Youth mental health concerns were on the rise before COVID-19, study finds

Younger people and children were seeking out more mental health resources even before the COVID-19 pandemic began, according to a new report from the Employee Benefit Research Institute (EBRI).

The analysis is based on claims data from employer-sponsored plans gathered between 2013 and 2020, so it does not reflect the ongoing impacts of the pandemic and may not fully capture the soaring demand in 2020 alone. EBRI found that spending on addiction and mental health rose from 6.8% of total healthcare costs in 2013 to 8.2% in 2020.

Employers and workers spent about $77 billion on mental health and substance abuse in 2020. People 25 and younger make up 36% of the U.S. population, and, while they accounted for 20% of overall healthcare spending for 2020, they accounted for 42% of spending on mental health and substance abuse.

Of the six age groups included in the study, spending on mental health and substance abuse for children 18 and younger increased the most, from 12% of total healthcare spending in 2013 to 18% in 2020, a 55% increase.

Valerie Barton is the executive director of the Youth Mental Health Project, a not-for-profit organization that advocates for better mental health care for youths.

“Because my organization helps parents and caregivers who are struggling to raise children with mental health issues, we know that that age group is highly vulnerable, from a mental health perspective, as they transition into adulthood and certain mental health conditions [such as schizophrenia] become fully developed,” Barton told Fierce Healthcare. “Health insurers can be allies to this group through public campaigns to normalize seeking treatment for mental health conditions at an early age.”

Young adults also need support. The 25-to-34 age group saw a 50% increase for mental health spending, from 7% to 10% from 2013 to 2020, according to the EBRI. The EBRI issue brief states: “Enrollees ages 45–54 experienced a 3% increase in spending, while those ages 55–64 experienced a 5 percent decrease when looking at spending on mental health care services as a percentage of total health care spending.”  

The COVID-19 pandemic appears to have made employers more aware of, and responsive to, mental health and substance abuse. And “higher spending will continue to be of great concern to plan sponsors,” according to the EBRI. Plus, what concerns employers also concerns commercial health insurance plans. 

“Health plans need to consider whether they have network adequacy to address the demand for mental health services,” Paul Fronstin, Ph.D., director of health benefits research at EBRI, told Fierce Healthcare. “To the degree they can’t meet the needs of their population, there may be longer term consequences.”

Insurers don’t have that network adequacy, according to an issue brief in February by America’s Health Insurance Plans (AHIP), the largest health plan lobbying organization in the country. The paper describes the challenges health plans face, which include “the size of the existing behavioral health workforce, the strength of available evidence and standards for assessing behavioral health care treatment and the consequent state of quality measures applicable to behavioral health conditions, and the readiness of providers to implement integrated care models.”

David Allen, AHIP’s director of communications and public affairs, told Fierce Healthcare that despite the challenges, health insurers “have been very active around the issue of mental health.”

In an AHIP survey of health plans covering about 95 million enrollees released in August, 89% of respondents said they’re actively recruiting mental health providers, and 72% said they are training primary care physicians to better care for patients with mild to moderate mental health problems.

And the AHIP issue brief names names, touting how some dozen or so health plans provide innovative mental health and substance use services. Allen adds that he anticipates “additional mental health resources focusing on young adults and children to be released very soon.”

Some experts aren’t convinced that health insurance plans are doing all that they can.

Greg Fritz, M.D., is the editor of the Brown University Child and Adolescent Behavior Letter and at one time served as president of the American Academy of Child and Adolescent Psychiatry.

“Due largely to decades of stigmatization of mental illness, psychiatric illnesses have long been underdiagnosed and then undertreated when they are recognized,” Fritz told Fierce Healthcare. “Systematic discriminatory tactics by payers and governmental agencies against those with mental illness through unequal and unfair managed care and payment practices were motivated by the desire for cost savings. Discriminatory practices continue to this day despite federal mental health parity legislation, at least partly because residual stigma made those impacted reluctant to come forward.”

The good news, said Fritz, is that psychiatric treatments have improved greatly because they are more evidence-based. Still, “we are experiencing a perfect storm in which a pattern of grossly underfunding mental health services is combining with the pandemic-induced higher prevalence of psychiatric disorders in a population newly less restrained by stigma and more demanding of treatment. It’s time to pay the piper.”

Barton said that “what I know from traveling around the country for my work is that communities are thinking of creative ways, such as peer-to-peer counseling, to fill these gaps, and these actions, though helpful to families, would not show up in claims data since they are rarely covered providers. Health insurers may want to consider thinking creatively and partnering with the physician community to address this shortage of front-line mental health providers.”

Fronstin says that “often young adults and children don’t get the mental health services they need in time. I can see situations where unaddressed mental health needs lead to greater use of inpatient medical services, and/or suicide. … Parents may need to take time away from work to address the mental health needs of their children.”

Danielle Carr, an assistant professor at the Institute for Society and Genetics at the University of California, Los Angeles, argues in The New York Times that social determinants of health should be considered in discussions about mental health and substance abuse. It’s no surprise that more people deal with mental health problems during a world-altering pandemic.

“A crisis that affects mental health is not the same thing as a crisis of mental health,” wrote Carr.

“If someone is driving through a crowd, running people over, the smart move is not to declare an epidemic of people suffering from Got Run Over by a Car Syndrome and go searching for the underlying biological mechanism that must be causing it," Carr added. "You have to treat the very real suffering that is happening in the bodies of the people affected, obviously, but the key point is this: You’re going to have to stop the guy running over people with the car.”

Carr argued that the underlying cause of much mental illness involves an absence of those things that alleviate stress: education, food security, housing, childcare, job security.

“A fight for mental health waged only on the terms of access to psychiatric care does not only risk bolstering justifications for profiteering invoked by startups eager to capitalize on the widespread effects of grief, anxiety and despair," she wrote. "It also risks pathologizing the very emotions we are going to need to harness for their political power if we are going to win solutions.”