{ gg ASPE OFFICE OF BEHAVIORAL HEALTH, ISSUE BRIEF pesuvino avo evacuaron DISABILITY, AND AGING POLICY November 1, 2022 RACIAL AND ETHNIC DIFFERENCES IN CHILDREN'S MENTAL HEALTH SERVICES IN MEDICAID BEFORE AND DURING THE COVID-19 PANDEMIC KEY POINTS e Average monthly mental health service use among children covered under Medicaid/Children's Health Insurance Program declined by 5% during the COVID-19 pandemic. e The size of the decline varied by race and ethnicity and was larger for Black (-11%), Hispanic (-5%), and Asian (-3%) children than White children (-1%). e During the pandemic, the amount of telemental health service use among children increased for all groups (Black 3580%; Hispanic 3311%; Asian 4117%; and White 2175%), but children of color still had fewer telemental health encounters than White children. e Increased telemental health use during the pandemic was not enough to fully offset the reductions in in-person mental health services. POLICY ISSUE The COVID-19 pandemic prompted a surge in mental health treatment needs among children, with recent research documenting a more than 20% increase in the incidence of anxiety and depression in 2020." In addition, the disproportionate impact of the pandemic for many people of color, including Asian American, Native Hawaiian, Pacific Islander; American Indian, Alaska Native (AIAN); Black; and Latino populations, has been documented across various age groups, including children." Disparities in rates of access to mental health services among United States children have been a concern for decades,' and little is known about the extent to which the pandemic may have exacerbated unequal access for children in Medicaid. This is an important omission from the literature, as the pandemic not only increased the need for mental health services, but also resulted in a significant shift in the delivery of mental health care from in-person settings towards telehealth.* In addition, Medicaid plays a significant role in covering children of color, as over half of Black, Hispanic, and AIAN children in the United States are enrolled in Medicaid.° To address this gap, we used a national Medicaid claims database to compare mental health services use among children across treatment settings, examining outcomes by race and ethnicity before and during the pandemic. This analysis seeks to inform policy initiatives in targeting racial and ethnic disparities in pediatric access to mental health services in Medicaid and Children's Health Insurance Program (CHIP). STUDY DESIGN The data for the analysis were drawn from the 2019-2020 Centers for Medicare & Medicaid Services Transformed Medicaid Statistical Information System (T-MSIS) Analytic File. T-MSIS data are the most current and complete Medicaid and CHIP data resource available that captures health services use for the more than 73 million low-income Americans from all 50 states and Washington, DC, who are enrolled in Medicaid/CHIP. The study sample included all Medicaid beneficiaries between ages 3-17 who were enrolled for 6 consecutive November 2022 ISSUE BRIEF 1 months in the year and used any mental health services in 2019 or 2020. Using a combination of Current Procedural Terminology and place-of-service codes, we examined the following outcome variables measuring service settings where Medicaid/CHIP-covered children received their mental health treatment -- telehealth, in-person outpatient, inpatient, intensive outpatient/partial hospitalization, residential, and emergency department. Psychotropic prescription medication (antidepressants, antipsychotics, anticonvulsants, antimanic, antiparkinsonian, anxiolytics-sedative, benzodiazepines-barbiturates, CNS, hypnotics, stimulants) use was also examined and was identified using National Drug Codes. Outcomes were expressed in terms of the number of encounters per 1,000 Medicaid/CHIP enrollees per month and were examined for the overall sample by service setting and within each of the following groups: non-Hispanic White, non-Hispanic Black, Hispanic, non-Hispanic Asian and non-Hispanic Other (AIAN, multi-race). For each group, March-December 2020 levels (COVID-19 period) of each outcome were compared to January 2019-February 2020 levels (pre- COVID period), showing monthly and average monthly rates, along with percentage change from the pre- pandemic period and the pandemic period for mental