Society of Behavioral Medicine (SBM) Position Statement: increase access to mental health services due to COVID-19-related parent and family stress.

COVID-19 has caused drastic increases in family stress contributing to deleterious social and emotional ramifications. Before COVID-19, millions of Americans lacked access to mental health resources, and now in the midst of a global pandemic, resources are more limited in times of greater need. In March 2020, the Coronavirus Aid, Relief, and Economic Security (CARES) Act provided funding for mental health reforms; yet many barriers remained to receiving sufficient care. In February 2021, the Society of Behavioral Medicine recommended federal legislators expand Community Behavioral Healthcare Centers, increase funding for Federally Qualified Healthcare Centers and School Based Health Centers, incentivize providers to accept Medicaid, and institute more statewide licensing flexibilities to expand the reach of mental health care. In March 2021, the American Rescue Plan was signed into law and provided an additional ~$4 billion in funding for community mental health services, implementing substance abuse prevention and treatment programs, increasing the behavioral health workforce, promoting behavioral telehealth within primary care, increasing school-based mental health services, implementing suicide prevention programs, and improving services for traumatized families. This significant investment in parents and children's mental health is a tremendous step in the right direction and provides reassurance that relief is underway. Ongoing surveillance of the programmatic and clinical outcomes that result from these new policy reforms will be important for identifying areas that may need continual support as our nation recovers from COVID-19. © Society of Behavioral Medicine 2021. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Practice: Promote mechanisms that support interjurisdictional practice and incentivize mental health practitioners to treat patients with Medicaid.

Policy: Increase funding for Community Behavioral Health Clinics, Federally Qualified Health Care Centers, and School Based Healthcare Centers.

Research: Quantify patterns in mental health policies, practices, and family stress as the American Rescue Plan Act reforms proceed, in order to identify changes that improve mental health and areas that need additional support as families recover from COVID-19.

Introduction

The COVID-19 pandemic has affected millions of families causing unforeseen medical, social, emotional, and economic challenges. Profound stressors, such as widespread unemployment, stay-at-home orders, disruptions in school and childcare, and essential workers’ demanding and hazardous jobs, have significantly impacted parents’ mental health. For children, increased stress may result from multiple factors, including home confinement and disruptions in social, family, and academic domains. When basic human needs such as safety, food, and shelter are threatened or not met, there are often serious mental and physical health consequences. Indeed, over half of US adults reported an increase in stress during COVID-19 [1], with even greater stress among parents [2, 3] women [1, 3, 4], those unemployed [3] and individuals with lower income and from racial/ethnic minority backgrounds [1, 2]. These increases in stress can be associated with profound mental and behavioral health concerns, with experts citing increased risk of anxiety, depression, post-traumatic stress disorder, substance misuse, and suicide [5-9]. It is imperative that the extensive social and emotional ramifications of this pandemic are addressed to respond to this mental health crisis.

Prior to COVID-19, millions of Americans had insufficient access to mental health resources [10]. Specifically, one in five adults with serious psychological distress were uninsured, and one in five did not receive needed medical care due to cost [11]. As of 2014, the majority of insurance plans were mandated to cover mental health and substance use disorders [12]. Yet alarmingly, an estimated 27 million people could be newly uninsured due to loss of employer-sponsored health insurance coverage since COVID-19 [13], further limiting access to mental health resources during a time of increased need.

Moreover, there are over 2,500 School Based Health Centers (SBHCs) in the USA, providing health care access to >6.3 million students, predominantly from low-income families. Most (65%) of these SBHCs offer behavioral health services [14], and students are 10 times more likely to seek mental health counseling when a SBHC is available [15]. Due to school closures, many SBHCs have transitioned to providing telehealth services; however, these mental health access points remain lower than pre-COVID-19 levels. Public health policies must address the vast mental health concerns of these youth and take action to expand access during this global pandemic and beyond.

