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1 UNITED STATES SENATE. COMMITTEE ON finance . PRESENTS. March 2022. MENTAL HEALTH CARE. IN THE UNITED STATES. THE CASE FOR FEDERAL ACTION. Contents Letter from Chairman Ron 1. Chapter 1. Report 3. Chapter 2. behavioral Health Definitions, Prevalence, and Spending .. 4. Chapter 3. Status of the behavioral Health Workforce .. 8. Chapter 4. Children, Adolescents, and Young Adults .. 12. Chapter 5. Access, Integration, and Coordination .. 17. Chapter 6. Mental Health and SUD Parity .. 21. Chapter 7. The Role of Telehealth .. 25. Chapter 8. Next 29. Appendix A. Senate Committee on finance Hearings on behavioral Health in the 117th Congress .. 30. Appendix B. Timeline of Federal Mental Health and SUD Parity Laws.

2 31. 0. Letter from Chairman Ron Wyden The United States is experiencing a profound crisis when it comes to mental health care. In a recent Senate Committee on finance hearing on youth mental health, Surgeon General Dr. Vivek Murthy shared that Americans wait 11 years, on average, between onset of mental health symptoms and first receiving treatment. This gap is staggering. The consequences are plain to see: higher suicide and drug overdose rates, more Americans without a safe place to sleep at night, more children experiencing depression and anxiety that will compound as they grow into adulthood. The house is on fire, and the nation is short on firefighters equipped to put out the blaze.

3 This crisis has been made even worse by the disruption, isolation, and loss experienced in the COVID-19 pandemic. This issue is deeply personal for me. For years, my brother struggled to access the mental health care he needed and our family struggled against the painful stigma that has surrounded mental illness for as long as I can remember. It is a tragedy that helping a loved one get care is still a challenge for millions of other families around the country. I hear about the challenges of getting mental health care every time I visit communities in my home state of Oregon. Mental health is the premier concern for families across my state because their loved ones need help and too often are unable to find it.

4 More people are in crisis and there are fewer people to take care of them. Oregon's rate of unmet need for mental health treatment is one of the highest in the nation, ranking behind just three other states. One in five youth had a major depressive episode last year, and less than half received care. Among adults, 43% of adults in Oregon who reported any mental illness received treatment. People are calling for help. Youthline, a peer-to-peer crisis line has seen a 15% increase in calls. As Chairman of the Senate finance Committee, I am partnering with Ranking Member Mike Crapo on a major bipartisan effort to bring behavioral health care to the forefront of the health system by leveraging the programs under this Committee's jurisdiction, including Medicare, Medicaid, and the Children's Health Insurance Program.

5 Ten members of the Committee five Democrats and five Republicans have stepped forward to lead on policy areas that will be vital for a path forward, including: Senators Debbie Stabenow and Steve Daines on the behavioral health workforce; Senators Catherine Cortez Masto and John Cornyn on care integration, coordination, and access; Senators Michael Bennet and Richard Burr on mental health parity; Senators Ben Cardin and John Thune on telehealth; and Senators Tom Carper and Bill Cassidy on improving care for children and young people. The Committee's work has begun. In the fall of 2021, the Committee issued a public request for information that received 300 submissions from experts and advocates around the country.

6 The Committee has held hearings bringing together leaders, providers and patients who shared their stories and offered solutions. From these testimonies, and staff review of relevant 1. research, a number of facts have come to light as presented in this report. These facts can inform the Committee's work ahead: First, the mental health care system needs a strong workforce able to provide appropriate care where people are whether that's in schools for youth, community clinics, residential programs, hospitals, or virtually by telehealth. Second, reforms must connect people to the care they need at the right time. That means improving connections between Americans experiencing symptoms or crisis and mental health and substance use disorder clinicians and primary care, removing barriers to tele-mental health care, and ensuring young people and adults get care early on before conditions worsen or escalate.

7 Third, insurance companies must be held accountable for putting mental health care on par with physical care. Medicare, Medicaid, and CHIP must also deliver on the promise of parity. There can be no cutting corners in mental health and SUD coverage. Across all of these issues, there must be a recognition of the disparities that underlie our health care system: including racial, ethnic, sexual identity, and geographic disparities. These disparities contribute to inequities in mental health and SUD outcomes. Closing these gaps requires addressing disparities in access to care and coverage, and creating a more connected, inclusive and diverse mental health workforce.

8 This report marks the finance Committee's next step in the bipartisan effort to understand the behavioral health care crisis in the and, further, to craft a legislative package, which the Committee intends to consider this summer. As I see it, the Committee's lodestar must be this: every American is able to access the mental health and substance use disorder care they and their loved ones need when they need it. Ron Wyden Chairman 2. Chapter 1. Report Purpose The Senate finance Committee is responsible for developing legislation and providing oversight of federal programs that finance and provide health coverage for more than 120 Key Terms million Americans under Medicare, Medicaid, the Children's Health Insurance Program (CHIP), Affordable Care Act (ACA) behavioral health conditions include marketplace coverage, and group health plans as defined by mental health and substance use section 5000(b)(1) of the Internal Revenue Code of 1986.

9 The disorders (SUD). Committee has an obligation to study the health challenges Mental health conditions can facing the individuals with coverage under these programs include mild to severe conditions and to propose modifications and reforms as needed. including autism, depression, anxiety, bipolar disorder and This report brings together the work of the Committee during schizophrenia. the 117th Congress to understand the behavioral health challenges in America. The purpose of the report is to SUD refers to chronic health support the current bipartisan initiative being undertaken by conditions wherein recurrent the Committee to improve behavioral health for Americans substance use causes clinically covered under federal health programs.

10 The Committee significant impairment, including takes a broad view of behavioral health to include both health problems, disability, and mental health conditions and SUD, reflecting the reality that failure to meet major responsibilities mental health and SUD are often, though not always, co- at work, school, or home. occurring. Medicare provides health care coverage for more than 60 million Thus far, the Committee has conducted public fact-finding adults 65 and older and individuals efforts through three hearings specific to behavioral health with disabilities. (described in Appendix A) and a bipartisan request for information (RFI). In response to the RFI, the Committee Medicaid provides health care received 321 submissions from organizations and coalitions coverage for over 75 million children and 229 submissions from individuals.