. 2022 Jun 23;49(5):834–847. doi: 10.1007/s10488-022-01201-6

Table 3.

Illustrative quotes from policymakers and advocates in reference to the three highest ranked policies

Policy	Included the policy in their most important policy list	Did not the policy in their most important policy list
School-based mental health services	Participant 8, SMHA: I think this is very important to have mental health services more accessible to children and their families. Especially in rural areas, the mental health clinic might be located far away from the school or the family's home… the school might notice things that maybe the parent hasn't noticed at home yet….if there's school-based mental health services, their teachers and counselors can easily refer the child for screening within the school and they can get screened and assessed earlier than they would be without the school-based mental health services.” Participant 11, SMHA: School-based mental health services seems like that's a no-brainer. That's where kids are Participant 1, NGO:…both sides of the aisle believe that kids can’t control the cards that are dealt to them, and they agree that school should be a safe place for them to really be able to grow and nurture their interests or their future trajectories. And so there’s generally been a conversation about how schools need to improve to more holistically address the diverse needs of students	Participant 2, NGO: If you’re a pre-school in a school-based setting, please don’t just use your school social worker as your consultant because they’re not going know, nine times out of ten, the infant and early childhood space Participant 12, SMHA: Schools traditionally don’t have the infrastructure to bill medical claims. And so that’s been the challenge Participant 13, NGO: My concern is that even in middle school and younger, most all our effective interventions are going be family-based, or should be, and it's very difficult to do that well. I don't think that that has been the typical service model versus just pulling the kid out of class time or something… I'd be more comfortable if it was school-based mental health with families
State mental health parity	Participant 3, NGO: We enacted mental health parity as a state when we were directed to do so to conform with federal law. When I raised that as the primary issue it’s not so much in that it doesn’t exist legally but in the actual implementation of that. When it comes to children, I think there is a lack of understanding on parents’ part, so just helping people understand, policymakers, parents, practitioners, educators, all understand just that mental health is physical health. Mental health is the same as physical health and you go to the doctor and your insurance will cover it Participant 7, SMHA: There technically is legislation and policy that makes mental health and physical health parity, but it's not enforced or overseen or regulated. I think a lot of the crunch on middleclass people who have health insurance but cannot afford the copays every week or month for outpatient therapy. The middleclass, that's where I think a lot of mental health work needs to be done	Participant 9, NGO: No, I think it's super important. In XX, the parity bill was passed into law. We looked at going forward with a reinforcement amendment on that bill, but we went out and queried our providers, and it turns out there is no issue with parity in XX Participant 11, SMHA: I'm just not seeing it in XX as being a problem. Maybe it's not perfect, but I see parity pretty regularly. If other states are struggling with that, I'm not gonna disagree that [parity] is a huge thing. Here's the other thing – when you do parity, then behavioral health care is medicalized. And that's not universally seen as a good thing by everybody
Increased Medicaid reimbursement rates	Participant 7, SMHA: I think increasing reimbursement rates for mental health services would help to bolster the community mental health workforce because you can attract talent with more competitive salaries and benefits at the agencies that are supporting these staff. Just being market competitive, right? Participant 9, NGO: All of the children's programs reimburse sub-cost largely because they only pay for actual treatment. It's become increasingly difficult to provide a continuum of children's care given the low-cost reimbursement across the continuum…Many of our children are sent out of state. Our providers are reimbursed so low for psychiatric residential treatment facilities that they have to take kids from outside of XXX to subsidize the kids that are seen in XXX, which reduces the number of beds available for XXX kids. Then they send the XXX kids out-of-state at 133 percent of in-state costs. So my argument is, pay the XXX providers slightly more. You still save money from the out-of-state providers and start paying their education costs, which we can track outcomes on and provide a much higher quality service	Participant 1, NGO: No, I agree with them. I just stayed away from Medicaid mostly because there’s just a widespread refusal by our current governor to do that, and that refusal has existed since the Affordable Care Act was passed. I just didn’t see them as feasible, so they weren’t a priority for me Participant 6, SMHA: I’m not surprised to see increased Medicaid reimbursement rates. I hear that from our providers, actually, so I’m not surprised to see that on the list

Policy

Included the policy in their most important policy list

Did not the policy in their most important policy list

School-based mental health services

Participant 8, SMHA: I think this is very important to have mental health services more accessible to children and their families. Especially in rural areas, the mental health clinic might be located far away from the school or the family's home… the school might notice things that maybe the parent hasn't noticed at home yet….if there's school-based mental health services, their teachers and counselors can easily refer the child for screening within the school and they can get screened and assessed earlier than they would be without the school-based mental health services.”