health services among children. Average monthly rates were calculated for the entire pre-COVID and COVID-19 periods respectively. FINDINGS The decline in mental health service use was higher among Black, Hispanic, and Asian children compared to White children (Figure 1 and Table 1). Children across all racial and ethnic groups experienced modest declines in any mental health service use (i.e., whether in-person or via telehealth, and across all service settings) during the pandemic (-5%). The rate of decline varied across groups. There was a 1% decline in mental health service use during the pandemic among White children, while among Black children the decline was 11%, among Hispanic children the decline was 5%, and among Asian children the decline was 3%. While the decline in mental health service use was seen for all racial and ethnic groups, the higher reduction in service use among Black, Hispanic, and Asian children highlights the need for continued policy efforts to address disparities in access to mental health care for these populations. Rates of telemental health use increased across all racial and ethnic groups during the pandemic, but were still lower for Black, Hispanic, and Asian children than for White children (Figure 2). Telemental health service use among White children increased from 3.4 encounters per 1,000 beneficiaries in the pre-COVID period to 76.7 encounters per 1,000 beneficiaries during COVID-19. Telemental heath service use among Black, Hispanic, and Asian-American children changed from 1.4 encounters per 1,000 beneficiaries to 53.0 encounters per 1,000 beneficiaries, 1.1 encounters per 1,000 beneficiaries to 39.0 encounters per 1,000 beneficiaries, and 0.4 encounters per 1,000 beneficiaries to 15.7 encounters per 1,000 beneficiaries, respectively. This shows that the rate of telemental health service use was lower for children of color during the pandemic compared to White children. This finding implies that while telehealth might help bridge the gap in differences in mental health service use between children of color and White children, more policy effort might be warranted. The literature has documented evidence of inequitable access to broadband infrastructure and Internet enabled devices among communities of color,® thus engaging with this modality of treatment might still be a challenge. Reduction in psychotropic medication use was larger among Black, Hispanic, and Asian children compared to White children (Table 2). This finding is consistent with prior research that showed a decline in psychotropic medication use during the early period of the pandemic among patients aged 18 and younger.' Our finding that this decline in psychotropic medication use is more pronounced among children of color may indicate higher unmet need among Black, Hispanic and Asian children, particularly if children previously reliant on psychotropics are not receiving other care given the overall decline in mental health service use. Mental health service use decreased across all in-person service settings (Table 2 and Table 3). Inpatient, emergency department, intensive outpatient/partial hospitalization, and outpatient settings saw a decline among all racial and ethnic groups, but the decline was larger among Black, Hispanic, and Asian children November 2022 ISSUE BRIEF 2 compared to White children. Black children experienced the largest decline in most service settings compared to children from other racial and ethnic backgrounds. LIMITATIONS A strength of this study is the use of a large, nationwide, Medicaid claims database that included 2 years of data from January 2019 through December 2020. However, as the mental health service delivery landscape continued to shift during the pandemic, it is possible that our data does not reflect the current state of mental health service use among children. Using more recent data and looking at racial and ethnic differences during the later period of the pandemic may be an important avenue for future studies to consider. Another limitation of the study is that it includes only children covered under Medicaid and CHIP, thus the findings cannot be generalizable to uninsured children or children covered under private insurance. Using a multi-payer claims data to investigate the changes in mental health service use among children by type of health insurance coverage will be an important contribution to the filed. Finally, the data used in the analysis has a large rate of missing information on race and ethnicity. While incomplete race/ethnicity data has been a longstanding challenge in T-MSIS?3 and beyond the scope of this analysis to address, high quality and complete data will be essential is understanding disparities in mental health treatment among children. CONCLUSION The COVID-19 pandemic has been linked to increasing prevalence of mental health conditions among children and adolescents.