Transcript
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We have Nia West-Bey with the National Collaborative for Transformative Youth Policy. And then we also have Alex Briscoe from Public Works Alliance. So you’ll hear from them today. I’m excited to welcome them to the webinar. They have some great information
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With that, I’ll just tell you a little bit about the agenda, and then I’ll turn it over to Nia. So Nia’s going to start us off, and Neil will be talking about the Mental Health Care Apprenticeships that young people need, and she will be talking about the Medicaid explainer. So she’s going to go through all things Medicaid.
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And then we’ll have Alex coming in, and Alex will be talking about reimagining healing, leveraging Medicaid’s new provider classes to address the youth mental health crisis. So we’ll go in that order. We’ll have Q&A throughout. So if you have
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A question at the end of each session, we will kind of open it up for Q&A. But if we don’t get to your question by chance, because we do have, 60 min will also be developing a QA document that has the, questions
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And the responses to that, that we’ll email out, and you’ll also get a copy of the recording. So with that said, we’ll get started with Nia. So, Nia, I will turn it over to you to get us started.
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Thank you so much for that intro, Kim, and hello, everybody. Welcome. So glad to see you here. As Kim already mentioned, I am Nia West Bay and I am the Executive Director of the National Collaborative for Transformative Youth Policy based in Washington, D.C. We can go to the next slide
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So our mission is to work with young people and community to achieve transformative policy and systems change by young people, for young people. We do that in a number of different ways and on a number of different topics in our collaboration with the partners that you saw on the earlier slide
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is a part of that effort at the intersection of youth workforce development and mental health.
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Next slide.
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And Kim already gave you an overview about the APA 2 project, and there’s some very important disclaimer language over on the right of the slide that you should take a minute to read. But we really entered into this space, as I mentioned, because we have a strong focus in our policy work on both youth economic justice and youth mental health
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And this project really sits at the intersection of those two issue areas and allows us to bring together our expertise in youth workforce development, in pre-apprenticeship and apprenticeship. And when I say our, I mostly mean my colleague Noelle
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And our expertise in youth mental health, including a focus on Medicaid and how it can support young people’s mental health.
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Next slide
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So really, before we get into it, we want to get a little bit of a feel for who I’m talking to today. Folks have been introducing themselves in the chat, but we have a poll question for you to just do a little bit of a temperature check on your Medicaid knowledge. So if just quickly you could click
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Anything from 1 to 5, or one being Medicaid what, and a 5 being I’m an expert, I know everything about Medicaid. Where would you put yourself on that scale? And we’ll just give folks a few
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Seconds to respond, maybe 30 or so.
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And then, Kim, once it feels like most folks have responded, you can go ahead over to the results. We’ll see where we are.
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Sounds good.
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Absolutely. So it looks like we have about almost 75%. So we’ll keep it open for maybe 10 more seconds. If anybody wants to chime in.
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All right, I will share the results.
