuum of mental health and supports. congress has the opportunity to support investment and technical assistance to assure that young people can get the mental health support they need. in my written testimony, i provide detail on several steps that federal and state leaders can take to advance comprehensive mental health systems. we have witnessed many states adopt new policies to advance mental health. tomorrow the hopeful futures campaign committed to ensuring that every student has access to effective and supportive school mental health care is releasing the first ever mental health report card and action center with individual report cards for all 50 states in d.c. and these report cards highlight

accomplishments and provide important action steps to help address the children's mental health crisis in every state. they can serve as a great starting point for policymakers who want to strengthen mental health supports and policies in their communities and you can find the report cards starting tomorrow morning. today americans acontracts the country are united and are concerned about the mental health of our young people and its impact throughout lives. i want to express my gratitude for opening up this discussion on youth mental health, for recognizing schools a an essential place to strengthen our well being and for committing to investing now to create hopeful futures for our nation's youth. >> thank you very much. and we're going to get you into this discussion in just a minute. trace, you really make all of us in oregon so proud and you said it so well.

i want to get into an area hadn't heard about from you. that is how serious this problem is of young people getting lost in the system. where they just don't get connected and the figure you used is 80% of referrals from schools for mental health support just go nowhere. they just get lost. how does this make students and young people feel when they just get lost in all of this red tape and bureaucracy? >> that's a great question. i want to clarify that that was from my school, so i don't know the national figure, but i imagine there's similar trends across the country. >> that was for your school? >> yes. i think right when we talk about

access to care, there has to be a conversation about what happens next. what happens next. who is going to provide the care? and i think for a lot of teens who get to this point and initially have that first conversation, not being able to get those accesses afterwards is incredibly isolating and incredibly defeating and really highlights some of the failures of our mental health care system and things that need to be addressed. teens who need help should receive help. and that help should be meaningful and sustainable for as long as they need it. >> sit tight. dr. hoover, that 80% bigger is really show stopping. my sense is we're just losing a lot of young people at a really crucial time. what can be done about that? >> totally agree. i would agree that it's probably not just in his school. we're seeing these figures

across the nation. so the bottom line is that getting care to kids in some of our traditional outpatient settings really is a challenge. as you heard earier, one of the first lines of action really is to bring services to where young people are in their schools. we know that every state and many districts within each state have examples of really effective school-based men health care. this includes expanding our workforce including our psychologists and counsellors, but also helping facilitate partnerships with community behavioral health organizations to bring their services into schools. school-based health centers are an ideal model of this type of care. so increasing support for school-based health centers is one ae avenue. we mentioned telehealth. it offers incredible opportunity to expand reach of specialists. not just into rural settings, but also to the urban settings. we have been providing telehealth from our hospitals to baltimore for a number of years

now. we heard from reasonable reimbursement that is a critical way of getting services to schools and to outpatient care and having providers there to receive students when they are referred. when they are referre. so those are some of the avenues. >> well, thank you both. and, trace, if ever there was an area, as you said, for the committee to work with young people, it's mobilizing in your words, to make sure that we don't see as many of these referrals get lost in the system. it's just too important because those are young people who are getting lost. i want to ask you one other question, trace, and that is you and i talked about barriers to care. and clearly still stigma with mental health challenges is a big part of this. i saw this with my brother who struggled with schizophrenia for

years as i went off and played basketball and all kinds of things like that. and my concern is i keep hearing from people in the schools and students like yourself that the stigma has clearly gotten worse as a result of the pandemic causing more young people to be isolated from each other. that there wasn't enough peer-to-peer contact and the like. can you give us your thoughts on that? >> of course, yeah. i think we definitely saw how the pandemic increased rates of loneliness, isolation, and other high acuity mental health struggles. the most important takeaway and our response to the mental health care crisis is the fact covid-19 exacerbated disparities that were already there. we know access to care was limited before covid-19, and the pandemic only amplified those

barriers. so if a teen's only way of receiving mental health support was with a school counselor, that relationship was no longer there and they could no longer have that conversation about mental health, right? that, in and of itself, is destigmatizing the stigma around mental health f. a teen feels like the only way they can express their emotions is through the barrel of a gun, what have we become as a society and our perception of mental health as young people? and we really need to talk about mental health. i think that first starts with having this conversation and recognizing how covid exacerbated already existing disparities. >> trace, we had high expectations for you this morning, and you went way over the bar. so thank you so much. and you're going to have a seat at the table as we go forward on these big issues, and thank you. senator crapo is next. >> thank you very much, senator wyden. and i agree, trace, with senator wyden's comments. i'm going to let you off the hot seat for a minute, though, and

go back to dr. hoover and then to some of our other witnesses. dr. hoover, for idaho and other states with large rural communities, the mental health care delivery system looks substantially different from other urban or suburban populations. even though the need for mental health services is similar between rural and urban areas, it's harder for children in rural areas to access those same mental health services. in your work with the state, can you elaborate on some of the specific risks and challenges that younger americans living in rural areas might confront with regard to mental health? and i ask this question in the context of already you've indicated our schools, many of them, have good programs in place and they are working well, need to be strengthened and enhanced and given more tools. but focus that a little bit on rural areas. how are we doing there, and what role do schools play in providing mental health services to our youth? >> thank you, senator crapo, for

the question. frankly, school mental health is perhaps even more relevant and important in our more rural communities just because of the workforce shortage and also some of the stigma issues trace just spoke to. we know that in rural communities our young people and families often have a harder time accessing services, as you mentioned, and there often is more of a stigma associated with seeking out mental health support. we hear often -- i was just working with some rural counties in maryland, and we often hear everybody knows each other. so seeking mental health supports can be even more risky from a student perspective or even from a family perspective. that being said we know schools can be a place where mental health can be destigmatized. it is one step i would say is critical in rural communities and in all communities is to really make mental health part of the education our young people experience. we can establish mental health as part of the k-12 curriculum.

a number of states are doing that. i know new york, florida, virginia have led the way to infuse mental health as part of what young people learn about. they learn about how to achieve positive mental health, how to recognize if there are some problems and how to seek support when they actually need support for themselves or for a family member or a peer. so part of it, again, is reducing stigma and it's particularly critical in our rural settings. i would say in terms of the workforce we know we have to get workforce into our rural communities. and some of that will require kind of reaching down into our high school and certainly our undergraduate training environments. i worked with some groups in nebraska who have done an excellent job of really fostering the high school interest in mental health specialties as they come into undergraduate and graduate training. but, also, really working with other providers in schools including our school nurses and other health providers and even our frontline educators to do some task shifting, right, to adopt some of the skills they can equip young people with.

we don't have to. we simply can't rely exclusively on our specialty mental health providers when we don't have enough. those are some of the solutions, and i look forward to working with you on that. >> thank you very much. and let me move next to ms. lubarsky. i'm not going to have time to get to all the witnesses. i apologize. we have lots of questions and we'll give you some even after the hearing. ms. lubarsky, your experiences can provide a deeper understanding of the range of services provided across the continuum of mental health care. one of the most common concepts discussed in the stakeholder responses we've received is the need for increased coordination and case management to lead to better outcomes. in your role as a community mental health leader, can you explain exactly what targeted case management means in practice when you're caring for the kids and their families? >> yes. thank you, senator crapo, for your question. case management i view as a fundamental important service for every youth who is receiving clinical services at a mental

health center. when we think about the hierarchy of needs and that ability to meet your most basic needs in life, that is why we utilize case management with our pediatric patients and their families. if you can't feel food secure, housing stable, be able to access your education in a meaningful way and really be able to be socially connected to your community in a manner so when you're done with your mental health care you're moving to your supports in your community, then you're not going to be able to reach that final goal which may be your therapeutic goal coming in for mental health care. providers here at the center for every youth available for mental health services have the ability to receive targeted case management as well so we're doing that very nice balance between providing the clinical mental health care while also looking at their needs outside of mental health to make sure we're bringing those worlds together. >> thank you and i'll submit my questions for the record to the other witnesses i didn't get to. thank you to all of you for your testimony today. >> thank you, senator crapo.

