Loading summary
Transcript57 lines
- [00:00]
A
Foreign.
- [00:08]
B
Hello, and welcome to a special episode of the City Journal Podcast. I'm Carolyn Gorman, fellow at the Manhattan Institute, and today we're bringing you a conversation about what I might call the real youth mental health crisis. Across the country, there's a growing number of children and teens with severe mental health and behavioral needs who have nowhere to. And that's because youth residential treatment beds over the past few decades have declined 94% across all states. And nationally, we have a shortage of beds that's leaving these kids with the greatest needs underserved and therefore abandoned in emergency departments, held in juvenile detention centers, and left in unsafe home environments. At the same time, we have sensationalized media attention and policy changes that are making these bed shortages worse. So to talk about what's going on, I'm joined by a few colleagues today, longtime City Journal friend and contributor and recent City Journal podcast guest, Naomi Schaefer Riley, who's a senior fellow at the American Enterprise Institute, Scott Jingelski, the president and CEO of the national association for Behavioral Healthcare and adjunct fellow at mi, and Christina Buttons, who's an investigative reporter at City Journal. So, Scott, we hear pretty often about a youth mental health crisis, but a lot of times when we're talking about that, we're talking about kids with maybe high levels of normal distress. When we're talking about youth residential care first, sort of, who are the kids that we're talking about? And what is residential treatment?
- [02:01]
C
Yeah, so when we're talking about this patient population, we're talking about, generally speaking, children that have serious emotional disturbances. So this is the term used for a set of conditions that we would otherwise call in an adult population, serious mental illness. We use a different term for children because it's much more difficult to put a definitive diagnosis on some of them. So if you think about the term serious mental illness, you're talking about a specific illness that these individuals have. When we're talking about children in this population, we use the term serious emotional disturbance because it's much more difficult to get a specific diagnosis. But these are generally children that have complex mental health conditions, and the reason they end up in residential treatment is typically because they've been unable to address those conditions at lower levels of care. For the question about where does residential treatment fit into the continuum? I think there's two ways to think about that. The first way is thinking about where along the mental health continuum it fits. But then also secondly, what is an equivalent type of service on the medical or surgical side? So where it fits on the behavioral health Continuum of care. The way to think about mental health treatment is we basically bracket it by amount of time spent in a given week in treatment. So if we think of traditional outpatient treatment, that is somebody going to see a therapist once or twice a week, that's about two hours a week. Then from there you go up to intensive outpatient treatment. That's somebody going into treatment for about nine hours a week. From intensive outpatient treatment, you go up to partial hospitalization, which is 20 hours a week. And then anything above partial hospitalization is gonna be a facility, and you're gonna be there 24 hours a day, seven days a week for a given amount of time. Residential treatment is that first level of that, and then above residential treatment, you'll have inpatient psychiatric care, which is higher clinical intensity and a more controlled environment for the patient. The equivalent that I use on the medical surgical side that help people contextualize where residential treatment fits is if you think about an inpatient rehab facility. So let's say you have an illness or surgery or an injury, you go to the hospital, the hospital treats that injury. But you are not well enough yet to go back into the community and take physical therapy from an office based physical therapist. You will sometimes go to a rehab facility where you'll do intensive physical therapy, at which point then you will transition into a community based therapist. Residential treatment very often plays that rehab role for this patient population that the patient ends up in the emergency room or in a hospital. They're stabilized, they're not necessarily ready for partial hospitalization or intensive outpatient treatment. So they'll stay for some time in a residential treatment program. The other access point is actually going up that chain. So somebody does, you know, intensive outpatient or partial hospitalization, and it's not meeting their needs. So then they'll end up in residential treatment.
- [04:58]
B
And typically a child who's in a residential treatment facility is someone who's. We've sort of tried those earlier, less intensive steps, correct?
- [05:07]
C
Yep, that's. That's exactly right, Carolyn. So they've tried Those sort of two hours a week, nine hours a week, 20 hours a week, and it was insufficient for their condition, or they had an acute emergency condition where they ended up in the emergency room or emergency department or a hospital, and then are stepping down to residential treatment.
- [05:26]
B
So what population size are we sort of talking about? Because I think a lot of confusion around residential care is thinking about any given kid being put in one of these facilities. And that's really not the case. Right. It's sort of a narrow population that we're talking about?