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All right, I love it when we are talking to the right people. So our largest contingent was a one. I don’t know anything about Medicaid. That’s fine. I hope that will move by the end of this conversation. We have some twos, and then we have some threes, almost no fours or fives
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So that means we are absolutely talking to the right audience. Our purpose in developing the brief that we have here and this presentation today is really to talk to folks who don’t know a lot about Medicaid, who don’t have a lot of experience in that space, maybe don’t, you know, it doesn’t come up in your day-to-day work
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But really inspired by the fact that we do work heavily with young people, as I mentioned, and we actually did a version of this webinar for some young people, several sets of young people at this point, because a lot of times there’s a lot of sort of mysticism around Medicaid and, oh, it’s just too complicated and we can’t get it
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Yes, you can. The young people got it. Y’all will get it too. And the goal with this piece was really to make it feel more accessible to folks who maybe don’t normally do this work as an entry point to think about how it might be related to your work. So today we’re going to start really basic and get pretty technical by the end
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But we’ll do a bit of an overview of the Medicaid program, why it’s different in different states, some really important policy developments over the last 25 years or so in this space that shape how things are looking at the state and local level
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We’ll talk about Medicaid and mental health care
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The specific group of professionals that we’re working on in the ABA2 project that we are referring to as shared experience professionals
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how Medicaid thinks about provider training, and then what it could look like to marry apprenticeship and the Medicaid system. And I’ll just flag, when we put out the slides, that image on the right is actually linked to the brief that has all this information in detail, because we’re only doing about 20 minutes’ worth today
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Okay, so I’m going to start with the thing that for a lot of people is what makes it be Medicaid what? And what is the difference between Medicare and Medicaid? So these 2 programs were both started by the same piece of legislation in the same year
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But are different in a few key ways. First of all, they are authorized by different sections, so the Medicare program is Title 18 of the Social Security Act, while the Medicaid program is Title 19 of the Social Security Act. And then we have these important differences in terms of eligibility, control, and funding
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Now, it is always more complicated than it seems, but, like, high level, these are the things that you should remember about what is different between these 2 programs. First, in terms of eligibility, generally, Medicare eligibility is tied to age. So it’s about being 65 years of age or older
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Whereas Medicaid eligibility is generally tied to income. So it’s usually for folks who have low income, some other specialized populations. But that’s the general rule. My mother-in-law has Medicare
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My son, who we adopted out of the foster care system, had Medicaid
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Just to help you sort of see what are the different types of populations that access these programs. Then there’s a piece that is about who controls the program. The Medicare program is wholly controlled at the federal level. So the federal government, if they say something goes for Medicare, then it goes for every state in the country, anywhere in the country, anywhere where anybody is on Medicare
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Medicaid is a state and federal partnership, and we’ll come back to that. But that means you can have many more differences in what the Medicaid program looks like from one state versus another state.
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And then last but not least is funding the Medicare program. All of us have seen Medicare deducted from our paychecks on our payroll taxes. So that is what funds the Medicare program versus the Medicaid program is a state federal partnership. So there is some portion that is paid by the federal government, and then there’s also a portion that is paid by the states.
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Because we are really focused on young people and young people’s mental health care, we’re going to hone in on Medicaid for today.
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So I just mentioned Medicaid can be very different in different states, even states that are right next to each other. And there are a number of reasons why that can happen. First of all, every state that has a Medicaid program and every state in the United States, as well as every territory and the District of Columbia
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has a Medicaid program. Each state has to have a state plan which governs what services they can provide, how much they’re going to pay, everything about what the program looks like in that state. So, since each state has their own approved plan that they can come up with within a few, like, specific guidelines
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They can look pretty different from one state to another. For example, some states might cover medical transportation while other states might not cover that, or some states might pay providers of a particular type a particular rate that is twice as high in the state right next door
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So how states set up their state plans is really important to what the program looks like in the state.
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A second piece that is important is what are called Medicaid waivers. So within Title 19 of the Social Security Act, there’s a bunch of requirements in there, many of which you just have to do them. That’s sort of core to the program. But there are opportunities through what are called 1115 waivers or demonstration waivers
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For states to try some different things that maybe don’t meet the normal requirements. So the biggest ones are that the Medicaid program says that if it’s available for people on Medicaid in one part of the state, has to be available to people in all parts of the state
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And then a second big one is if a service is available that one person has Medicaid, it has to be available to everybody else who has Medicaid, right? So that’s called statewideness and comparability of services.
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What the 1115 waivers allow you to do is to waive either or both of those requirements to maybe you want to focus on a particular population, like young people or folks experiencing homelessness. Maybe you want to focus in on select counties within a state because they have higher need or have some kind of issue
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And so it is through these 1115 waivers that states get the opportunity to make those kinds of changes where they don’t have to do it for everybody at the same time. But again, different states put in different waivers for different things that can change what the services look like in a state.