as we said at the outset we're going to make this a bipartisan effort. this is one of the most important undertakeings the finance committee has been part of and we thank you for your leadership and, also, focused on bipartisanship, senator stabenow, who for years has worked relentlessly to improve behavioral health with our colleague senator blount is with us. senator stabenow? >> i want to say thank you to you and to senator crapo this is so important. spending not one hearing but multiple hearings on mental health is absolutely critical. and has not been done since i've been in the senate. i thank you for your leadership and this is an area of bipartisanship we've begun a process of changing to address health care above the neck the same way we address health care below the neck and the funding

and so on, that we have models that work now. we just have to move forward and get it done, and there's a lot more to do. and i want to also just give a shout out to trace. thank you so much. thank you for coming forward and sharing your experience and for now being a part of really making a difference in young people's lives and a part of overcoming the stigma is all of us just telling our own story, the story of someone in our own family so that we're treating anxiety or mental illness the same way we would if somebody was a diabetic or had a broken leg, a broken arm. it's just part of health care. we're going to work together and get there. by the way, i also wanted to say, trace, in your written testimony i appreciate you mentioning both our school-based health clinics that i think are the model for us in the school

setting and our certified behavioral health clinics that are the model for quality, comprehensive care in the community now that's fully funded where professionals are fully funded so that we can move forward. dr. benton, i wanted to ask you particularly around that point because i appreciate all of our witnesses and their wonderful testimony, but our community behavioral health clinics that we now have demonstrated in ten states fully funding what can happen if we are funding behavioral health like our fqhcs, our community health centers with high standards, full funding as health care. we're seeing now the difference that can make, and we're working hard to have this be the structure across the country really.

which i believe can transform the services we're talking about. the ccbhcs as we call them make help available where children are and we nearly have about 25% so far of the community services being given to children and there's a lot more we can do. i wonder if you might speak a little bit more. i know you discussed this in your testimony. highlight the importance of these comprehensive community clinics particularly on underserved communities. >> thank you so much, senator stabenow, for that question. the community behavioral health clinics are key components of the mental health continuum, and a significant component of the problems we face this year related to those services being overwhelmed by the number of patients and limited numbers of providers.

it's vitally important to address equity for all children to have care in their communities where they are every day, successful to their families, culturally competent and introduced cultural humility. academic centers like the children's hospitals we partner very strongly with the community centers to expand access. and so we should be able to provide and fill in the gaps where they exist in those clinics. so, for example, because the reimbursement isn't always what it should be. they tend to run with the lower number of high cost providers and it's our responsibility in centers where there are more resources to be able to provide that support to the communities. but without a strong partnership, we'll never be able to successfully address the concerns of young people in our country. >> absolutely. i totally agree. we can do this. we have done this on physical health. we absolutely can do this.

i know my time is running out. time is too short. i have many questions i will submit. i did want to also indicate i'm excited to be leading the committee's working group on workforce issues which each of you have raised and so critically important and working with senator danes, my colleague, on this and we'll be reaching out to each of you to ask for your further input. so thank you, mr. chairman. >> thank you, senator stabenow. i was about to mention the good work we know you are already beginning with senator danes. so our guests have an understanding of how we're going to work, we have got a democrat and a republican serving on each of the key areas that we have to tackle, and because senator stabenow's expertise in this area and her advocacy is so important, i think we're especially lucky to have her handling the workforce issue which i think we've heard people

mention repeatedly. we thank her for all her leadership. senator grassley is next and we welcome him. >> thank you, mr. chairman, i will lead into questions with dr. benton. the dea issued its first public safety alert since 2015. it warned of a significant nationwide surge in counterfeit pills that are mass produced by criminals in labs, deceptively marketed as prescription drugs. these counterfeit pills are killing unsuspecting americans, particularly young people. an unprecedented rate. many are getting illicit pills knowingly or unknowingly through snapchat or tiktok. this use of illicit drugs is

driven by mental health challenges, anxiety, suicide thoughts and resulting in accidental overdose deaths. so do you believe kids dying of suicide or accidental drug overdose is driven by mental health challenges? >> thank you for that question, senator grassley. it is a complicated one. definitely there are increases in rates of mental health that contribute to suicide. mental health conditions are not the only factors that contribute to completed suicide, one of the reasons it's been so difficult to prevent. other things you just identified, exposure on the internet, all kinds of unregulated advertisements for young people all contribute to those challenges. i also want to call out

something else you've highlighted with your question, the focus on medications and pill treatment for young people with mental health conditions discounts the fact most young people need social psycho interventions. psycho social factors that we need to consider when thinking about treatment not just emphasizing treatments available i think would diminish some of the focus on young people obtaining medications. >> we'll go on to another subject, dr. benton. in your written testimony you mentioned the importance of patient-centered medical homes for kids who have access. we passed an act that focussed in pediatric home health for kids with complex medical

conditions. last fall the centers for medicare services issued guidance for a.c.e. kids and is working in the same way. for you, dr. benton, is access to out-of-state providers a challenge for kids with complex medical needs? and let me follow it up with what might be my last question for kids with these needs what does coordinated mental and physical health care look like and describe the medical home? >> thank you, senator grassley, for your leadership. the patients in a medical home has provided significant support for young people can complex medical conditions. we still have work to do in the area of integrating the medical and mental health benefits and treatments and so the patients in a medical home we do better

at providing support but we still face challenges around mental health and medical services. so within our own institutions when young people come to us locally or from judd of state it is easily acceptable. they frikly find themselves in a situation they are being billed for a service out of network or they're not paid at all. it poses challenges for people who need the care. we've made significant progress and i look forward to your continued work in leading us through these co-morbid conditions. we still have more work to do. >> for mr. terrell, you'll have to give a short answer because my time is up, but what effort should be taken to address rural

mental health needs? >> like i said, access to care is super important, and i really appreciate the question because i think youth have so much stewardship about the issue. if we can really bring -- personal i live in a rural community, if we could bring care to where people are. school based health centers and other community-based mental health supports that help teens get the support they need. it's easier to be on a school campus and get medical services than it is to be at home, have to coordinate transportation and get there, which is a barrier so many teens in rural communities face. >> thank you. thank you, mr. chairman. i'll submit questions in writing. >> very good. senator cantwell is next. are you online?

let's give this just a quick moment because i think she is. senator thune would be after senator cantwell. senator menendez. senator portman. senator carper. and for our guests, you should know that this is a particularly hectic day in the senate, so members will be coming in and out. senator carper? senator cassidy is here. senator cassidy, a very valued member with his expertise in health care as a physician. senator cassidy. >> thank you very much for that. by the way, i thought i had 15 or 20 more minutes to listen and everybody else is out. so anyway, thanks for going

there. dr. hoover, i used to work with school-based clinics to do hepatitis b immunizations. very aware of how well they can function bringing care. now, first, i think we have to acknowledge if the child is not in school it's difficult for the child to be evaluated. but that said -- but now kids are back in school so there's some progress there. let me ask, and you may have covered this while i was in another committee hearing meeting, my understanding is the schools and the school systems would benefit would cms give updated guidance as to the possibility of providing these services in that venue? any comments on that, dr. hoover? >> that's exactly right, senator cassidy. i appreciate the question. and you are correct that it is easier to get school-based care

to children when they are in schools. one of the things we are hoping congress to support is to modernize the existing school guidance in school. this guidance has not been updated since 2003 and it's critical for states and education and state medicaid agencies to work together to actually be able to support and resource mental health providers -- >> now let me ask you, i have limited time, what is the problem with the current guidance or lack thereof that limits the ability to expand mental health services through the school clinic? >> so just quickly, a lot of states don't want to move forward with implementing the current medicaid-supported mental health services in schools. they're worried, hesitant expanding programs may put them at audit risk.

it's not updated to reflect the policy reversal in 2019. there are a lot of updates that would need to be reflected in this guidance for states to move forward. >> you mentioned telemental health. i'm really struck. if you look at adolescent psychiatrist this is my state, they're in the cities. they're not in the rural area so, one, expanding services throughout the state is huge. you have to get the adolescent psych in shreveport to be able to communicate to the child who may be in another parish. you don't know my state but that's urban to rural. what is the rule to the utilization of that telemental health? >> so, as you know during covid we saw a huge expansion of telehealth and providers and families need guidance and technical support to use the telehealth equipment.

we need to see reimbursement and policies that support teleproviders to be able to not only provide services within their communities but even across state lines as necessary to adros some of the workforce shortages. >> if you gave advice to this committee -- because we have jurisdiction -- to urge cms to update these, is there any single point? you're talk to go wyden and crapo right now. they're the straws that stir the drink of medicaid and cms. if you had to sit down and pound your hand on the table, what would you say to our chair and ranking member we have to get this done before we move on? >> absolutely. i would say that congress should encourage all states to cover all medically necessary mental health services including prevention services for all medicaid enrolled students and simultaneously ensure school medicaid programs have guidance, best practice and technical assistance that they need.