- [05:42]
C
Yeah, that's a very good question. So we are talking about a very small subset of kids generally. So to give you some idea, there's between 400 hundred and 600 of these facilities in the entire country. Right. So we're not talking about a large number of facilities, and most of them are probably not more than the average number is probably somewhere between 50 and 75 beds. So we're not talking about an enormous number of facilities or children in these facilities.
- [06:06]
B
Just to put that into context, we have about 50 million public school students in the US so very small segment of the population, it sounds like. So you published a report for the Manhattan institute back in 2020, 2024, that found youth residential treatment programs have been have declined by over 60% since 2010, and the number of youth served has declined by nearly 80%. So one implication of that has been articulated in a recent report out of Congress finding that in 25 states, youth were being held in juvenile detention centers for days or even months because they were waiting for a placement in one of these residential treatment facilities. That was that that had no beds available and there was no other sort of safe and secure option for those youth. That's one concrete sort of downside of this now shortage of beds. Christina and Naomi, can you guys talk a little bit about some of the other implications you've written about these for us in City Journal, and we can link to those pieces in our show notes.
- [07:18]
D
So, I mean, I think one thing we need to look at too is the question of sort of not just who this population is, but why we're seeing a lot of these kids come into need these services. And so, you know, I do a lot of work in child welfare. And one of the things that I think we don't have a good sense of is that over the last basically couple of decades, we've made a decision in a lot of child welfare systems to leave children in abusive and neglectful homes for longer. We're not removing them as quickly. We've decided we want fewer kids in the foster care system. That is a decision that you can make. But the problem is that the implication is for some of those kids, that'll work out fine and their parents, their families will be rehabilitated and things will work out for them. But for some portion of those kids, that means that when we do finally remove them, they're going to be suffering, they're going to have suffered for many more years of chronic abuse and neglect. And that in Turn is leading to some of the mental health problems that we're seeing in this population and behavioral problems. Absolutely. That they're acting out, they've become a harm to themselves or others. And we have left them in these situations for so long that by the time we remove them, it's not really appropriate to just place them in an ordinary foster home. We need they. As soon as they come out, they're going to need probably a higher level of care because they are acting out so much and they are a danger to themselves or others.
- [08:53]
A
Yeah. As. As part of my reporting on Utah, which is kind of considered a hub of youth residential treatment facilities, I interviewed a juvenile justice employee who told me that half of the kids there were kids who basically had gotten kicked out of residential treatment programs. And he attributed it to a law that had been passed in 2021 that was championed by Paris Hilton and Senator Mike McKay in Utah, who placed restrictions on the types of restraint and seclusion that can be used. So now these youth who could have been helped in a residential treatment facility, it's too dangerous for them for staff to be able to keep them there anymore. And they get kicked out of the program, they end up in juvenile detention. And what some of the examples that he offered, I mean, this is. These are not youth, which is sort of mild distress going on. One of them had, you know, choked a female staff member unconscious, and it was no longer safe for them to remain in youth residential treatment. And now they're sitting in a detention cell. So normally they would have staff members would have had the tools necessary to be able to keep themselves safe and to restrain the child from being able to hurt anybody else. There's limits on what they can do now. They're ending up in juvenile detention instead. And this is happening more states than just Utah, a number of states, including Oregon and Michigan, others, maybe, that have placed these types of restrictions on restraint and seclusion.
- [10:34]
B
So we've got kids that are in the juvenile justice system because there are not enough ways that we can appropriately treat them in a therapeutic setting. We've got kids that are being left too long in the home. And another issue that's been being seen a lot are abandonment in ERs or boarding in ERs. So kids, their challenges are so complex, so difficult, that there. And there are no beds available, that they're either being boarded in ERs waiting for beds, or parents are actually abandoning them in ERs. So we're talking about real sort of like family disconnection that shouldn't have to happen. If we had more of a appropriate bed supply. So I want to talk a little bit about kind of how we got here, because there have been some sort of explicit policy changes that have led to this shortage. And there's also this kind of media or popular ideological narrative. So would anyone like to start off with talking about any of those explicit changes?