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And then last but not least, the federal medical assistance percentage or FMAP.
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This is the amount of match that the federal government is going to provide to the state for the Medicaid services that they’re providing. And this can range because it’s made based on the population of the state, what median income looks like in the state and all those kinds of things. So it can both vary just in general by state
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And then sometimes the federal government does leverage FMAP to try and incentivize states to do particular things. We’ll come back to this in a minute. But when you think about the Affordable Care Act and Medicaid expansion, there was an FMAP incentive, a higher match rate from the federal government
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That was to encourage states to take up this expansion of the Medicaid program. Or we’ve had examples where there’s maybe an increased match rate for a particular service, like crisis response services when the 988 crisis hotline was launched
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So as I mentioned, the federal government can’t dictate everything as far as the Medicaid program because of that federal state partnership, but they do sometimes use FMAP as a tool to try and incentivize states to do certain things
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But it’s just that an incentive, it’s not a requirement. So again, we can have variability depending on how states take that up.
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Next slide.
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So, as I also said at the top, we’ve had some really important policy developments as it relates to Medicaid since the year 2000 or so. The 1st one I already alluded to was the Affordable Care Act, or Aca, or Obamacare, as you might know it
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There are many, many, many components of that bill, but it did do a lot in terms of reducing the number of folks who are uninsured in the United States. And I already alluded to Medicaid expansion as one of the key pieces of that, where basically there was an enhanced FMAP. Initially, it was higher, it’s dropping down slowly over time
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for states to make the program available to folks up to 138% of the federal poverty level. So basically making more people eligible for the program than had been in the past.
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But as we’ve also flagged, this is a choice. It was an incentive, not a requirement, as the Supreme Court says. So as of right now, there are 10 states that are in green on this map that have not expanded Medicaid. And so what I’ll flag for the purposes of this conversation
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Is those states all have much higher uninsured rates than the states in the blue, and particularly for young adults, because part of what the Medicaid expansion did for young adults is in the same way that under private insurance in the ACA, parents were able to keep kids on their insurance up to age 26
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Medicaid expansion let young people whose parents don’t have employer-sponsored health coverage or whose parents can’t afford to keep them on their plan gave them away into health insurance so that they weren’t just getting dropped off of Medicaid as soon as they hit their 19th birthday.
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So just to flag, this is a huge piece. It made a cover, you know, got a lot more people insured, but in the places where states have not chosen to do that expansion, we continue to have higher uninsured rates for young people, especially.
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Next slide.
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Another key piece is the mental health parity and Equity Addition Act, which was passed in 2008. I feel like I’m getting to a place where fewer and fewer people remember the days before the Affordable Care Act, but I certainly do. Hopefully, maybe some folks on this call do as well
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But before the Affordable Care Act, there was actually no requirement that health insurance plans had to cover mental health
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And those that did often made it more expensive or more difficult for people to access than physical health care. So the mental health parity and Equity Addiction Act was trying to address that by saying, hey, you can’t have more barriers to accessing mental health care
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than you have in your plan for accessing physical health care. Now, there’s lots of issues here in terms of enforcement, but it established an important principle that your mental health care is just as important as your physical health care and that your insurance company
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Should not be putting up barriers to you accessing mental health care. One important note is that because Medicaid is a partially federally sponsored program
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Medicaid is not required to follow the mental health parity and Equity Addition Act, but
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A lot of Medicaid, which we’re going to get to in a few slides from now, is managed by private health insurance companies now. And so those plans actually are accountable to many of the terms of this act.
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Next slide.