>> ms. terrell, school-based clinics as regards to mental health? >> of course, yes. this is a great question because i think it's so relevant. when the teens are able to get care where they are, that just encourages behavior and promotes self-care and general health and well-being outcomes. i think the fact that teens are sometimes able to just walk over to a medical clinic and get the help they need is essential especially if they can't at home, if they don't have reliable internet access. it's really important to make sure we build these partnerships. >> in my experience with school-based clinics sometimes there are issues that should not be, for example, abuse by a parent, which can be discussed in safe setting with a licensed

health care provider and so it also, frankly, helps the business model of the school-based clinic. some states have a difficult time keeping their doors open. if they can provide a service that benefits. with that i yield back. >> senator cassidy and senator carper are going to be leaving the task force on young people so they're going to be invaluable on the issues we're dealing with. senator cantwell, senator thune and senator menendez and members have been coming in and out. senator cantwell is next in the order. >> thank you, mr. chairman, and continuing on that same theme of young people, ms. lubarsky, the general advisory on mental health, one in half of students had feelings of sadness and hopelessness during the covid pandemic. we already know what our challenges are.

the washington hospital association said major depression disorders are leading in the diagnosis in my state. so when it comes to seeking treatment, not everybody gets a fair shot at that. the numbers on individuals with lower income is that they're nearly 20% higher than the rates for those people with higher incomes. so affordability is a factor. i know my colleague, senator stabenow, had a chance to ask questions earlier, but i'm very supportive of her certified community behavioral health clinics. these have been great programs. there are five community clinics in my state that serve low-income populations, and this grant over the past two years has been used to enhance the care of those experiencing mental illness. we really are building capacity. clinics like comprehensive health care in yakima were used for innovative purposes creating a program to offer mental health

first training critical incident stress debriefings, and helping to receive support. do you think these programs such as the certified community behavioral clinics and their grants have been helpful in reducing the barriers for treatment of youth and families particularly in some of our less accessible areas in more rural parts of the united states? and should congress consider expanding these programs to address disparity and access, and what would you prioritize within that system? >> senator, thank you very much for your question. i am so pleased that you mentioned mental health first aid as a youth mental health first aid instructor it's a vital component of youth mental health. in regards to the ccbhcs and other health care facilities, i think they're one of many ways we reduce the barriers to accessing mental health care for pediatric population. there really is no one size fits

all for the right delivery model and so where some youth and their families are comfortable coming into an outpatient clinic because of the stigma that's often attached with mental health services, having the ability to access your mental health care at a community health center, at a pediatric office at your school setting or through a telehealth device is crucial to make sure that we have mental health care accessible to everybody. in our community it may be hard for some of our families who lack adequate transportation to get to our offices, yet one of our federally funded health care facilities is on a bus line, and so we've worked in partnership with that health care facility to have staff there. if that's the only means to get to the appointment families can still access their health care. i think it's critical. >> what about this issue of integrated health care, treating physical health in the same location, because most times people come with both issues or

things that exacerbate one or the other. like you said, there's less stigmatization and the treating of the whole person. >> it's critical. i think physical health and mental health braid together. when our mental health is not doing well we will see poor sleep, poor diet, isolating from others, not engaging in physical activities that can provide good mental wellness. >> well, thank you. is there anything you would prioritize in the improvements of that program if we had more dollars for the certified program? >> i think as i spoke in my verbal statement it's around the reimbursement rates. and we sustain the workforce to deliver the crucial care. >> thank you, mr. chairman. >> thank you, senator cantwell.

the northwest is going to be very united in this effort. i believe senator menendez will be next. senator menendez, are you out there on line? we may have lost senator menendez. senator menendez? senator portman is next then. >> thank you, mr. chairman. i appreciate it. i appreciate the testimony and the fact you are in the trenches every day doing great work with our young people. dr. hoover, you talked about telehealth. i want to be sure we are focused on the broader behavioral health and substance abuse. telehealth is one of the few silver lineings with regard to covid and with regard to substance abuse treatment there have been some real improvements. would you agree with that? >> i would. the opioid crisis has brought

attention and that has been exacerbated during covid. the funding provided by the federal government to states and communities to support the opioid crisis has been tremendous and an improvement in care. telemental health has improved that. >> that's why we have to continue the reimbursement under medicare/medicare for substance abuse at a time when we had 100,000 drug overdose deaths in the period from april this year to last year. in one year a record level, a 28.5% increase in overdose deaths. really hard breaking because we made great progress and now, unfortunately, we're seeing more and more people dying of overdose deaths. we have seen anywhere from an increase of three times higher the number of overdose deaths to 13 times higher compared to the

numbers from 2019. particularly concerning. ohio state has done a report and said how many years have been lost. their analysis is that beyond the numbers we already know the loss of years more than 21,000 young people they tested from overdoses show that adolescents and teenagers lost cumulatively 200,000 years of life. when they expand to include 10 to 24-year-olds proved to more than 1 million years lost. it's a shocking way to look at it but think of all that lost potential ruined. this is a huge reason that we need to figure out as a congress

how to get back on this issue and deadly fentanyl is killing, we think, two-thirds of these kids. synthetic opioids streaming across the border. we've done more in the prevention side and treatment and recovery side but obviously not enough. in ohio we've seen this deadly fentanyl is masked as other substances, like a pain or hdhd medication and we've had paurnts approach me to talk about the issue because they believe their son or daughter died by being deceived what was in a pill. dr. hoover, talk to us about that. what do you think the reason is in the jump of overdose deaths and how much do you think is attributable to these cartels putting fentanyl in other medications? >> i'll jump in quickly and defer to dr. benton on the

impact of drugs and the medical side of this but certainly in terms of the co-morbid mental health issues, substance abuse you shall use are very related to their increase in depression, anxiety and posttraumatic stress. not only increases prepandemic but exponential growth in the context of covid. so we know when that happens we see increases in substance use. it's not surprising when you get the tragic numbers. i will defer my time over to dr. benton -- >> you're talking about self-medication because of other behavioral and mental health challenges? >> that's a piece of it, absolutely, that self-medication to address anxiety, trauma and to really cope with the isolation and loneliness our children have experienced the last couple of years. >> dr. benton, can you talk about the issue of fentanyl getting into other medications?

>> what i can say is that we are seeing increases in utilization across the country. and, unfortunately, i have to say that in many mental health programs there's not the robust substance use and addiction programs we'd like to see and a focus of expansion of resources and treatment for young people needs to focus on increasing the integration of substance use and mental health treatment services. we know that for young people with any mental health condition the co-morbid use of substances only makes the outcomes worse and the substance use is associated with worse outcomes including suicide and other impulsive behaviors that land young people in bad situations. and so that has to be a phone cuss. right now they run almost as two separate systems in some ways. and that needs to be a focus of our efforts going forward if we're going to address the

substance related morbidities that we're seeing right now. >> okay. i think my time has expired. trace, i'd love to hear from you on this if you have a minute, mr. chairman, if trace has any thoughts. >> yeah, i would love to. thank you, senator. i think when we talk about all these statistics it's really alarming but i also think there is a beacon of hope. we've experienced an annual increase in contact volume of about 15% annually with an additional increase of 3% to 5% since the covid-19 pandemic. obviously while that proves there's a need for mental health care also so many teens are reaching out for help. i think that is really inspiring and shows the resilience of teens in regard to mental health challenges and substance use challenges. i think if we can really ensure the people reaching out for help are able to receive help, we will get really far on this issue. >> thank you. >> thank you, trace. next is senator menendez.