- [11:36]
C
I can maybe do the quick history and then maybe you guys can dive in where you'd like. The way I break down the decrease in access to residential treatment, decrease in number of children getting it, decrease in the number of beds, decrease in the facilities is three parts. It starts in the 90s, the series of state based policies, which are generally referred to as gatekeeping policies. The way to think about this is a series of states determined they wanted to use residential treatment less, so that anytime a child was referred to residential treatment, there was somebody there to redirect that child to another setting. So you can imagine if you're a residential treatment program in one of these states, your referrals for treatment are declining as they're pushing children to other settings. Even though the clinician recommended the residential treatment. It puts downward pressure on your ability to operate that facility and you see a decline in the 90s. Then fast forward to in the early 2010s. What you have is. I'm going to use some technical terms here for these next two. You have a change in how psychiatric residential treatment facilities, PRTFs are treated by CMS and so Centers for Medicare and Medicaid. Correct, Centers for Medicare and Medicaid. So for that first 1990s example, Illinois is like the poster child, is the poster child for that model of gatekeeping. For this 2010 issue, Minnesota is the poster child. And what happened was in 2000, around 2000, the center for Medicare and Medicaid Services put a definition in statute or a regulatory definition around PRTF psychiatric residential treatment facilities. And what they did was allow states to start reimbursing, getting reimbursement from Medicaid for providing services in these facilities. But then in 2010, starting around that period, CMS started enforcing these definitions very strictly. And the example that I used for Minnesota, or why I mentioned Minnesota, is because they did a report on this issue. And in the report it specifically says, we had an agreement with CMS for years that this was an appropriate use of the psychiatric residential treatment facility. We had agreed we had provided the service for children. And then CMS came in later and said that understanding that we had operated on for about 10 years was no longer in play and There was a new interpretation which resulted in a lot of these facilities closing. So that's prtf. And you saw the decline in that era. And then More recently in 2018, Congress passed the Family First Prevention Services act, which created a new definition for a separate type of residential treatment facility, qualified residential treatment programs. QRTPs. And essentially what this did was focus more on a foster care population than a general mental health population. But it's foster children who have a mental health condition. And the way they designed the bill was to say there's going to be rigorous standards that these facilities, these residential treatment programs that focus on foster kids have to meet. So upping all these standards, but not providing any reimbursement or funding to meet those standards. And what happened was providing these additional services, providing all these additional treatment options or other components of the law required money to do so, but they didn't have additional funding to do so. So a lot of them have to have closed their facilities. So that's the three stages of reductions in residential treatment over time.
- [14:41]
B
I'm just going to try and summarize those. So we have sort of mechanically depressed demand, we have maybe a little bit of overzealous enforcement of regulations and then new regulations that make it harder for providers to operate.
- [14:58]
C
Yeah, that's exactly right.
- [15:00]
D
And so I think, you know, to get to your question about kind of how this was being portrayed in the media and sort of how popular opinion has shifted, it wasn't just public dollars, a lot of private dollars shifted. There was a lot of philanthropic support for these kind of institutions. And that dropped away. At the same time, the narrative became that these facilities were abusive toward children. Christina can talk a lot about that, of course, but there was this a whole sort of general shift in public opinion there. And even the way Family first was presented, I think the narrative around it was, and this is a lot of child welfare is we're going to go upstream, we're going to sort of try to do a lot of these sort of amorphous kind of prevention things that will stop kids from ever entering the child welfare system. And then we won't ever need these kind of high level interventions at the other end. And it was a, it was a fascinating narrative. It just didn't have much basis in reality because all of these like prevention services that were, there's not a lot of evidence behind them, but you know, more parenting classes for, you know, for parents who are involved in the child welfare system or anger management or those things, those didn't actually turn out to have much of an impact on kids who have these high levels of need and these, these families that needed much more intensive services.
- [16:24]
B
And by the way, this is the same narrative that we had with the deinstitutionalization movement that shifted adults out of mental hospitals and into the community. The whole idea was, you know, oh, we can prevent mental illness upstream and treat people. Everyone in the community and everyone will be able to be adequately treated in the community. And as long as we give people
- [16:47]
D
counseling, connection, yes, all these things, yes. Better laundry facilities, all these things, like somehow that's stopping schizophrenia. And you're like, I'm sorry, where is that study? And that is exactly the narrative in child welfare too. It's like, yeah, how do these things really prevent that high. And you're always going to have kids with those high levels of need. But like I said before, I think you actually increased the number of kids with the high levels of need when you said, you know, we are going to leave kids in abusive and neglectful homes for as long as possible.