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Last but not least, we’re going to go to a very recent one just last year, the one big beautiful bill act, otherwise known as H.R. One that was just passed last year. That bill has made a bunch of changes to Medicaid that are just now starting to go into effect
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And we’ll be rolling out over the next several years. The long and the short of it is that these changes amount to massive cuts to Medicaid over the next
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Several many years. Basically by increasing the frequency with which people have to prove that they’re eligible for the program, imposing work requirements, and again, particularly as this relates to young people who are sort of just starting out, learning how to navigate bureaucracy
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A lot of paperwork requirements, which is what work requirements actually end up being, are particularly developmentally inappropriate for young adults and is particularly tough for them to meet these burdens. So if nobody’s told you, I am predicting that a lot of young people are going to lose their health insurance coverage
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And what is already one of the populations that has one of the highest uninsured rates of any group in the US, we’re going to see that get worse over the next few years.
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Next slide.
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Okay, so that’s things going on at the federal level. Now we’re going to touch a little bit on Medicaid and mental health care. This is that slide that I was talking about that I said we were kind of come to in a few minutes.
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Sometimes people don’t know this, but a lot of times, most of the time, for 75% of people on Medicaid at this point, they’re actually getting their Medicaid through a managed care plan. So their Medicaid plan is being administered by Aetna or Blue Cross or like one of these companies that we know as a private health insurer
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And there are a couple of ways that states sometimes set this up as it relates to mental health. There’s one model known as a carved in model where the same managed care entity that is doing physical health, generally speaking, is also responsible for
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For mental health. At this point, this is the more common approach. There are pluses and minuses to that model, but it impacts who we as workforce providers are potentially partnering with to foreshadow later on. The other approach, which is a carved out approach
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States tend to use either a specialty mental health care organization, so they are
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taking their mental health services and putting them under a different umbrella than their physical health care services. Again, pluses and minuses there in terms of specialization. But the thing I’ll highlight as it relates to the particular mental health professions that we’re talking about
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is when folks carve these services out, they tend to be a little bit more traditional in how they pay for things.
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So a lot of times they’re using what’s called a fee-for-service model. They’re reimbursing for 15 minutes of service at a time in a particular increment, which can be particularly challenging for the types of fields that we’re talking about
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Next slide.
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Another key piece that I want to flag is there’s another set of waivers. I mentioned 1115 before. There’s another set called 1915C and 1915I waivers, better known as or otherwise known as home and community-based services waivers
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These waivers were set up to allow Medicaid to pay for services in the community to keep folks from needing a higher level of care generally in an institution. And many states have home and community-based services waivers
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Including for behavioral health care services, and not only that, because of these waivers, there’s actually been an increase in demand for community-based providers to meet all of the need of all the eligible folks in the community
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So this is a really important piece of how we think about the shared experience professions and how folks in general, and young people in particular can get the support that they’re looking for in their community and in spaces where they already live, work, and play
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Next slide.
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So let’s get back to those shared experience professionals. What am I talking about? There are a set of folks that maybe might be less well known in that space, but are actually preferred by young people for receiving mental health support. Those are things like
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Peer supporters, which are folks who have lived experience, particularly for young people with the mental health system, with the foster care system, with the justice system, any of these places, that lean into that lived experience to provide support to other young people in a similar situation
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We have community health workers who are people deeply embedded in their communities, usually from the community, that provide services and supports to folks in that community. This map, take a minute, find your state on here, conveys a lot of information, but what I want to highlight here is every state has at least one color
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So many, many states now are reimbursing community health workers and peer support specialists
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Through their Medicaid plan and there’s also some specializations within peer support in terms of youth peer support, family peer support. These are growing fields where Medicaid is increasingly reimbursing for this service
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Within state plans or through waivers.
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Next slide.
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Back when we went a little too far.
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There we go.
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And this slide really some of the challenges with this workforce, both in terms of not having enough of these types of providers within these different states
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And the financial struggles that the organizations that tend to host these professions are having. So the red on here are states that have shortages of community-based mental health providers, and then the purple are states with permanent closures
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of the organizations that host these folks as of 2023. So we have, at the same time that we have a strong desire from young people to access these types of professionals, at the same time that Medicaid is increasingly reimbursing for these professions
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We’re also seeing huge shortages in the number of folks that we have available, and we’re seeing the organizations that we want to host these folks struggling financially and having to close down.