>> thank you, mr. chairman. across the congress we all talk about the provider shortages the nation is facing especially mental health providers that are available for black and latino communities and the pandemic has taken a disproportionate toll and the provider shortage has only grown more dire. more dedicated support for a larger and more diverse pediatric workforce is critical, i believe, to address children's mental health needs now and into the future. dr. benton, what are three things this committee can do to address the recruitment, training, retention and professional development of a diverse clinical and nonclinical workforce? >> thank you for that question, senator, and it's one of the issues i struggle with every day as a training director and as a physician. some of the things we could do now is developing pipelines at a

much younger age. so in my testimony i mentioned the fifth graders interviewing me about why did i become a child psychiatrist and i was pleased they were asking these questions in fifth grade. where we're present and reaching out to communities of color is really important. education and destigmatizing mental health conditions in the black and latino community by partnering with trusted community organizations, loan repayment is an incredible issue. many say i can't work for you because i have loans to repay and you don't pay enough. incentives for people to choose mental health that could be part of loan repayment would be really helpful. and then reaching into the communities where minority populations are would be

extremely important. so we tend to recruit from communities that are affiliated with academic centers. we don't reach into the communities where patients aly . those are things for diversification of our workforce. >> i appreciate those insights. and we may reach out to you to build upon them as we explore the initiatives here. and part of the reason i raise this, i look at the first half of 2021 alone, children's hospitals reported cases of self-injury and super side in ages 5 to 17 at a 45% higher rate than the same time frame. and for children under 13 the suicide rate is twice that for black children than for white children. what can we do to reduce the likelihood particularly in minorities and better target our

resources? >> thank you, senator menendez. this is one of my areas of passion. across ethnic groups the rates of suicide attempts are higher than among nonminority groups. and one of the challenges has been identification manage minority youth and access to service that is are culturally competent. the data demonstrates pretty strongly that culturally comported therapists and patients have better retention and treatment and better outcomes over time. and certainly it will never be the case that we will have one to one matching for patients by ethnic group nor am i sure that's the goal but the goal is for groups where there's not concordance between the patient and therapist there be cultural humidity, that we train

individuals to learn to inquire and understand the cultural experiences of others when we're engaged in treatment. and so the training opportunity is there but it is essential because we are seeing for youth across each ethnic group increasing rates of suicide while they are declining for nonminority populations. it's vitally important. >> and finally about roughly 17,000 3 and 4-year-olds are expelled from their preschools each year and despite black children making up only about 18% of the school population they make up 40% of all expelled children. and even more troubling is that within the high rate for black toddlers is how often black boys are expelled. basic behavioral health techniques to give these

important social and emotional regulation tools to children from their earliest ages? i'm happy to entertain anybody who can answer that. >> well, thank you, thank you, dr. menendez. i would hope dr. hoover would respond as well, prevention in education is key, addressing bias among school personnel is essential to address this. providing more resources and supports in centers where children appear every day, in daycare and in primary care with some preventive education around what's normal and abnormal development. i'm sorry, dr. hoover, i wanted to give you an opportunity to comment. >> i know time is short. i will add that investment in mental health programs is critical and as you alluded to culturally responsive teaching, this helps discipline referrals and expulsion. >> thank you all. >> thank you, senator menendez.

senator cardin is next. >> let me thank all of our witnesses. i think this panel has been extremely helpful. this is an area as you can tell by the questions you don't nope who are the democrats and republicans on the committee. we have a mutual desire to try to get this right and we recognize we have a real challenge in mental health in this country but particularly with the experiences of covid-19 we know we have a greater challenge than ever before. i want to talk about the school setting for one moment, what we can do. as one of the co-chairs of the group, the deal with telehealth, and i'm curious you've all talked about the importance of expanding telehealth but what are the challenges in the school setting of expanding telehealth services? where do we need to try to put our attention, policy or

resources to expand the school setting? either dr. hoover or whoever would like to respond to that. >> sure, i'm happy to jump in. thank you for your leadership on this issue of mental health across the nation and particularly in parity and mental health. telehealth has been in the schools for years. our child psychiatrists were delivering across schools in maryland and baltimore city when i was delivering services in the early 2000s. we know that there are continued infrastructure improvements necessary and that would include enhanced broad band, internet connectivity services to some of our rural communities. we know that policy expansion is important including reimbursement and expanded access to medicaid and

children's health insurance and telehealth. there are areas we've seen improvements in that we need to continue and to expand. and that applies to schools as well. >> we've made a lot of resources available to school systems in response to covid. have they been used to expand the connectivity you're talking about for mental health services? >> some have. again, happy to defer to dr. benton as well. some have. one of the things some of the covid relief funding is creating one and done or some hiring -- short-term hiring fixes, but we know it's critical to make some of these policy adjustments for other mental health services. dr. benton? >> i would concur with dr. hoover. i think many of the systems have used resources well but many were understaffed before the pandemic.

they've reached out. communications between mental health providers and schools through hipaa are issues that really need to be addressed in communicating about mental health concerns. some schools may have one or two school counselors but not necessarily access to a provider team, a psychiatrist that can partner with the schools as dr. hoover described to provide that additional level of care that's not necessarily available in the schools. in addition to that we do need to think about our care models very differently. so, for example, there are service that is are cheaper to set up that are available right now such as school-based crisis services. so when a school is under resourced and there's a crisis, it's very possible to send someone to that school to see that youngster on site with the

family or urgent care that is are on site at schools. so there are other things we can do to support our schools. i thank you for your leadership in supporting the schools through the pandemic. we should retain those things and there are other things we can do to expand access. >> dr. benton, you talk about the need to have improved screening in regards to mental health for our students. can telehealth be helpful in dealing with screening, recognizing that you need personnel in the school itself, but can that be better utilized today for screening? >> yes, senator. that's an excellent recommendation and, yes, it would be very helpful. one of the challenges for schools they screen and then they can't respond. and so having telehealth allows them to screen youngsters for problems or challenges before they become major problems. and telehealth can be used to address some of the more acute

things on site. currently screening is not viewed enthusiastically. if you find something, you can't do anything about it. the utilization of telehealth to connect with a crisis provider would allow the school to be able to respond in a safe and effective way. >> thank you, mr. chairman. >> thank you, senator carper. we appreciate your leadership on these issues as well. next i believe senator langford -- are you out there? senator brown, senator barrasso are here. senator barrasso and senator bennett. >> thanks, mr. chairman. first, i want to congratulate and compliment you on your opening statement. i thought you really hit the point on the head in terms of how long this is often brewing. i'm an orthopedic surgeon and

worked with the wyoming state medical society. i think you are right in the comments up made. being from wyoming, rural health is a big, you for us. senator crapo started by talking about that. and then telehealth is something we use from a mental health standpoint long before the pandemic. there are other kinds of health care as well as the ability to try to use telehealth much more productively. i hope we're fast forwarded with the acceptance of, as senator cardin was saying, the acceptance of telehealth. my question about trying to just get enough providers on site in rural america, which is what senator crapo talked about. for dr. benton and dr. hoover and ms. lubarsky, when itches in the united states senate, we were very blessed with additional revenue that we weren't expecting, but we had it and the commitment we made was to mental health. so we put a lot of financial

resources and made a deliberate effort to try to train, recruit and to attract more mental health providers to wyoming. but in spite of our best efforts, wyoming and other rural states trying to make those similar commitments continue to face huge shortages of all types of mental health providers. so the money was there and we still had the challenge. can you discuss solutions to workforce development you may believe help improve our ability for us through our mental health facilities that we can attract and maintain staff into rural and sometimes remote areas? >> if i may, and inthink it's a great question, senator, one of the challenges that occurs within our state of new hampshire are the licensure requirements. we have a lot of silos of who is allowed to provide supervision for an individual who comes out from their masters degree

program, and that at times creates the barriers who we're able to hire. if we have to have a specific credentialed professional to provide supervision to that same category of professional and we don't have them employed at our center that candidate no longer looks at us as a place they want to be employed at. i've talked to colleagues across our state who have lost employees who went to other states because not only could they make a higher income, but they needed to get the licensure supervision from a particular person. i think we need to make licensure requirements, flexibility on who can provide that supervision, in order to attract the staff needed to provide the care. >> anyone else? go right ahead, please. >> i was going to say i echo your comments. telehealth also adds another opportunity. it is for training remotely. and so for areas where there's a shortage of providers, we've been able to partner using telehealth to expand skills and to train people. thinking about dr. hoover's

comments about task shifting, it's an excellent opportunity for us to provide skills for masters level clinicians. clinicians who need supervision and may be in another state, for backup consultation across counties, but, also, by allowing us to continue with licensure across state lines we can actually also provide support for clinicians in those areas. i also just want to mention a quick win is really educating the people that we already have so the pediatricians, nurse practitioners, other health clinicians, masters level people, trace, okay, peer navigators, all of those resources in communities can be utilized to support individuals. we have programs where we're teaching grandmothers to do cognitive behavioral therapy for their anxious grandchildren. and so i think thinking about how we provide care differently

could provide us more opportunities for mental health support. >> thank you, dr. benton. to ms. lubarsky, to your point -- i'm working with senator smith, it's bipartisan, marriage counselors who do mental health work as well, and they're not able to be reimbursed through medicare and different federal issues, too, where they can provide health care. so it's the siloing by state but the federal government sometimes gets in the way as well. and then i know i'm running out of time. we have a commitment, my family, to working with families who have lost someone to suicide, what we can do along those lines. we're continuing to look not just to raise awareness but for best practices. dr. bennett, you are shaking your head yes on this. it's a biggish be you. i don't know if you have final thoughts on that. >> thank you, senator, for that question.