- [17:18]
B
We're also increasing a lot of false positives, which is something I've been writing about a lot in the last two years. We're doing all these sort of ubiquitous, like superficial, universal programs that just makes everyone think that they have a mental health problem, which pushes people towards the system, and then it's harder to spot the kid with the real problem or the real challenge and they just sort of get lost in the noise.
- [17:43]
A
Exactly the same thing in youth residential treatment where I recently did an investigation into California's youth mental health policies. They had, you know, defined a youth mental health crisis by severe outcomes, by emergency room visits increasing for self harm and suicidality. And then the Newsom administration devoted a significant sum of money towards broad based population prevention. Very few dollars allocated for the kind of psychiatric residential treatment facilities that could help kids who repeatedly access emergency rooms for crises. And the result was just a total mismatch between what was needed and what was offered to people.
- [18:30]
B
You sort of have too much of this superficial stuff, not enough of the intensive stuff. And no one's helped them where they're
- [18:37]
A
now, you know, turning schools into sites of mental health service delivery and offering ostensibly healthy children who are experiencing ordinary stress with psychiatric evaluations and therapy during class hours, build to insurance and a real misunderstanding of.
- [18:56]
D
By the way, I think the government's role here too, which is to say, like, you know, now the government sort of becomes involved in every aspect of every child's life instead of a core government function, which is really Protecting and trying to help the most vulnerable people who are in serious crisis. And those are cases where the private sector really is not, you know, often best equipped to help. Whereas, you know, in terms of just kind of fostering connections and communities, you know, I feel like a lot of that could have been outsourced to the private sector and maybe is not best done by your local public school.
- [19:32]
B
Totally. And we see this in the adult population as well. I mean, these are real mirrors. We have anyone in New York or San Francisco, major cities, sees the downside of this when they see the homeless schizophrenic who's deteriorating on the subway platform. And, and some tragedy happens that could have been prevented if we spend the hundreds of billions that we spend annually on mental health and wellness, broadly on a very small population who isn't being served by the private sector, just not
- [20:01]
A
being seen or talked about because of juvenile privacy laws. And I recently reported on a case, her name, Jasmine pellegrini, she's a 15 year old girl in California who was experiencing these sort of repeated mental health crises. She had had 40 admissions across 10 facilities in a two year period. They just repeatedly were offering her outpatient treatment and psychiatric stabilization, you know, which is typically like a six day stay in an inpatient hospital in California. They placed her in an unlocked facility. She ran away immediately, of course, was hospitalized briefly again, and then three days later she was just found dead on the streets of San Francisco. And this is somebody who her whole care team had said she needs long term psychiatric residential treatment facilities. California didn't have anything to offer her. And this is, this is where we end up. But her story is only public because her mother is suing state. She had relinquished custody in order to help her get access to. She was having so much difficulty accessing one of the only two facilities in California that is currently able to lock their doors and keep children there based on medical need, not an arbitrary time limit. And in California, they typically want to keep kids in the least restrictive settings for the shortest length of time, typically offering something like a one to three month type of residential treatment program, if at all. But it's very hard for them to even access that.