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Oh, sorry, go back. One more thing I forgot to say again. There is this piece where some states have been using something called state directed payments to try and address some of these challenges. So that is a tool within Medicaid where you can use those funds potentially to increase people’s pay, increase training, those sorts of things
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To help deal with this workforce shortage and help to make sure that
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you know, that we’re able to get more people… get people in these professions to be paid at a reasonable rate to avoid burnout and that sort of thing. We’ll come back to that tool and what that’s looking like on, I think, my final slide. Okay, now, Kim, we’re good to go
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Okay, so not to bury the lead, the whole purpose of this brief was like, what is the role of Medicaid in provider training? Because we are workforce folks on this call. We are thinking about what it looks like to apprentice folks into these professions.
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And the short answer is that Medicaid will not pay for any training up until the point where the person is a certified provider, so that is to say, up until the point where the person is meeting whatever requirements there are in that state
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to provide services, to be a qualified Medicaid provider, Medicaid is not going to cover that training
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However, Medicaid will cover training for continuing education, and that’s what’s really important here as it relates to apprenticeship. Now, in order for us to be able to do that, we have to do one of two things.
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Either we have to build the training cost into the rate for cover services, right? We have to make sure that when states are determining how much they are reimbursing these professions, that they are building continuing education training into that cost
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Option one
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Or there’s also an option to do some training under what is called administrative claiming. So this would be at the level of the state or the managed care organization contracting with folks to provide training, and then they can
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get reimbursed for that as an administrative cost, right? So we got two potential pathways, but you can’t bill continuing education under administrative training, so we got to make sure that that is covered. Basically, you have to do the first one regardless. And then you also want to do the second one as well
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Next slide.
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Okay, so with all this information, what does that mean for us and what this could potentially look like? I have these as a set of interlocking gears because we need all of these things working together. If we want to be able to think about the interplay of apprenticeships
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And Medicaid. First, I’m going to start with the sponsors. Sponsors either have to become Medicaid providers or intermediaries have to think about contracting with the state Medicaid agency or the managed care organization to become training providers
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Now, I said that very casually, this is not an easy step, and Alex is going to go more in his presentation into what that looks like for folks who are not traditional clinical providers and maybe don’t have that experience before
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But as a baseline, that is a path that workforce providers would have to be on in order to make this work.
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The second piece is how we design our apprenticeship. I already said, right, that Medicaid is not going to pay for anything up to the point where the person becomes a qualified provider. But we have some tools to deal with that within our apprenticeship toolkit.
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We could have a world where maybe there’s a pre-apprenticeship that gets you to the point where you are qualified provider, and then once you transition into your apprenticeship, that is now continuing education and potentially whatever services are provided as a result of that are potentially billable
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to Medicaid.
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Alternatively, because the requirements to become a certified peer support specialist or community health worker in most states are lower than what is required for a high quality apprenticeship, maybe it’s like your first half of your apprenticeship gets you to the point where you are a qualified provider. And then the second half of the apprenticeship
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is able to be considered continuing education while you specialize in a particular field or get supervisor training or something like that
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So a few options, but we have to make sure that we’re designing our apprenticeships with intention from the beginning.