in addition to the suicides, you know over 160,000 young people have lost parents to covid. and, of course, the threat is always not just grief but traumatic grief and we're not ready for it. fortunately there are quite a few support services available to families who have lost family members to suicide, and for those who are suicide survivors. so the american foundation for suicide prevention is a resource for all families that provide a lot of support and information nationally for families who have experienced that loss, but we have to pay attention to those populations who have experienced traumatic grief because it's closer to the onset of depression. we need to develop early interventions and support for youngsters who lost their parents during covid and for individuals who have lost their families to events like suicide and homicide.

thank you for that. >> thank you, mr. chairman. >> thank you, senator barrasso. we are very much going to focus on the best practices you mentioned. it's a very solid way forward. we're having colleagues come and go so we're going to have senator thune, senator bennett and senator langford and we're going to lock in those three, okay? senator thune? >> thank you, mr. chairman. i appreciate your continued focus on youth mental health, and i appreciate the panel for joining us today, and as i discussed last week when i talked to parents, teachers and school administrators across south dakota addressing the behavioral health needs of students is a big priority. dr. hoover, your testimony you mentioned we need to be looking for more formal partnerships with community behavioral health providers. we have multiple cooperatives in place in my state where schools

that are in close enough proximity share a provider but in some circumstances distance is a barrier. do you know of instances where the partnerships you refer to have been formed using telehealth or a combination of in-person and telehealth services and what are the biggest barriers schools or school boards encounter in forming these types of partnerships? >> thank you for the question, senator thune. absolutely we've seen actually tremendous partnerships that rely almost exclusively on telehealth especially for some of our rural communities, some of the best examples in south carolina several years back where they had the medical university of south carolina providing telehealth services to schools across some of their most rural districts in south carolina. so we've seen these community behavioral partnerships with the standard memoranda of understanding with schools and community behavioral health where sometimes they'll do onsite support but really much of the service that's provided is through telehealth. as we've mentioned earlier some of the rural barriers are

reimbursement. sometimes schools are not allowable as sites of service and certain provider types are not allowable, which really does require taking a look at state medicaid plans and thinking how to expand school health programs under school medicaid. and certainly just a lack of awareness of some of the guidelines in setting up the partnerships and get reimburred and supported. >> dr. benton and dr. hoover, youth mental health has been a significant challenge for some time now. some of the stories are heartbreaking. there was a 2017 department of education report that confirmed kids in public schools and on the reservation have a greater risk of behavioral challenges and risk of suicide. do you know how to improve access to culturally appropriate care on the reservations and especially how we can grow the

workforce there, finding providers recruiting and being able to retain providers in tribal communities has really been a challenge. >> we have challenges you identified. the behavioral centers are an excellent way to attract and clinicians tend to focus on supporting populations that are similar and so the chances of working in your community are greater if you're a member of the community. how do we increase providers in those communities by targeting the communities who need the treatment and identifying individuals in those areas and providing the support needed. so many of the challenges for minority populations relate to finances. high student loan burden, low support for strong academics in

the community. those are all areas where we would be able to support education, increase interest and support individuals who would go on to get education in those areas. in those areas. some of our focus could be on supporting them in their communities. so, many times in acadeia we're all familiar with the idea that we recruit people away from their communities as opposed to providing resources in that community to educate young people through their high schools, their community colleges, training programs and then diversifying opportunities for support. so in line with dr. hoover's comments about task shifting, it's teaching people to provide services at the batch bachelor's level or other levels that would allow to expand support for care in their communities. >> just to piggy back on that, in addition to recruiting members within communities and retaining them in their communities to support their

communities, also investing in technological assistance and training centers and resources within those communities. a great example of that is the national mental health technology transfer center which is funded as part of the substance abuse mental health services administration and then i'll just also add really expanding the federal workforce development programs that we already mentioned including loan repayment, but also things like the minority fellowship program and national health service corps can really help in this regard. >> and i would add to that that some of our national organizations that support children's mental health, the american saemd academy and othe support the development of other mental health professions. partnering with the for programs that primarily serve hispanic and native american youth

professionals who remain in those communities. >> thank you, both. chairman, my time is expired. thank you. >> thank you, senator benoit is next. >> thank you very much, mr. chairman. can you hear me? >> we can. >> i appreciate you having this hearing and we are having a crisis in colorado. in fact, colorado's children's hospital was the first hospital in the country, i think, to declare a state of emergency in mental health for youth. i want to thank the witnesses for being here to testify and particularly grateful to have mr. terrell advocating on behalf of his peers and his generation. and i've got a second question for him. but let me start first with this. on reimbursement and prevention. last week the surgeon general was here and i raised the importance of reimbursement for

mental and behavioral health services something our committee has jurisdiction over cms and while i was going through your testimony the common theme is that we need improved and meeting youth where they are and where whole heartedly agree with this. so, i would ask dr. benton first maybe, what kind of services should be reimbursed by medicare and medicaid or private payers that are not usually covered and what services need increased reimbursement? can you highlight what you believe reimbursement parity is failing the american people? dr. benton, let's start with you and see anybody else that would like to add after that. >> well, thank you. thank you, senator, for that question. so, currently most of the early childhood services are not reimbursed. so, there are services that are required in the medical and mental health setting that are

comprehensive services that should start from birth through adulthood. but services that don't necessarily have a psychiatric diagnosis attached are not frequently reimbursed. for example, if a mother who was having difficulties attaching or parenting her newborn, those services are not necessarily reimbursed by traditional mental health providers. furthermore, for pediatricians who are typically the best people to identify early childhood problems because children have frequent visits in the first year of life, they're not reimbursed for the time it takes to provide the level of counseling that's needed for new parents who have new infants. and so if we target it, the reimbursement for those services, the pediatricians would be allowed to do their jobs, the nurse practitioners could do their jobs and people working with young children could do their jobs. for young children who are not yet impaired by a mental health condition preventive services would allow families to seek

that care in appropriate facilities and reimbursement could occur at the same time. so, i think the early childhood services currently are under reimbursed for the ones that are available and for children who don't necessarily have a mental health condition already, they're not able to seek the services they need and get the payment that's required. >> thank you for that answer. very much appreciate it. let me ask my second question because i know time is short. as i mentioned so important to have a young person here, mr. chairman. thank you for doing that. to give their perspective on the crisis. we should think about, i think, including young people here more often. as you know, the national suicide prevention lifeline will be transitioned to 988 by july 16th, 2022. in colorado we're having, i'm sad to say, an epidemic of teenage suicide. the numbers are just staggering

and senator and i have increased legislation and funding to make sure that this transition to the prevention lifeline is successful and we're thinking about how to incorporate texting and connect individuals with services they call or text in to make it more effective. i just wonder, mr. terrell, can you share your thoughts on all of this and what types of resources and improvements we should be thinking about that would be most meaningful in your mind. >> yeah, thank you, mr. bennet. that's a great one. and one that takes a lot of conversation to get to a great policy solution. statistics show that teens talk to their friends more than anything. the more that we can empower and equip youth with the skills needed to support their friends in crisis, i think the more we'll see kind of general health and well being trends for youth increased.

all youthline volunteers get the opportunity to go through pretty extensive training. i personally went through 6,300 and applied suicide intervention training and cpr and those are all master kind of clinician level trainings. so, we know that youth have the capacity to take on this role as supporters in their communities. and so like i mentioned in my testimony, i think the idea of a national youthline where we expand across the country and we really invite youth from all different communities to be involved in this process and help destigmatiz the conversation around mental health would be really helpful. i think i would be really happy to connect with you later on that. >> great. i will take you up on that. i know the chairman has your contact information. i will track you down and i very much appreciate it. thanks, mr. chairman. i know i'm out of time.

