"Our kids are suffering," is how one Cincinnati professional summed up the mental health landscape that teens and younger are navigating today. The markers of a healthy emotional life were already trending the wrong way before the pandemic, but the isolation and trauma caused by that event led to a surge in rates of depression, anxiety, and mental health emergencies nationally, including suicide. In 2021, three leading U.S. medical associations declared a national emergency in youth mental health.
It's an urgent problem, and in Greater Cincinnati, leaders from the medical, social services, education, and philanthropic communities are collaborating to work on the issue. Parents, medical providers, care givers, mental health professionals, and youths themselves will be part of the solution. This story is the second in the Soapbox Cincinnati series, Amplifying Youth Voices, which raises awareness of the problem and looks at possible community-based answers to it.
In the midst of a crisis in youth mental health, as the demand for help has surged, a chronic shortage of psychiatrists and other professionals trained to care for those suffering has resulted in long delays – and high costs -- to receive care. For children at a vulnerable age, gaps in the system mean that their conditions may worsen or never be treated at all.
A lack of insurance coverage for mental health care, low reimbursement rates from insurers who do cover it, and burnout among providers have combined to make timely access to care a struggle for many families and their children, professionals in the field agree.
“Ohio doesn’t have enough trained, qualified professionals to meet the needs of people of all ages seeking mental health and addiction care across the state,” said Lori Criss, then-director of the state’s mental health agency, last fall when announcing a plan to beef up the behavioral health workforce.
The need is especially acute for the most susceptible population – children in need of psychiatric care. “Child and adolescent psychiatry is the most underserved of all medical specialties,” says Dr. Paul Crosby, CEO of Lindner Center for Hope and himself a child psychiatrist. “There isn't a greater need anywhere in medicine than there is for child and adolescent psychiatrists.”
The shortage means kids in need of care must wait or don’t receive it at all, with the possibility that their symptoms escalate into crisis, increasing the need for care that is already in short supply.
In Ohio,
63% of children with major depression, about 76,000 youth, do not receive any mental health treatment. The situation is similar in Kentucky, where 59%, or 27,000 individuals, do not receive care despite suffering from
major depression, a serious disorder that can worsen if not treated. Nationally, 60% of youth with major depression do not receive any mental health treatment.
In the Greater Cincinnati and Northern Kentucky region
, one-third of the counties have no practicing child psychiatrists. The need is severe in the most rural areas: Adams and Brown counties in Ohio, and Grant, Pendleton, and Bracken counties in Northern Kentucky all lack a single child psychiatrist.
The shortfall is occurring as the need for child mental health care is increasing.
The demand for mental health services more than tripled from 2013 to 2019, and spiked again during the Covid-19 pandemic.
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new survey of youth released in March by Cincinnati-based PreventionFirst found that 20% experienced depression "all or most of the time" in the last 30 days, and 35.6% experienced anxiety all or most of the time. More than 47 percent of students said in general they feel stress often or a lot. The survey was conducted with students in seventh through twelfth grade at 38 public and private schools in Butler, Clermont, and Hamilton counties.
“We've seen the need continue to grow,” says Debbie Gingrich, chief program officer for Best Point Education and Behavioral Health, one of the leading nonprofit behavioral health providers in Greater Cincinnati. “And the workforce is growing, but not keeping up with that demand.”
NewPath Child and Family Solutions, another leading nonprofit provider, received 700 referrals to its residential program last year, up from 120 three years earlier, says CEO Eric Cummins. It can only accept a fraction of the applicants. “We were only able to serve 55 to 60 of those kids,” he says.
The wait time to see a child psychiatrist as an outpatient is more than 30 days, he says.
At Best Point, the median wait time for services is 88 days, Gingrich says. About a thousand youth are on the agency’s waiting list. When their name finally does come up, “We may not be able to get hold of that person, or circumstances have changed and they don't end up accessing care, ultimately,” she says.