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The third gear is state Medicaid policy. I already talked about the rates and how we have to make sure that we’re building our rate structure in a way
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That we can actually bill for the training. Again, I say that very casually, but one of the things that I found in the brief is that most people in most states couldn’t tell you how they came up with their rate, including the people that work in the Medicaid agency. So there’s a lot of work to do there in terms of unpacking how states are developing their rates and make sure they’re making sure that they’re building in a way
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This actually matters for what they’re getting paid for those services. And then last but not least, there’s our federal gear. I mentioned with the one big beautiful bill act, not only are we looking at the young people that we are trying to benefit with these services, potentially losing their coverage
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State budgets are also going to be impacted in ways that make it tougher to do things like directed payments to make sure that folks are getting a living wage, that to do the types of training and things like that, that people need to really make these professions sustainable and function in the ways that we want them to
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So the moral of the story is there’s potential here. There really is, but it is going to take years of sustained effort on our part as a field to get to a place where all of these gears are actually working in concert so that we can
00:29:31.000 –> 00:29:32.000
bring
00:29:32.000 –> 00:29:47.000
apprenticeship and Medicaid together in ways that are really supporting young people’s mental health. So that is it for me. We can go to the next slide. We can put this back up at the end or it’ll be there when we share
00:29:47.000 –> 00:30:02.000
If you all want to follow me on LinkedIn, open to that. If you want to follow Tip on social media, we have QR codes for both of those things. And excited to have Alex talk to you. He’s done some great work with helping folks get on this path that we’re talking about
00:30:02.000 –> 00:30:10.000
But Kim, do we want to do a few questions now, or should we just go ahead to Alex and do questions at the end?
00:30:10.000 –> 00:30:15.000
Yeah, so we can, if anybody has any questions, you can put them into the chat box
00:30:15.000 –> 00:30:22.000
And we’ll get those answered before we have Alex on. So if you have any questions for Nia
00:30:22.000 –> 00:30:25.000
You can put them into the chat box now
00:30:25.000 –> 00:30:31.000
And I’ll go ahead and stop sharing my screen. And Alex, if you want to get your screen going
00:30:31.000 –> 00:30:46.000
And if you think of questions as we’re going through, feel free to put those in the chat box and we can come back to it at the end. But Nia, it doesn’t look like we have any questions right now, so we’ll continue to monitor that and then
00:30:46.000 –> 00:30:48.000
Alex, we will let you take it over.
00:30:48.000 –> 00:30:50.000
Thank you, Nia.
00:30:50.000 –> 00:30:54.000
Great information.
00:30:54.000 –> 00:31:01.000
Thank you, Nia. Can everybody hear me? Kim, can you give me a thumbs up if you can hear me? Great.
00:31:01.000 –> 00:31:02.000
So
00:31:02.000 –> 00:31:09.000
Very few of us think Medicaid is really cool, but me and Nia do. So I just want everyone to like stick with us a little bit here.
00:31:09.000 –> 00:31:13.000
Because at the heart of this is a truth
00:31:13.000 –> 00:31:19.000
that Medicaid provides health insurance for more than half of all children in America.
00:31:19.000 –> 00:31:20.000
So.
00:31:20.000 –> 00:31:23.000
What I’m about to talk to you about
00:31:23.000 –> 00:31:27.000
is what is happening with kids in America
00:31:27.000 –> 00:31:31.000
And why Medicaid is so important
00:31:31.000 –> 00:31:33.000
To addressing it
00:31:33.000 –> 00:31:40.000
And how some of the themes that Nia named, particularly these new workforce classifications that are proliferating across America
00:31:40.000 –> 00:31:43.000
are increasingly in demand
00:31:43.000 –> 00:31:50.000
And so stick with me because I want to ground this in some hard data about what’s going on with young people.
00:31:50.000 –> 00:31:53.000
So if anybody here has a kid, or you ever were a kid
00:31:53.000 –> 00:31:58.000
You probably know this is a very difficult time to be young in our nation.
00:31:58.000 –> 00:32:03.000
We put the internet on mobile platforms in 2009
00:32:03.000 –> 00:32:14.000
And some crazy stuff started happening. So let me take you through what’s going on. Who are we? The Public Works Alliance is a national consultancy. We’re filled with recovering bureaucrats like myself, I should say.
00:32:14.000 –> 00:32:17.000
I was a therapist in the Oakland Public Schools
00:32:17.000 –> 00:32:22.000
I ran the emergency department at Children’s Hospital Oakland, a level one pediatric Trauma center
00:32:22.000 –> 00:32:26.000
I provide a direct clinical care in juvenile detention and foster care and sexual assault unit
00:32:26.000 –> 00:32:34.000
And then I led one of California’s largest health systems for 14 years. A system that had 14 hospitals and 10,000 employees.