- [21:41]
C
Yeah, I want to say something on that because I think it also dovetails nicely with what Naomi said. And I think there's two challenges from an outsider perspective or policymaker perspective when it comes to residential treatment. And the two misconceptions that I think always come up is that a failure in the system has occurred if somebody's been placed in residential treatment. And I think that's the wrong way to think about it, right? The they think about it, oh, outpatient failed, partial hospitalization failed, and then somebody ended up there. But that's not really how it works. That level wasn't appropriate for them, and we found that out. And then they ended up going into residential treatment because that patient had a very specific set of conditions that was not appropriately treated at those levels. Not because those facilities did something wrong, those treatment programs did something wrong. It's because it just wasn't appropriate for that particular condition for that particular patient, which results in them. So the idea that a residential treatment for results from some failure lower down the chain is not necessarily true. But to approach policy from that way, you're gonna make bad policy. Cause you're thinking about those lower levels wrong. And then the other one that I think is really important to what you said is that we use from time to time, on the policymaking side, length of stay as a proxy for quality. And we're saying, this child's been there for a year. That means he's not getting good treatment there. That's too long. We should have shorter stays. So we try and shrink the length of stay. But the reality is, for this pat patient population with these conditions, longer lengths of stay are actually associated with better outcomes. So the policymakers are making these decisions about, oh, we're going to use length of stay as a proxy for the quality of a facility. This is what happened with QRTPs, and they're trying to put downward pressure on those lengths of stay. When the reality is we should be thinking about longer, more stable lengths of stay for these patients, because it's associated with those positive outcomes. And I think what you just said right there is so important.
- [23:32]
A
Exactly.
- [23:33]
B
Stability is key, I think, to this, because we know that it's really bad to have a lot of transitions, a lot of different environmental changes. And so if you can sort of have someone in the same stable environment, you can actually develop a treatment plan. You can really make progress. And especially from an education perspective, you know, if you have a child who's in and out of ERs, at what point do they actually not only get their health care services, but how do they keep up with their, you know, just basic schoolwork, when they're then sent right back to the traditional neighborhood public school? And so if you can have some type of stability, there's a lot more opportunity, I think, for real progress as opposed to being a band aid.
- [24:17]
D
I think, you know, a lot of the people that Christina's interviewed. It's their family members, by the way, who want them in these facilities, which I think is another kind of myth that's out there, that somehow the state is grabbing these kids and, and putting them in these facilities, you know, against their families. Well, as you, as you mention, you know, you have families who are literally legally abandoning their kids, not because they want to abandon them, but because they think that's the only way their kids can access treatment. And these are parents who are completely overwhelmed. They cannot be in a situation where they have to. They are monitoring a child 24 hours a day to make sure that they're not harming themselves or others. And you can't ask their families to do that. And you also can't ask foster families to do that, which we're also, you know, in the, in the habit of doing. So just, you know, trying to understand, break down, I think some of the myths about who, who needs these, these treatments and, and, and who is really pushing for them. It's the people who care about these
- [25:18]
B
kids the most, I think that's so critical here because these parents are, as you said, I mean, desperate, like waving their hands, saying we need support, we need this type of setting. But meanwhile we're going out and searching for all these kids who might have like a tiny bit of anxiety that needs like some little intervention when the people who we know need help aren't getting nearly enough. We're just asking far too much of families, I think.
- [25:45]
A
And there's another point to make too about repeatedly offering somebody short term interventions can end up reinforcing the cycle that some of these kids get into. Their behavior escalates, they enter into a crisis, they become a danger to themselves or others. They often enter the emergency room, at which point they may go to psychiatric hospital for six days and then they're sort of released back into the home and community. When they're offered maybe outpatient treatment like therapy or a day program, something like that, that stabilizes them temporarily, but they end up learning through this process to escalate into a crisis again. And it's just not sustainable. It's very disruptive to families and communities and schools. And it's really not healthy for the child. There's no incentive really to change the behavior and to get better. Until you put them into a setting like a long term residential treatment program where the incentives are gone and reinforcement is gone, they have no choice. They have to make some changes to their behavior, develop self control and learn how to regulate their emotions and Have a desire to get better and to return to the society that they came from and be able to manage their emotions and live amongst their family and community.
- [27:16]
B
So this is not the popular narrative we should say like we are, I think looking at this from a very clear eyed perspective. There are just going to be some youth who really need intensive services to get better. But, but the popular narrative isn't really like that. You sort of have these investigations for one off incidents that over sensationalize things. And Christina, you've written a little bit about this if you wanted to talk sort of about how the media can be a little bit of a problem here.
- [27:42]
A
Yeah, I mean, well in, I mean there had already been a policy disinclination towards institutionalizing use is what they often call it. But I think that really escalated in 2020. Paris Hilton came out and released a documentary about her experiences over 30 years ago in the youth residential treatment program in Utah. And with it she sort of began advocating for, she became, you know, some an anti troubled teen industry advocates and inspired a lot of other, mostly young women who went out, so had experiences many decades ago to come forward. And there's been so much negativity around residential treatment since then. A lot of media investigations that look at, you know, their testimonies, isolated incidents that have occurred and have, you know, created this narrative that, you know, these kinds of treatment centers are abusive systemically when the evidence doesn't really hold on to that.