Participant 11, SMHA: School-based mental health services seems like that's a no-brainer. That's where kids are

Participant 1, NGO:…both sides of the aisle believe that kids can’t control the cards that are dealt to them, and they agree that school should be a safe place for them to really be able to grow and nurture their interests or their future trajectories. And so there’s generally been a conversation about how schools need to improve to more holistically address the diverse needs of students

Participant 2, NGO: If you’re a pre-school in a school-based setting, please don’t just use your school social worker as your consultant because they’re not going know, nine times out of ten, the infant and early childhood space

Participant 12, SMHA: Schools traditionally don’t have the infrastructure to bill medical claims. And so that’s been the challenge

Participant 13, NGO: My concern is that even in middle school and younger, most all our effective interventions are going be family-based, or should be, and it's very difficult to do that well. I don't think that that has been the typical service model versus just pulling the kid out of class time or something… I'd be more comfortable if it was school-based mental health with families

State mental health parity

Participant 3, NGO: We enacted mental health parity as a state when we were directed to do so to conform with federal law. When I raised that as the primary issue it’s not so much in that it doesn’t exist legally but in the actual implementation of that. When it comes to children, I think there is a lack of understanding on parents’ part, so just helping people understand, policymakers, parents, practitioners, educators, all understand just that mental health is physical health. Mental health is the same as physical health and you go to the doctor and your insurance will cover it

Participant 7, SMHA: There technically is legislation and policy that makes mental health and physical health parity, but it's not enforced or overseen or regulated. I think a lot of the crunch on middleclass people who have health insurance but cannot afford the copays every week or month for outpatient therapy. The middleclass, that's where I think a lot of mental health work needs to be done

Participant 9, NGO: No, I think it's super important. In XX, the parity bill was passed into law. We looked at going forward with a reinforcement amendment on that bill, but we went out and queried our providers, and it turns out there is no issue with parity in XX

Participant 11, SMHA: I'm just not seeing it in XX as being a problem. Maybe it's not perfect, but I see parity pretty regularly. If other states are struggling with that, I'm not gonna disagree that [parity] is a huge thing. Here's the other thing – when you do parity, then behavioral health care is medicalized. And that's not universally seen as a good thing by everybody

Increased Medicaid reimbursement rates

Participant 7, SMHA: I think increasing reimbursement rates for mental health services would help to bolster the community mental health workforce because you can attract talent with more competitive salaries and benefits at the agencies that are supporting these staff. Just being market competitive, right?

Participant 9, NGO: All of the children's programs reimburse sub-cost largely because they only pay for actual treatment. It's become increasingly difficult to provide a continuum of children's care given the low-cost reimbursement across the continuum…Many of our children are sent out of state. Our providers are reimbursed so low for psychiatric residential treatment facilities that they have to take kids from outside of XXX to subsidize the kids that are seen in XXX, which reduces the number of beds available for XXX kids. Then they send the XXX kids out-of-state at 133 percent of in-state costs. So my argument is, pay the XXX providers slightly more. You still save money from the out-of-state providers and start paying their education costs, which we can track outcomes on and provide a much higher quality service

Participant 1, NGO: No, I agree with them. I just stayed away from Medicaid mostly because there’s just a widespread refusal by our current governor to do that, and that refusal has existed since the Affordable Care Act was passed. I just didn’t see them as feasible, so they weren’t a priority for me

Participant 6, SMHA: I’m not surprised to see increased Medicaid reimbursement rates. I hear that from our providers, actually, so I’m not surprised to see that on the list