00:32:34.000 –> 00:32:40.000
So everything I’m telling you about, I learned in the process of like make it payroll for a very large system
00:32:40.000 –> 00:32:45.000
And our politics diminish when we’re running 911 systems or trying to help kids who are suffering
00:32:45.000 –> 00:32:54.000
So what I’m about to take you through is something that’s happening in our nation, which is a general consensus. That’s what’s happening with young people is pretty scary.
00:32:54.000 –> 00:32:59.000
What’s going on is young people are overwhelming the demand of our public mental health systems
00:32:59.000 –> 00:33:04.000
There’s just too many kids who need care, too few are getting it
00:33:04.000 –> 00:33:13.000
And mental health and substance abuse is the leading disease burden in America. Literally, we lose more human potential
00:33:13.000 –> 00:33:20.000
To behavioral health than any other disease burden more than cancer, more than heart disease, more than all of them
00:33:20.000 –> 00:33:24.000
When you actually look at death rate per 100,000
00:33:24.000 –> 00:33:33.000
We have the highest death rate per 100,000 due to behavioral health of any industrialized nation in the world and almost twice the rate of other states, of other nations.
00:33:33.000 –> 00:33:38.000
And when you take those big data points and drop them down into the lives of children
00:33:38.000 –> 00:33:43.000
In that decade before the pandemic, from 2007 to 2017
00:33:43.000 –> 00:33:48.000
We saw a doubling of hospital admissions for self-injury
00:33:48.000 –> 00:33:53.000
That means you hurt yourself so badly that we had to check you into the hospital to treat you
00:33:53.000 –> 00:33:57.000
We saw a 50% increase in pediatric bed days
00:33:57.000 –> 00:34:00.000
Children were telling us that it’s a uniquely difficult time to be young
00:34:00.000 –> 00:34:07.000
With a 61% increase in self-reported mental health needs, and as you know, the pandemic poured gasoline on that fire
00:34:07.000 –> 00:34:12.000
And we are now in the unbelievably unfortunate circumstance.
00:34:12.000 –> 00:34:18.000
Where suicide has surpassed cancer as a cause of death for our children
00:34:18.000 –> 00:34:24.000
The CDC reports that 42% of young people experience persistent sadness and hopelessness
00:34:24.000 –> 00:34:31.000
One in four 16 to 24 year old has seriously considered committing suicide, which means they had a plan, a date, and a method
00:34:31.000 –> 00:34:37.000
And when young people come into our public systems, juvenile justice, child welfare, these self-injury rates spike
00:34:37.000 –> 00:34:44.000
So I know these are really heavy numbers, y’all, but the youth mental health crisis is real. Like this is actually happening in our world
00:34:44.000 –> 00:34:51.000
our most precious resource, our children are telling us that this is really difficult world to live in
00:34:51.000 –> 00:34:57.000
So we have to understand that this data doesn’t come from individual psychopathology, right? Like we didn’t spike the water
00:34:57.000 –> 00:35:11.000
It’s about how young people feel about themselves and their future. And we don’t have to go into all the rules, like all the whys. But clearly it’s comorbid with young people seeing what’s on their phone
00:35:11.000 –> 00:35:14.000
At rates that they’ve never seen before
00:35:14.000 –> 00:35:19.000
And I don’t blame individual platforms or anything. Those messages are not developmentally appropriate
00:35:19.000 –> 00:35:32.000
Like it was not right for children to see images of sexual object themselves as sexual objects or school violence or community violence or the politicized narrative of our current discourse.