- [28:53]
D
I just want to say, I mean, I think what's reinforced that and when you look at the testimony before Congress, whenever this issue comes up, what you get is, you know, the people who come testify are typically the people who are most, who feel that they have been most harmed by these centers. And you know, none of us are saying that abuse never happens in these centers. But the incentive is, you know, for the lived experience of the people who have experienced abuse. And the, the problem is that for people who have been helped by these kind of institutions, many of them have just gone on to live normal, happy lives and they're not flocking to Washington to go advertise their past before Congress, which I think is a very reasonable decision. But then you have to take into account that you're getting a kind of skewed understanding of what's happening in these facilities.
- [29:44]
B
A little bit of selection bias.
- [29:45]
D
Absolutely.
- [29:46]
B
So I think that's a good dovetail into what the evidence actually does say about residential treatment. Where can we sort of help dispel these common misconceptions about how residential treatment can be useful.
- [30:00]
C
Yeah. I think one of the narratives that comes out from the media and these media reports is the question of are these facilities safe? Right. And I think the way to look at that and the way to understand that from a larger perspective, not the sort of one off reports, but to look at an systemic view of are these facilities safe or not, is to look at a subset of facilities which are the psychiatric residential treatment facilities, PRTFs, they are certified by CMS, the Center for Medicare and Medicaid Services. And as part of that, they have to be surveyed by a surveyor for safety checks once every three years. And then after any report of a complaint about safety about that facility, and these reports are reported, these surveys are done and the results are reported to CMS in Baltimore. And CMS in Baltimore will publish the results of those by facility type. So general hospitals, so acute care hospitals, all these facilities that get surveyed have to report this data. And there's a database that CMS has that allows you to look at the rates of safety concerns at each facility. So if you violate a safety measure on the survey, it'll get reported to cms. You can organize them on the website. And if you look at the number of safety survey citations for psychiatric residential treatment facilities over the last 13 years, all every year, except for two, they've been lower. So lower rates of safety concerns at psychiatric residential treatment facilities than acute care hospitals. Two years that they were higher. But in, on average, a psychiatric residential treatment facility is, according to CMS data, safer than an acute care hospital. So when somebody takes their child to an emergency room or an acute care hospital for any other injury or takes them to a residential treatment facility, they are as safe, if not safer, at that psychiatric residential treatment facility from a safety standpoint than they are at a
- [31:54]
B
general hospital that says this is certainly not a systemic problem. And I mean, ers, when you think about it, they are just a sort of busy, stressful place to be. Do we really want to serve kids in ERs or worse, you know, juvenile detention centers than a therapeutic center or
- [32:14]
D
child welfare or offices or homeless shelters? I mean, the number of places that we. Inappropriate places that we are putting kids who are in crisis is just astonishing.
- [32:22]
B
Yeah.
- [32:23]
C
And I have to say this because it fascinates me every time when we think about this is the emergency room, the juvenile detention facility, the state foster care system. Children end up there because those facilities have to take them. Right. If a juvenile detention facility gets somebody sent to them, they take them. If the emergency department, same thing. There are residential treatment facilities in the United States saying, we want to take this child, we want to help this child, we want to make this child better so that they can live in the community. And the policy is saying, no, we don't want to send them there. We would much rather them go to the emergency department. We would much rather than go to the juvenile detention facility. And that's the thing that's just so hard to consider. The reason children end up there is because those facilities have to take them. But there's other facilities that are clinical that can help these children that want to take them. But our policy is made in such a way that they're not allowed to take those child.
- [33:15]
B
Not everyone is going to be able to be successfully treated in the community on an outpatient basis. And those kids don't disappear when the appropriate setting does.