That can result in a mental health emergency. “Sometimes, the conditions worsen or they just drop out,” Gingrich says.
On a recent morning at Cincinnati Children’s Hospital, eight children were in the emergency department needing urgent psychiatric care and awaiting hospital beds, says Dr. Suzanne Sampang, medical director of
child and adolescent psychiatry. “When they're coming into the hospital, it's because of a safety concern and they need 24-hour nursing care and psychiatric care to get stabilized,” she says.
Best Point has opened a pediatric mental health urgent care unit where emergency care can be delivered on a walk-in basis. But people who suffer from mental health maladies typically need long-term care, not just emergency stabilization.
The Lindner Center opened a partial hospitalization program in January that permits children to spend the day in the care of the Center’s staff but return home at night. “Within a few weeks, we were maxed out and had a waiting list,” says Dr. Tracy Cummings, chief of child and adolescent psychiatry.
Insurance for mental health care lags
Behind this dearth of care is a health insurance system that doesn’t value mental health care and fails to reimburse providers adequately. “As a society, we have so under-invested in the whole system of mental health care that we're only really equipped to address problems when they become crises,” says Ross Meyer, vice president at Interact for Health, a Cincinnati nonprofit organization that works to improve community health. “Then it becomes a cycle of crises, and we're not actually effectively treating the person.”
Although a federal law enacted more than 15 years ago promised equal insurance coverage of mental health services, the law is filled with loopholes. In Ohio, more than 7% of children whose families have the benefit of private health insurance, about 33,000 youth,
lack coverage for behavioral health. In Kentucky, the figures are 9% of the insured without behavioral health coverage, or 15,000 children.
For families whose private insurance does cover mental health care, “those plans vary pretty wildly,” says Best Point’s Gingrich. They often come with network restrictions on which providers they will pay for, and steep out-of-pocket costs, including high deductibles.
“It’s expensive,” says Dr. Cummings. “When it’s a sustained need, that’s a challenge. Even for a family that has multiple resources.” She calculated that under her own employer-provided health plan, seeing a behavioral health provider once a week for a child would cost $640 a month out of pocket. “That’s not reasonable to ask every family to do,” she says.
The Hollowell family of Cincinnati has been arranging for treatment and medication for their daughter, Kayla, since she was 2 (not their real names; the family asked that we change the names to protect their daughter’s identity). Kayla experienced prenatal drug exposure and was adopted at birth. She is bright and loves to learn, but experiences attention deficit hyperactivity disorder and is prone to sudden, impulsive bouts of anger and aggression. “We spend a lot of time trying to find resources for her to help her succeed,” her adoptive mother says.
“We spend a lot of money out of pocket,” her mother says.
She felt fortunate to get Kayla enrolled in a therapeutic class in preschool, but this year, kindergarten has been a different story. She can’t remain in school all day and transfers to an outpatient behavioral health program for half the day. That’s required her mother to quit her job so she can drive Kayla to the program. Kayla and her parents periodically see a private psychiatrist who handles complex cases. The cost is $500 an hour, which their health insurance plan does not cover. Kayla has trouble swallowing pills, so she is prescribed a liquid ADD medication. But insurance doesn’t cover it, and it costs $360 a month.
Unlike many acute and chronic physical conditions, mental health issues often require long-term, consistent therapy that can add up to be very costly. “We're low-tech as a medical discipline,” says Dr. Crosby. ‘It’s really a provider's training and skills and ability to sit in a room across from somebody and make them feel comfortable enough to share things that they usually wouldn't share with others,” he says. “And then listen to that in a way, and ask questions in a way that helps them.”
But the current reimbursement system provides perverse incentives. “The way that reimbursement works in this system, it encourages reducing the amount of time you spend with somebody,” he says. “The more patients you can see per hour, the more you can make.”