PREVIOUS POLICIES

The Coronavirus Aid, Relief, and Economic Security (CARES) Act [16], signed into law in March 2020, included $425 million dollars in funding—only 0.02% of the entire package—for Substance Abuse and Mental Health Services Administration (SAMHSA) programs, including dedicated funding for Certified Community Behavioral Health Clinics (CCBHCs), suicide prevention programs, and mental health and substance use disorder emergency grants. Moreover, $50 billion in provider relief was available to known Medicaid providers for health care-related expenses or lost revenue attributable to COVID-19, with $10 billion allotted for rural providers (including rural Federally Qualified Health Centers [FQHCs]). Yet, there is an extreme shortage of mental health providers who accept Medicaid; e.g., only 35% of psychiatrists accept new patients with Medicaid, with low reimbursement rates cited as the most common barrier [17].

Via Waiver 1135, the Centers for Medicare & Medicaid Services (CMS) has broadened access to telehealth services, with reimbursement rates equivalent to in-person visits for the duration of the COVID-19 public health emergency. States can also seek CMS approval for certain flexibilities, including requests to temporarily waive the requirement that out-of-state practitioners be licensed in the state where they are providing services, as long as they have an equivalent license in another state [18]. There have also been some local-level initiatives for increasing access to mental health care that can potentially serve as models for adoption in other areas (e.g., the Chicago Department of Health partnered with community mental health organizations to provide enhanced funding and telehealth capabilities to expand access to mental health services among people living with serious mental illness) [19].

RECOMMENDATIONS

The COVID-19 public health emergency has highlighted both longstanding and novel barriers to mental health access and reinforces the urgent need for mental health reforms. In February 2021, Society of Behavioral Medicine (SBM) recommended that federal legislators catalyze mental health reforms in the following ways [20]:

Increase funding for mental health care access via expanding CCBHCs in every state. CCBHCs help meet critical mental health needs, as they provide a comprehensive range of mental health and substance use disorder services to systemically oppressed populations and receive an enhanced Medicaid reimbursement rate based on their anticipated costs of expanding services to meet the needs of these populations [21].

Expand funding for FQHCs to more adequately meet mental and behavioral health needs. This is imperative given the extreme shortage of mental health providers for patients who have Medicaid, and compromised access to telehealth due to lack of universal Internet broadband availability.

Support and promote mechanisms or policies that facilitate interjurisdictional practice.

Incentivize qualified mental health practitioners to accept and treat patients who have Medicaid to increase the availability of high-quality services for the most vulnerable populations.

Increase funding for SBHCs to include expanded coverage for remote delivery of services for schools providing remote education (e.g., telephone, video [including dedicated sites for video conferencing to overcome internet access barriers]). School reopening plans vary across districts, so this expansion will be particularly important for schools that will be fully remote.

RECENT POLICIES

Since the release of this SBM Position Statement, the American Rescue Plan Act was signed into law in March 2021 [22]. This new COVID-19 relief bill provides nearly $4 billion for mental health services and substance use disorder initiatives. Specific funding has been allocated for:

Community Mental Health Services Grants to provide community mental health services ($1.5 billion).

Substance Abuse Prevention and Treatment Block Grants to implement and evaluate efforts that prevent and treat substance abuse ($1.5 billion).

Behavioral Health Workforce Education and Training to expand the workforce of professionals delivering quality behavioral health services ($100 million).

Pediatric Mental Health Care Access Programs to promote the integration of telehealth behavioral health services in primary care ($80 million).

Project AWARE to improve school-based mental health services and train personnel who interact with school-aged youth to respond to mental health issues ($30 million).

Suicide prevention programs to mitigate suicide risk ($20 million).

National Childhood Traumatic Stress Network to improve access to services for traumatized children, families, and communities ($10 million).

Additional funds have also been allocated to establish programs for health care providers and provide educational campaigns that increase awareness and encourage the use of mental health and substance use disorder services. This more robust COVID-19 relief package has made a significant investment in the mental health of families nationwide and is a tremendous step in the right direction. During the many challenges of COVID-19, and the continual challenges that lie ahead, this relief package provides reassurance that increased supports are underway. As these policy reforms proceed, ongoing surveillance will be important for monitoring programmatic and clinical outcomes, to identify aspects of mental health care that achieve sufficient relief and areas that might need additional support and resources as our nation recovers from COVID-19.