® At the same time, many children have not been able to access mental health services even if they could maintain their Medicaid and CHIP coverage.® The findings of the current analysis show that the pandemic was accompanied by a significant shift in the type and modality of mental service use from in-person to telehealth visits for both children and adolescents, consistent with findings from prior research on youth and adults.? The findings suggest that while the use of telemental health services during the pandemic could have a larger role in reducing disparities in accessing mental health services, telemental health alone might not be sufficient to make up for the overall decline in mental health service use that was observed during the pandemic. While telehealth has often been hailed as a new way to improve access to care, the pandemic has also exposed longstanding issues with access to telehealth services for underserved populations such as reliable broadband Internet, technology costs, billing challenges, lack of buy-in among clinicians, among others.>*? Given the current findings, it is possible these challenges have potentially impeded use of telemental health services among racial and ethnic minority pediatric populations in Medicaid and CHIP.° This finding could be specific to behavioral health care, as behavioral health was one of the most common services that states allowed to be delivered via telehealth before and during the pandemic Given our large sample, the results could be indicative of the beneficial impact of the modified regulations and guidance that the Federal Government instituted in improving access to telehealth services overall and specifically for Medicaid populations. Increased flexibilities in removing geographic restrictions, expansion of providers eligible to bill for telehealth, reduction in cost sharing and removal of interstate licensing barriers could have been effective in improving access to telebehavioral services for pediatric populations in Medicaid and CHIP." The Federal Government has outlined an agenda to transform access to mental health services and to meet children where they live, study and play."? This agenda specifically aims to reduce disparities in pediatric mental health through investments in prevention and treatment in both community-based settings (such as schools) and clinical settings. The observed overall decline in mental health service use during the pandemic, in spite of a significant increase in telehealth, implies that a sustained investment in child mental health initiatives is warranted to improve how children and their families access and use mental health services. November 2022 ISSUE BRIEF 3 Figure 1. Trends in Child Mental Health Service Use Covered Under Medicaid/CHIP by Race/Ethnicity COVID-19 ---L-----/d4 b uw oO No. of encounters per 1,000 child benificiaries 100 1 1 1 1 I 1 a) 1 © Q 5 ++ FS} OD FS DO KP HRP FF FV f& 2B Ss Fs SF ODO SF DW KP KR SF YV a = a 9 Qa = Qa 8 S@#s¢s5Sezego2zh68 2 S35 328026 2019 2020 Asian --- Other Black - - -Overall --- White Hispanic Overall 201.3 192.0 Asian 47.3 46.0 Black 195.3 172.9 Hispanic 129.0 122.7 Other 200.0 202.0 White 288.5 284.8 Notes: Average monthly service use (number of encounters per 1,000 child beneficiaries per month). Pre-COVID: January 2019-February 2020; COVID-19: March 2020-December 2021. November 2022 ISSUE BRIEF 4 120 wn o s = 100 oO Cc oO Qa = 380 <& oO oO oO S 60 S| © Qa % 40 9 Cc oo] 8 2 20 oO So S 9 = Cc Q _ s2s - - - Overall -- White May o > w 534 2019 Sept Black ra Qa ad COVID-19 Figure 2. Trends in Telemental Health Service Use Covered Under Medicaid/CHIP Aug Sept Oct Nov Dec Overall 2.3 Asian 0.4 Black 14 H nic 1.1 Other 3.1 White 3.4 56.5 15.7 53.0 39.0 57.5 76.7 2336% 4117% 3580% 3311% 1762% 2175% 150.3 37.9 158.3 102.0 156.3 204.3 139.1 36.0 137.1 94.3 154.2 195.5 -7% -5% -13% -8% -1% -4% 47.7 8.3 33.5 24.8 40.2 79.7 47.3 8.5 30.6 24.9 42.7 82.2 -1% 2% -9% 0% 6% 3% Notes: Average monthly service use (number of encounters per 1,000 people per month). Pre-COVID: January 2019-February 2020; COVID-19: March 2020-December 2021. November 2022 ISSUE BRIEF 5 Overall 1.8 1.3 -26% 0.8 0.7 -16% Asian 0.6 0.4 -30% 0.3 0.2 -18% Black 1.7 1.2 -29% 0.8 0.7 -17% H nic 1.2 0.9 -25% 0.6 0.5 -14% Other 2.0 1.5 -24% 1.0 0.8 -17% White 2.5 1.9 -23% 1.1 0.9 -11% Notes: Average monthly service use (number of encounters per 1,000 people per month). Pre-COVID: January 2019-February 2020; COVID-19: March 2020-December 2021. REFERENCES 1. 