>> thank you for all your leadership, senator, bennet. senator lankfordt and senator brown. >> dr. benton, i do want to start with you. for individuals within a school whether it be a school counselor or teacher that may discover some mental health challenges that a child would have, any communicating in the system whether hiipa or just process issues with that individual communicating with parents, other school counselors or engagement, law enforcement or outside medical entities or barriers that we need to be aware of? >> thank you, senator lankfordt for that question and defer my question to dr. hoover who has more expertise. you cannot able for a mental health clination caring for a youngster and his teacher or

school counselors without permission either through the school and for hiipa for the provider. those two groups don't often communicate with each other, posing barriers for care. it leaves us, it creates a situation where for teachers and for counselors that addressing mental health concerns may require sending that young person off to an emergency department in order to get the care that they need. so, yes, there's definitely barriers in communication related to privacy laws. dr. hoover, i didn't know if you had further comments. >> agreed. many school systems and partnership with behavioral health systems have really navigated those privacy issues. for example, by initially sending paperwork home to families even at the start of school year to inquire about whether they are willing to give consent for communication to occur when in the best interest of the child's health and well being and academic success allowing for some of that communication to occur. again, with privacy in mind, but also supporting academics.

the other area that i would say is critical is really expanding data systems that allow for the seamless sharing of data between health and education sectors. and that has been done well in several districts in state. so, there are a good example of why it is not widespread enough yet. >> change in statute to allow more of that communication to occur at this point or do you think the statute is appropriate and we just need additional permissions and access points? >> yes. >> good question. i mean, you know, frankly i think that technical assistance and training and just raising awareness that hippa do not have to be barriers to communication as long as you have family engagement and consent. that may be enough. it has been enough in several communities to actually bridge the divide here. >> i will also say there are state laws who govern who can actually release information. that also becomes a barrier because sometimes the young person actually has control over that information.

and the parents don't. in some places it works but greater guidance in standerization of these processes would help all the communities. dr. lubarsky, i know this must come up for you often. >> it does come up quite a bit. the training involved and making sure the schools and mental health providers. when i think of examples where we're integrated in over 25 schools in our region providing mental health care or delivering that for our staff it is working collaboratively with the school and with the family system, parent, guardian and caregiver to make sure everybody is involved. where we see this as a barrier and come up as a challenge failure to communicate with the family system about the youth's need and making sure in advance of providing care or suggesting care that those conversations are happening, as well.

>> i would agree. in oklahoma we just had a law passed within our state that is allowed for training for everyone within the school on suicide prevention. we have 13,000 people in schools that have been trained just in the last couple years just to be able to help suicide prevention and to be able to know how to engage and next steps on that. in our state we have been very forward leaning to do what we can to be able to help. mr. chairman, a conversation that we could have at some point to be able to have on this whole issue, as well, is the whys and the prevention behind the scenes. we always on the finance committee we look at what we can do with more medicare and medicaid and the tools that we have. the next big question behind it as we watch suicide rates rise 57% among teenagers and young adults over just the last 15 years as we watch all the other things occur and ask the practical question of why. our nation has been through difficult challenges in the past. world war ii, the great depression and all these other things. why are we watching some of the rise now? what is happening in technology and happening in the engagement?

for myself personally i worked with students 22 years before i came to congress working with middle school and high school students. the scenario worked extensively and a lot of questions that we've not asked the one behind the issue, not just how do we fix it, but why are we seeing the rapid rise and what do we need to do? the issue in telehealth is very important and also another angle with telehealth that is important and we have to help resolve some of theish issues i some of the days ahead, as well. >> thank you, senator lankford. senator brasso took note, as well. this will be another opportunity for both sides to work together and i appreciate both of you and senator barrasso bringing it up. senator brown is next. >> mr. chairman, i ask that written testimony offered by the director of pediatric psychology

and psychiatry be included in the record for today's hearing. >> ordered. >> thank you, mr. chairman. dr. benton, as you probably recall from your time some time ago spent in my state for medical school, ohio has excellent children's hospitals and pretty much almost every part of the state, cincinnati children's, dayton's children's and nationwide in columbus and akron's children and home to several outstanding pediatric, as you know, centers of excellence. despite the resources our state has, ohio's children and health workers are still struggling during this pediatric mental health crisis. ohio's just like counterparts across the country are children's hospitals need our support to rise to meet the needs of children, adolescents and address this serious, serious public health crisis. experts tell me one of the challenges is meeting the needs

of multi-system youth. could you talk about action, dr. benton, actions that congress could take to better support children's hospital and youth served by multiple systems. for example, those in foster care or justice involved or have a developmental disability, how can we ensure effective communications between and among juvenile justice and child welfare systems to best support these children who so often just get left out. >> thank you, senator brown, for that question. just so you know, cincinnati is my hometown. so i am an ohioan. i just wanted to say that that's an excellent question and one of the greatest challenges that we face in mental health care now. so that the systems in which children exist, as you've highlighted, child care, education, juvenile justice, foster care and others have little or no collaboration. and systems are actually not in place to facilitate that collaboration. the attempts to coordinate it

are either baffled by bureaucratic challenges or unwillingness to acknowledge that the systems are actually connected. and, so, what would be required is a focus on requirements among those organizations. that there's better coordination. you know, we talk often about case management. you know, as a broad term but those individuals are often the ones who are facilitating communication between organizations that do parallel work, caring for the same kids but don't necessarily have an effective means for coordination. some of the data shows us pretty clearly that about 50 to 75% of over the 2 million children who are adolescents juvenile detention actually have had limited mental health treatment or limited mental health support. so, essentially, communicating expectations that those agencies collaborate around the care of

the same kids by establishing systems that facilitate that could go a long way. for children's hospitals, we struggle at times with children who are admitted to the children's hospital with a medical condition and a mental health condition. the medical condition is resolved and the mental health issues are resolving, yet they're waiting for placement in foster care. sometimes remaining in the hospitals for up to a year. and at that juncture, payers are not accountable, the agency who acts as the parent is not accountable and then the hospital is accountable for providing all of those services that require multi-agency collaboration. expectations and accountability for those agencies who are often managed by federal governments and states would be essential for being responsible for coordinating care of young people. >> thanks, dr. benton. i have a question i would like all of you to answer, but very briefly because my time is short

and the chair is always tolerant but his patience probably wears thin. i asked the surgeon general last week how we better integrate mental health service to our schools. my question to each of you, based on dr. benton's home town oiler which has become a template for the whole state and country. briefly describe if you had a chance to offer a suggestion one thing schools can do to leverage relationships with community partners, state or local health departments, human service centers or whatever. give one simple recommendation of what we do better, schools can do better to leverage that. dr. hoover do you want to start and then dr. lubarsky. >> familiar with the school and the cincinnati area that does this well and, as you said, serves as a model for the nation. one simple thing that can be done, there are good templates for memory of understanding and request for proposals that could

go out to districts to solicit community behavioral health partners to come in and engage in behavioral instead of being a hodgepodge of services and organized for request for proposals process with standardized memorandum with behavioral health. >> go bear cats as a graduate of the university of cincinnati. this is something we have done really well in our community. establishing not only the agreements of understanding but an assessment tool that schools would feel comfortable utilizing and do that screening to pass it on to the behavioral health care whether it's mobilizing the crisis team going into crisis in the school setting or the mental health supports that our school can provide. using standardized screenings that schools feel comfortable with is one step in that

direction. >> trace? >> i also think part of the big reason is we need to invite youth and kind of see what they actually want and what resources would be helpful for them. one thing to offer resources and another for teens to actually access them. so, when we conduct needs assessments and really see what works for youth, i think we'll experience better outcomes in that regard. >> well said, thanks. dr. benton, close with you. thank you, mr. chairman. >> thank you. i just want to say that i support all of those things that were just mentioned. and putting a system in place to make sure those things could happen easily and accessibly. >> thanks, thanks, mr. chairman. >> thank you, senator brown. and thank you for having brought me to ohio over the years to meet with a number of your healthcare providers and we've seen advocacy in action. next is senator casey. >> mr. chairman, thanks very much. in light of all the references to ohio that senator brown made possible, i want to make sure we emphasize that dr. benton is now at the children's hospital of