- [33:25]
D
I think what's so frustrating is when I talk to people about sort of this crisis and you have of. For any number of reasons, this sort of just comes to the attention of the public. You know, they'll, they'll say, oh, did you see there, you know, in Philadelphia, you know, a couple years ago, the Philadelphia had. The Inquirer had this report that there were, I don't know, 90 kids sleeping in the child welfare offices. And people are sort of puzzled. We've created this problem through policy. I mean, it is not, by the way, like it. There has been, you know, as you say, sort of a lot of headlines about an explosion in mental health crisis or something like that. But this particular problem, these particular acute cases, we have sort of eliminated the possibility of putting them in appropriate places with the ability to sort of help them therapeutically. And we have sort of said, no, no, no, these problems will just disappear. And when they haven't, they've ended up in, you know, homeless shelters or offices. I mean, with caseworkers sleeping overnight in offices, or we're hiring off duty cops to stand in child welfare and supervise kids who are. Have been harmed to themselves or others.
- [34:38]
B
You're institutionalizing kids still just in a place where they're not actually getting any treatment.
- [34:42]
D
Yes.
- [34:44]
B
So going forward, what's needed, what is the current policy landscape and how can we sort of start making changes there?
- [34:55]
C
I think there's a couple things you can do. One is allowing more facilities to receive Medicaid reimbursement for the services they're providing. So there's a long standing issue when it comes to inpatient or residential mental health treatment in the Medicaid program, which a lot of these children are on that program through what's known as the Institutions for Mental Diseases exclusion. This is a longstanding prohibition on Medicaid dollars flowing to inpatient and residential treatment for individuals on Medicaid. That is a large challenge for appropriate reimbursement for these services. So I think there needs to be policy reforms in that space. I think the other really important one is there is a workforce. There's two more important ones. One, there's a real workforce challenge. I think there's the number of children versus the number of providers that are able to treat children. I think there's an asymmetry there that needs to be balanced out through policy. But I think the last one, and I think it's a really important one, is we focus so much from the policy perspective. And Christina talked about this about, and you've obviously written about it too, Carolyn, making sure our schools have mental health services available in them. But from this patient population perspective, you need to start thinking about better education in these residential treatment facilities. How are we educating the kids there? How are we allowing the services and the dollars to follow that kid when they have to leave the school because of a mental health condition and they're now in a residential treatment program? How are we making sure that that facility is getting the help and the support and the funding it needs? I know of a facility that I visited last year, and they actually had to start their own private school inside the facility because they couldn't get the right quality of teachers to come in and teach the school. So what they did was form their own private school inside a hospital. That is the type of thing that we should be incentivizing so that these children can get those education services. Because if you think about a child who was pulled out from their school, they're sent to a residential treatment facility, they are getting the clinical supports that they need, but that facility is not getting the educational funding to keep that child at grade level. When that child then returns to the school, they're going to be behind all of their peers. And that creates a whole separate issue about graduating and the future of that child. We can address that by making sure these residential treatment facilities have the ability to educate the kids and the money follows the child to that facility so that they can provide those services.
- [37:25]
B
I think it's important to just point out something about what you've said about sort of focusing mental health resources in schools. Just at baseline, the population that we're talking about, they are least likely to be served or treated or even in the traditional neighborhood public School, classroom. They are so severely in need or so high acuity that they are being already sort of out of that population. So we're putting a lot of workforce effort into putting school counselors in the traditional public school or social workers. Really, where the workforce shortage is is these more intensive settings.
- [38:03]
D
And I just want to add to Scott's list the insurance problems. A lot of these residential treatment facilities are having a great deal of trouble getting insurance. They have seen their insurance rate skyrocket. That's related to kind of larger problems that we have about tort reform. You have, in recent years, a number of states have eliminated the statute of limitations on suits over, let's say, sexual abuse at schools or other kinds of facilities. And the result is that many of these facilities cannot afford insurance because the insurance companies know that they may have to pay out, you know, 10 million, 20 million, $30 million payout for something that may have happened, you know, 40 years ago. The city of Los Angeles, I can't remember the number they entered. I think they had a $50 billion settlement. I don't know if I'm remembering that correctly. Yes, you know, because of abuse that happened in a facility 25 years ago also, by the way, now they're finding that many of the claims about that particular facility may have been fraudulent. But regardless, the city agreed to pass pay it out. And now the question is, if you're an insurer that is looking at one of these facilities and they want to provide insurance, you have to say, no, we can't do that. We can't absorb those kinds of costs. So we need to find a way to make sure that these facilities are insured. And that's probably going to involve some kind of reform over these lawsuits. But in the meantime, we have to come up with other ways to fix that.