10. 11. Lebrun-Harris LA, Ghandour RM, Kogan MD, Warren MD. Five-Year Trends in US Children's Health and Well-being, 2016-2020. [published online ahead of print, 2022 Mar 14]. JAMA Pediatr. 2022; e220056. doi:10.1001/jamapediatrics.2022.0056. White A, Liburd LC, Coronado F. Addressing Racial and Ethnic Disparities in COVID-19 Among School- Aged Children: Are We Doing Enough?. Prev Chronic Dis. 2021; 18: E55. doi:10.5888/pcd18.210084. Rodgers CRR, Flores MW, Bassey O, Augenblick JM, Cook BL. Racial/Ethnic Disparity Trends in Children's Mental Health Care Access and Expenditures From 2010 to 2017: Disparities Remain Despite Sweeping Policy Reform. [published online ahead of print, 2021 Oct 7]. J Am Acad Child Adolesc Psychiatry. 2021; $0890-8567(21)01875-X. doi:10.1016/j.jaac.2021.09.420. Zhu JM, Myers R, McConnell KJ, Levander X, Lin SC. Trends in Outpatient Mental Health Services Use Before and During the COVID-19 Pandemic. Health Aff (Millwood). 2022; 41(4): 573-580. doi:10.1377/hithaff.2021.01297. Guth M, Artiga S. Medicaid and Racial Health Equity. Kaiser Family Foundation. 2022. https://www.kff.org/medicaid/issue-brief/medicaid-and-racial-health-equity/. Swenson K, Ghertner R. People in Low-Income Households Have Less Access to Internet Services--2019 Update. Washington, DC: Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services. Nason I, Stein DT, Frank RG, Stein MB. Decline in New Starts of Psychotropic Medications During the COVID-19 Pandemic. Health Aff (Millwood). 2021; 40(6): 904-909. doi:10.1377/hlthaff.2021.00028. Ali MM, Schreier A, West KD, Plourde E. Mental Health Conditions Among Children and Adolescents With a COVID-19 Diagnosis. [published online ahead of print, 2022 Jun 2]. Psychiatr Serv. 2022; appips202100646. doi:10.1176/appi.ps.202100646. Mental Health and Substance Use Conditions. 2021. Available at: https://www.whitehouse.gov/briefing- room/statements-releases/2021/10/19/fact-sheet-improving-access-and-care-for-youth-mental-health- and-substance-use-conditions/. Chu R, Peters C, De Lew N and Sommers B. State Medicaid Telehealth Policies before and During the COVID-19 Public Health Emergency. HHS, ASPE. 2021. Available at: https://aspe.hhs.gov/sites/default/files/documents/eb9e147935a2663441a9488e36eea6cb/medicaid- telehealth-brief.pdf. HHS. Medicaid Payment Policies During COVID-19. Available at: https://telehealth.hhs.gov/providers/billing-and-reimbursement/medicare-payment-policies-during- covid-19/. November 2022 ISSUE BRIEF 6 12. 13. White House Fact Sheet: Boden-Harris Administration Highlights Strategy to Address the National Mental Health Crisis. Available at: https://www.whitehouse.gov/briefing-room/statements- releases/2022/05/31/fact-sheet-biden-harris-administration-highlights-strategy-to-address-the-national- mental-health-crisis/. T-MSIS Analytic File DQ Atlas. https://www.medicaid.gov/dq-atlas/welcome. November 2022 ISSUE BRIEF 7 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Office of the Assistant Secretary for Planning and Evaluation 200 Independence Avenue SW, Mailstop 447D Washington, D.C. 20201 For more ASPE briefs and other publications, visit: aspe.hhs.gov/reports hel ABOUT THE AUTHORS Mir M. Ali, Ph.D., Kristina D. West, M.S., L.L.M., and Timothy B. Creedon, Ph.D., work in the Office of Behavioral Health, Disability, and Aging Policy in the Office of the Assistant Secretary for Planning and Evaluation. SUGGESTED CITATION Ali, M.M., West, K.D., Creedon, T.B. Racial/Ethnic Differences in Children's Mental Health Services Use Before and During the COVID-19 Pandemic (Issue Brief). Washington, DC: Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services. November 1, 2022. 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