Many children receiving behavioral health care, about 20% nationwide, are insured through Medicaid, the government program for low-income families, people with disabilities, and others. At some agencies, such as BestPoint, the majority of clients are Medicaid-insured. But Medicaid reimbursement is generally worse than private insurance and that of its sister program for the aged, Medicare. States set their own Medicaid reimbursement rates, and the
rates in Ohio and Kentucky are among the worst in the nation.
That has an impact on access to care. “Low reimbursement is a financial disincentive for mental health professionals to treat Medicaid enrollees, a population that disproportionately experiences serious mental illness and barriers to care,”
says a 2023 study by the Oregon Health and Science University.
A number of providers have opted out of both the public and private insurance systems, and only accept patients who can pay the full cost themselves. That sets up a three-tiered system of reimbursement of Medicaid, private insurance, and self-payers, meaning that those who receive timely care aren’t necessarily the ones who need it, but are those who can pay for it.
“You have a health care system where the people who are actually able to access immediate care are those that have the financial means,” Gingrich says.
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Agencies are addressing a shortage of mental health professionals.
Paths forward to potential solutions
The shortcomings in the system will demand long-term, coordinated attention to be resolved. There are some steps that can and are being taken to address the issue, say those interviewed for this article:
- Complain to those who can do something about it. “When we meet with the Department of Labor or the Department of Insurance, one of the things that they cite as data that the system is working just fine is that consumers aren't filing complaints,” Gingrich says. Consumers often complain to their health plans rather than to the regulatory agencies that oversee health insurance. The Department of Labor enforces laws pertaining to employer-provided health insurance. For concerns about mental health benefits, the agency can be contacted online, or by calling 866-444-3272. State departments of insurance oversee health insurers. In Ohio, the Ohio Department of Insurance can be contacted here or by calling 800-686-1526. In Kentucky, click here or call 800-595-6053.
- Best Point, NewPath and other agencies are strategically working to recruit people into careers in behavioral health and retain them to address the workforce shortage. “Part of our work is building awareness and then building opportunities,” Gingrich says. Mullins says NewPath is focused on recruiting people at entry-level positions and then supporting them as their career develops. “We can bring somebody in at the front end and we can help them develop their skill sets so they can continue to grow within this field,” she says. “We have found that to be very successful.”
- Create a shared policy agenda for the community. Last year, more than 200 leaders from 115 organizations that serve youth met to identify the top factors affecting youth mental health. The result was an assessment, published in January, called “Greater Cincinnati Youth Mental Well-Being.” Its purpose is to create a shared awareness among the multiple organizations working in the mental health arena so they can act together with focus and create a greater impact working in concert than they can acting separately. A common agenda could help advocate for mental health parity with insurance companies, encourage streamlining Medicaid coverage among the different states in the region, and advocate for cross-state recognition of professional licensures, which could help alleviate the workforce shortage, the report says.
- The report also recommends creating a coalition of major employers that would purchase health plans that treat and reimburse mental health care equally with medical or physical care. Big employers collaborating that way could have an impact on the community’s caregivers and patients.
- The report also recommends starting a pilot project on a holistic care model that would fund preventive care and risk-reduction efforts and gathering data on its results.
- Philanthropic funding. The grantmaking arm of Bethesda Inc., bi3, had made youth mental health a priority. Among its grants has been $1 million to BestPoint to help that agency recruit, train, and retain professional staff. “They have been able to significantly reduce their wait list for kids,” bi3’s Miller says. “But think about the scale of that. It took $1 million to strengthen the team and build the team to expand access to reduce their wait list, and that's just one organization.”
The collaboration of the dozens of agencies, hospitals, providers, and other stakeholders that resulted in the community assessment is critical to making progress, NewPath’s Cummins says. “We're all in this together,” he says. “There's not one agency that can solve this problem alone. We need to work as a community to address it as a whole.”
READ MORE:
Safe spaces: Collective action emerges on crisis in youth mental health
The Amplifying Youth Voices series is made possible with support from Interact for Health. To learn more about Interact for Health's commitment to mental health and well-being, please visit here.