- [39:36]
C
I have to agree with you 100% on that, and I should have said it. So I'm glad you said it because that the ones that I talked about are important. Right. These are sort of systemic things. But if you talk to any residential treatment program, anybody dealing with foster kids right now, every single one of them will tell you those other issues are important. But the urgent one for us right now is the insurance one. So it is way more timely than the other one. The other ones have sort of been percolating for a while and things that need to be fixed if we want to turn around the system. But that urgent one, if you talk to any facility in the country right now, they're going to say we are very, very Worried that we can't get the insurance, we just can't provide care. Right. It's a condition of participating in these healthcare programs that you are insured. And if they can't get the insurance, they can't treat these.
- [40:17]
A
There is a real breakdown in communication between policymakers and the people who have firsthand experience in dealing with youth who have severe emotional and behavioral mental health crises. And I've written about this in my reporting, especially in Utah, when there are, where they're forming new policies and making laws, they exclude the treatment providers from the process. And then you get, I mean, this is, that's how we end up where we are now in California, same story. They, you know, respond to these kind of media panics and activist pressure. They eliminate some form of care without an adequate replacement. And you see it happening over and over.
- [41:01]
D
And they're excluded because the providers are deemed to be like greedy capitalists who only want this if you want to make money. This is not what you go into, just to be clear.
- [41:11]
A
But yeah, that's one of the popular narratives. They're just sort of raking in all this money by abusing kids. That's something that the anti treatment activists like to say.
- [41:21]
B
But I think that is a useful sort of segue to the sort of final change that we need to think about. And that is this sort of broader ideological conventional wisdom that's misguided and that is that every child can be appropriately treated in the community on an outpatient basis, I think that's a big issue. We just have realized that that is not a reality. And we also have this sort of instinct to be against. I don't want to say discipline, I want to say structure. But structure is what a lot of kids need rules to understand. This is sort of how you can get better by these rules. If we incentivize kids to sort of continue to behave in a way that's going to get them, you know, attention in by being sent to an er. I mean, they may really need this attention because they're a neglected child. But if this is a cry for help, there are better ways to address that cry for help than continuing to see these youth cycles. So having this narrative change, narrative shift around structure and rules, I think is one place that we can think about change.
- [42:33]
A
Right? I mean, discipline doesn't sound nice, but it's short term and it can help in the long term. And people are just very wary about, oh, we don't like behavior modification. But you know, behavior is being shaped either way. You're either shaping behavior towards continued destabilization and recurring crises, or you're shaping it towards stabilization and long term better outcomes.
- [42:59]
C
And I think there's a very good story that a gentleman who runs a facility told me about this exact issue. So they had somebody come in, a child come in to their facility. He had looked at the history and there was a lot of churn, right? Lots of different placements, emergency rooms, all sorts of things. So the kid comes in and in the first week he pulls the fire alarm. So it's a huge challenge if you're in a residential treatment facility to get these kids the fire drill. So they organize everything, they get everybody out of the building, they bring everybody back in. And he sits down with this kid to sort of figure out what happened here. And after talking to him for a while, he eventually gets to the point where the kid says, well, I know if I pull the fire alarm enough, you're going to kick me out of here. And he goes, we're not going to kick you out of here. We're going to help you get over that and we're going to make you comfortable here and we're going to create a new relationship between you and the adults here. Now that is discipline, saying, we are not going to kick you out. But there are times where children are trying to do that so that they can churn through the system, right? They don't want to be at that facility. That is a behavior that you can work on and you can correct. And I think that's the type of thing that residential treatment programs, when given enough time to do it, can really change that child's life because he clearly did that because he had done it before in a crazy work, right? And he now got to a facility where they've said, no, we're going to work on this so that that doesn't continue to happen.
- [44:12]
B
And that's system taking accountability correct. Any last thoughts before we wrap up? I think that was a positive note to end on. So thanks so much for, for having this conversation and hopefully we can start talking about more reasonable sort of common sense solutions for the kids who are really not most in need.