philadelphia. settled most recently in pennsylvania. dr. benton, i wanted to start with you and start with a critically important program that so many americans know the name of and so many americans have a sense of what it does. but maybe none of us fully appreciate how important it is. that's medicaid. i've often said that medicaid often tells us who we are as a nation, but maybe more importantly tells us whom we value. whether it's children or older americans who need skilled care or nursing homes paid for by medicaid. we also know that medicaid is the largest insurer for children, but it pays, unfortunately, pays significantly lower medicaid rates and commercial rates, which has terrible consequences often for the pediatric health

workforce and inequitable access to care. i know in your testimony you highlight how low reimbursement rates access the concerns you have about that, particularly with regard to underserved communities. on page 7 of your testimony you said, quote, better reimbursement for mental health services in medicaid would make it possible to resource the full continuum of care our children and youth need, unquote. so, the additional years to specialize in child psychiatry are not financially rewarded in the current payment structure with medicaid, where a provider could earn more providing care to adults. so, this makes it hard for child-focus provider, particularly challenging for families covered by medicaid. so, how would aligning medicaid

reimbursement for children's mental health services with medicare levels impact kids access to care? >> well, thank you for that question, senator casey. you know, aligning those incentives would increase the reimbursement for medicaid at a rate that would be more acceptable to most institutions. and that's key. community mental health centers really struggle to meet the needs of young people based on reimbursement. children's hospitals really struggle to meet, you know, meet the care for children with reimbursement and in addition to that, lower pay for providers is discouraing for sub specialists, not only to serve the populations of young people, but to even train to serve the populations of young people. generally psychiatry training takes four years. child psychiatry training takes six years. six years of accumulated debt, which has resulted in mental

health professionals opting out of payment structures for reimbursement for mental health care. so, increasing the medicaid reimbursement rates to be on par with medicare and medical rates would increase our opportunity to address the gaps in the continuum. so, there are areas in the united states where there are no services on any continuum available to young people. medicaid reimbursement would allow us to develop a full continuum of care, not just emergency and in-patient crisis services, but ambulatory services and home-based services, day hospitals, intensive outpatient programs where young people could be with their families and be at home getting the level of services that they need. and so the current medicaid reimbursement rates impact all of those things. and increasing them to be better, which would be consistent with medicare rates would allow us to provide the services that we need and would

allow us to encourage young people to pursue careers where they provided mental health care for young people. >> doctor, thanks very much. i might submit an additional question for the record for dr. benton. and i will give back time. but i did want to thank, again, the panel for their testimony today. in particular, i want to thank mr. terrell for coming forward on behalf of his generation. and i hope there are other opportunities for us to engage. but, thanks very much, mr. chairman. >> thank you, senator casey. trace, you are now clearly the people's choice because both democrats and republicans are praising you to the skies and it is richly deserved. senator hassan, we welcome you and all your good work. >> thanks so much, mr. chair, and thanks to you and the ranking member for this committee. i will add my thanks to trace,

as well and also note the good news for america is that trace is representative of his generation and there are lots of wonderful young people in my state and i know across the country really advocating for the mental health of their peers and in new hampshire it's very true. i actually had a 9-year-old look at me one day and say what are you doing about mental health, senator? thank you, all, for just being the kind of advocates that make a difference. i want to touch on a few topics that have been discussed but i want to drill down a little bit and let me start with ms. lubarsky. in new hampshire a small pool of providers are working overtime to help the number of children with mental health needs. it's just not sustainable. we all talked about that. following up on the testimony you've already given, what are the main causes for this mental health workforce shortage in new hampshire and what can we do to help alleviate the crisis? >> thank you very much, senator hassan. i think we have all spoken to

this very well this morning and now going into the afternoon. it's really the ability for centers to reimburse their staff at a rate that they can survive on. when we look at the cost of living and we just spoke about medicaid rates being significantly low. so we have a workforce that is burdened because other providers within our state and country could accept medicaid and choose not to because reimbursement is so low and we burden the providers who are accepting of it but the facilities can't reimburse to sustain the staff long term. we hear that all the time in our exit interviews. >> thank you. dr. hoover, you also touched on this, but i want to drill down on mental health in schools. schools are often the only place that children can receive mental health care but lack personnel and infrastructure to meet demand. what are the barriers that schools face, particularly when it comes to recruiting and retaining mental health providers? >> thank you, senator hassan for

your leadership on this and for the question. we know we suffer the same issues that the general workforce shortage reflects, as well. simply put we don't have enough providers, they are not trained well enough and are not paid enough. what i mean by that is not only do we have shortages and workforce coming into the field, but they don't really represent the populations being served in terms of race, ethnicity and language spoken and we have to do a better job. they're not trained well enough. what i mean by that is that we have not enough health providers but not specialized to work in schools. as we already said, they're not paid well enough so reimbursement rates are a large issue. again, i would go back to that we need to reenvision how we think about our mental health force and think of all the other professionals and also nonprofessionals that can do this work well. i love a grandmother providing

cognitive behavior therapy to children as dr. benton mentioned and our peer and family navigators. we need to do more to invest in that workforce as a way to support mental health. >> thank you. i know in new hampshire, peer to peer training and student empowerment has been really, really critical, as well. ms. lubarsky, mental health resources need to meet children where they are. in the school year that is in the classroom but mental health doesn't end when the school year does. so you led an innovative program based on that insight working with the community behavioral health association and the state government. offered mental health training for camp counselors and provided on-site resources at summer camps throughout the state. following up on where we were going with dr. hoover. what was the impact of this program and how can we scale up this model so that more children have support year round? >> so, i was so excited about

this program. our commissioner of education labeled it rekindling curiosity and it was really a means to tackle the mental health needs of students after being isolated from their peers. so, we began last summer by training summer camp staff and recreation programs in camps across our state and continued the funding into the school year. we continued to utilize it for professional development days and i have staff right now that are planning for february vacation week here in new hampshire to go out and support young people to be maintained in camp settings or recreation settings that otherwise may not be able to be maintained because of their behavioral health needs. rather than excluding them or expelling them from these programs, we have staff going on site and supporting the counselors and the youth to stay with their peers and really get a meaningful camp or recreation experience. >> thank you so much. it's a great program. thank you for everything you're doing for new hampshire. we really, really appreciate

you. and last thing i'm going to follow up, dr. benton, with a question on the record for you on particularly concerned about the isolation of children who are immuno compromised right now during the pandemic and whether there are specific ways we can help those kids. i'll follow up with you on that. thank you, all. what an excellent panel. >> thank you, senator hassan. that last question is particularly important and it hasn't gotten enough attention and thank you for asking it. senator cortez masto and then senator young and we'll wrap up one of the best hearings i have certainly been to. senator cortez masto. >> i agree. i want to thank the winses for being here. it has been a long morning but a fruitful discussion. thank you the ranking member of the committee so much for having this hearing. let me just say i hear every day that one of the critical ways we could protect kids' mental health is by keeping our schools open. that's one of the reasons i have been working to make sure that

our schools stay open and have what they need to help and keep our kids in the classroom and provide important services and support that we're talking about today. one of the areas i'm going to start, ms. lubarsky with you is stigma. our goal is to tear that down barrier and do away with stigma. i think that anybody who goes and talks about the physical health and has a funding source for that, that should be on par with mental health. that if you, it should be the same thing. you can walk in, get help for your mental health and it should be funded and there should be no stigma associated with that. but ms. lubasky, can you talk about the impact that telehealth, telehealth has had there? have you seen patients more inclined to follow through on the course of treatment through telehealth and is there, does that knock down some of that stigma associated with receiving services for mental health? >> absolutely, senator. thank you for your question.

when i hear your question, it makes me think of a young lady i worked with years ago and at the conclusion of every one of our sessions regardless of the weather, she'd pull over her hooded sweathat and a hat and classes and say i don't want anybody to see me walking out of this building with a giant sign that said mental health center out front. for a youth like that having the option of sitting in the comfort of her home behind a screen and nobody know she was accessing care with me was a game changer. i think the addition of helhealth not only knocked down barriers but eliminating the stigma that many youth and families see around mental health care. >> one thing that everybody has been talking about i so agree is access to the resources, the funding to support your services when you seek those for mental health. that's one of the reasons why i partnered with senator gaines on legislation that actually enables families with high deductible health plans to access no-cost telehealth

services before they meet their deductible. what i find that is often the barrier, as well. just accessing the payment plans, the resources to pay for these services. so, thank you. let me ask you this, mr. terrell. i saw you nodding your head. based on your work with youthline, can you talk a little bit about the value that peer-to-peer relationships have in helping kids feel less isolated and more willing to seek services for their mental health? >> absolutely. thank you, senator. i think that's a really great question because part of the reason that youthline works so well is that it is peer-to-peer and we know from statistics that youth are more likely to turn to their friends than anyone else. so, when we foster that partnership, right, it really helps to destigmatize mental health in that regard. it helps was it is a crisis support. there is a difference. when we talk about mental health

this conception that you only have to be suicidal or experiencing kind of acute high-stress situations. when that's not true. we know mental health incompasses a lot of things. when we talk about support, youthline is one of the only crisis lines in the country that offers teens the ability to talk about their mental health struggles without the fear of being the problem being too small or too big. we emphasize no problem too big or too small. when we talk about mental health, we really need to recognize that and just something that my supervisor always says we teach young people to call 911 when they're in emergency settings. unfortunately, that permeates over into how the national suicide prevention line and 988. so the sooner we can teach children that it's okay to call a crisis line, that it's okay to reach out for support for mental health, i think the more better we'll see this issue become in the future. >> and thank you. i couldn't agree more.

i just so appreciate the comments today on the need for robust crisis services for kids. the chairman and i have worked on this. i truly believe that when we are in crisis mode or they are in crisis mode, there should be places to call and it's not law enforcement always's a mobile c. it's based on the best practices in oregon, in his state. i think really the focus for me is addressing that crisis mode and bringing those essential services at that time. you know, senator corner and i would set standards for crisis services and, again, provide insurance coverage which is lacking, as well. i know my time is up. i cannot thank you so much for this conversation. mr. chairman, i'm hoping that with telehealth services and so many other areas that we have to focus on we're going to actually

implement more work around bringing mental health services to so many in our communities. thank you, again, everyone. >> i thank my colleague for her leadership and you made mention of the fact that working together, we were able to put together a model that brings together mental health folks and law enforcement folks. and, so, if you go off and you talk to senator booker, he's really interested in the program. if you go off and talk to senator scott, which i've done repeatedly and i know my colleague has. he's very inest thered in the program. the finance committee is really trying, as you suggest, break some new ground and fill in these gaps. i just want to thank my colleague for all her leadership on all these issues. she's been invaluable, and i thank her. senator young, you're next. >> thank you, chairman. i want to thank all our panelists today. such an important hearing. why we may not fully understand the pandemic's long-term impact

on america's youth, early data is alarming, especially to this father of four teens. according to the indiana youth institute, teen suicide deaths in my state increased 73% in 2020 compared to 2019. while teen deaths by overdoses increased 66% from the previous year. dr. hoover, what additional research do you believe is needed to better understand these trends and identify effective evidence-based interventions? >> thank you, senator young, for that important question. and just for raising awareness, again, about the dire statistics that we're seeing both with respect to mental health and suicide and also substance use. we can't forget substance use in this conversation of mental health. with respect to research, we are fortunate that we're seeing greater investments in research, in both mental health prevention and intervention and also in the substance use arena.

we would certainly urge congress research in those areas. some of the areas that we think we need more investment is novel treatment specific to certain populations. racial ethnic populations, immigrant populations and different student populations in rural versus suburban versus urban settings. thinking about how we development and implement interventions that are specific and tailored to the community. we also need to understand who is actually thriving or succeeding in these environments of adversity, trauma and stress. so, often the research looks at those who are suffering and how we can provide treatment, but it's really important that we also look to research to understand what are the protective factors whether it's individual protective factors or community factors that promote thriving and flourishing and how can we bolster those through school-based interventions and other community interventions. >> thank helpful.

i would open this up to our panel. if you could keep your response really brief, if you have one, panelists. what steps can the federal government take right now, right now to help reach at-risk teens at their individual moment of crisis? >> i have two brief suggestions. one would be educating our frontline providers right now around addressing mental health challenges. the second is setting up more mobile crisis programs. they can provide crisis intervention. >> i would add to that, senator, having worked with school educators recently, they're feeling like mental health is walking through their classroom doors every day. i think we need to afford educators the professional development time and give them that fundamental training in something like youth mental health first aid so they can recognize the sign and symptoms and bring that young person over to the next level of mental health care that they need.

>> i think we should also make sure that this isn't the last conversation that we have about teen mental health. as a teen, we need you to continue to have these conversations and continue to involve us in this work. we deserve a seat at the table and i think that's it. >> trace, i think that's really important. all the solutions need to be grounded in the realities of individual human beings. folks on the front line of this crisis, right? which is our teens. dr. benton, in your testimony you discussed the web of systems beyond health care that impact the well being of children in adolescents, such as foster care, education, food programs and how these systems rarely collaborate or when they try, our foiled by bureaucratic barriers or unwillingness their interconnected nature. research has, indeed, shown that these types of factors which we often refer to as social

determinance of health can positively impact the health and well being of the most vulnerable americans, including our nation's youth. doctor, how can we better leverage existing programs to help children and their families and address the barriers to coordination between mental health and social services programs? >> well, thank you for that question, senator. one of the things that we could do right now is demand a higher level of accountability for agencies responsible for coordinating the services. i will just take child welfare as an example. so child welfare as the parent and acting for any child in their custody is responsible for coordinating school, mental health, medical care and all the services. and, you know, i am assuming there are barriers to them doing that because it's challenging to make that happen. but i think for those agencies, there needs to be clarity and

reinforcement around expectations that that coordination happens. from where i sit, it's the greatest challenge that i am facing in the care for young people at the children's hospital right now really is the child welfare system. >> so you need accountability metrics and you need to identify who is responsible for achieving those metrics. is that accurate? >> you summed it up well, thank you. >> all right. thank you much. chairman. >> i thank, i thank my colleague. and there's a vote on the floor, so i'm going to have to be very brief, but i just want to say this has been one terrific panel. i mean, each of you have really made the case that trace started talking about two and half hours ago. trace terrell of la pine,

oregon, basically said look, what we have to do in america and we students are starting it, is mobilize. get active and mobilize for real reforms. of american healthcare and each of our witnesses, trace, in their own way, sort of reaffirmed what you're saying. so, the first thing i want to say is, trace, we're going to dedicate, we're going to dedicate our efforts for mobilizing the congress for these fundamental reforms the way you've said you're mobilizing young people. so, that's number one. number two is the message of so many young people getting lost in the system. is another extraordinary take away from today's hearing. i noted in your testimony you said that at your school with

respect to referrals to mental health services. 80% of them went no where. and what was so striking to me, trace, is a number of our experts from around the country said, hey, trace is speaking for his school, but by the way, that's pretty much the pattern around the country. it might not be 80%, but we're just losing too many young people. by the way, that's what dr. murthy said last week. we're just losing too many young people. so i'm going to close with this and we're going to dedicate this to you, trace, because this is a hearing on young people. i want to thank all our experts for being so helpful. trace, i want you to know right at the heart of our work is our judgment, democrats and republicans, that our country is better than this. we are better than this.

and as we go forward, you are going to have a seat at the table. you're going to have a seat at the table. we're going to be reaching out to young people across the country and we're going to stay at our work until we find some real solutions to the issues we've talked about. big thanks to everybody. just a terrific hearing. one of the best >> coming up today on c-span, a look at u.s. efforts to protect allies and interests in russia aggression in eastern europe. that is live at 10 a.m. eastern from the house oversight subcommittee on national security. then, a house committee discussion on digital privacy. on c-span two, at 10:00, the u.s. is back and consider

defense nominations, including the secretary on international affairs. on noon at c-span3, the head of the telecommunications and information initiative testify about broadband expansion in-house energy and commerce subcommittee hearings. everything will be live at c-span.org or c-span now, a free video app. >> c-span is your unfiltered view of government. we are funded by these television companies and more, including comcast. >> you think this is just a community center? it is way more than that. >> comcast is partnering with community centers so students from low income families can get the tools they need to be ready for anything. >> comcast supports c-span as a public service along with these other television providers. giving you a front row seat to democracy. >> on today's