00:35:32.000 –> 00:35:36.000
These messages are really scary to young people, and they’re telling us that they are
00:35:36.000 –> 00:35:41.000
But public opinion has really rallied around this issue
00:35:41.000 –> 00:35:54.000
State and federal administrations across Democrat and Republican administrations have both committed their money and their policy chops to addressing this crisis. So this isn’t a political thing, y’all
00:35:54.000 –> 00:36:07.000
I work in Georgia and California. I work in Iowa, and I work with Democratic Medicaid directors and Republican Medicaid directors. They’re all good people. They all care about kids and they all know that this is a really tough time to be young
00:36:07.000 –> 00:36:12.000
80% of Americans say this is one of the most important issues to them, the mental health of their children.
00:36:12.000 –> 00:36:15.000
And 40 states
00:36:15.000 –> 00:36:22.000
And he explained, have now moved to this managed care model, meaning kids in Medicaid have the same kind of coverage that commercial kids have, a health plan
00:36:22.000 –> 00:36:25.000
With a defined network, with a primary care provider
00:36:25.000 –> 00:36:39.000
And states are doing really amazing things, like extraordinary things to address this crisis. Like the people I see trying to take care of children, the things they’re doing inspire me literally every day. And at the heart of that inspiration
00:36:39.000 –> 00:36:42.000
Is this nexus with new workforce opportunities.
00:36:42.000 –> 00:36:49.000
And why Medicaid NEA did a great job describing Medicaid, but I can tell you, having led a large system
00:36:49.000 –> 00:36:57.000
That what we call the child serving safety net, meaning these public systems that serve kids, public schools, early childhood, foster care, juvenile justice.
00:36:57.000 –> 00:37:03.000
and the region like developmental disability systems. These systems all have a common denominator, which is Medicaid
00:37:03.000 –> 00:37:06.000
Meaning they all use Medicaid in one degree or another
00:37:06.000 –> 00:37:08.000
And they’re all starved for staff.
00:37:08.000 –> 00:37:17.000
So the invitation I’m offering to all of us, and I think Nia created a great roadmap for us, is these systems need people
00:37:17.000 –> 00:37:20.000
They need people who understand mental health
00:37:20.000 –> 00:37:25.000
They don’t need to be therapists, and states have created these new workforce classifications
00:37:25.000 –> 00:37:33.000
So to take advantage of this moment, this consensus we have as a nation that it’s a tough time to be young, that we got to do something
00:37:33.000 –> 00:37:49.000
Everyone has to understand Medicaid. So I know that was a lot, you know, and me and Nia go down the rabbit hole all the time with Medicaid. So I could just all I can tell you is please embrace it, learn it. The key thing to hold is that half of all children are covered by it. So if we’re going to address this thing
00:37:49.000 –> 00:37:51.000
You gotta know your Medicaid
00:37:51.000 –> 00:37:59.000
And embrace the need to think in new ways about how we pay for services. New types of providers.
00:37:59.000 –> 00:38:06.000
And these new providers give us a chance to help low-income communities get access to family sustaining employment
00:38:06.000 –> 00:38:14.000
This is one of the greatest growth sectors in employment and gross domestic product in America. And so follow the money
00:38:14.000 –> 00:38:17.000
because the system is changing, and it needs these people.
00:38:17.000 –> 00:38:28.000
And one of the key, I think, intellectual changes I would invite us all to think of is mental health is a support for healthy development, not a response to pathology.
00:38:28.000 –> 00:38:39.000
So don’t get stuck in this idea that you have to have a specific diagnosis because states are changing that all the time. Most states are now saying, hey, if young people are suffering, we can treat them. They don’t have to meet specific diagnostic criteria
00:38:39.000 –> 00:38:49.000
So the things that states are doing around the nation is they’re removing diagnosis, as I said, as a gatekeeper. They’re creating new pathways. They can say if you might not yet have a diagnosis, we qualify
00:38:49.000 –> 00:38:53.000
Or maybe there’s other things that qualify you, like an adverse child experience
00:38:53.000 –> 00:38:56.000
They’re reimagining the workforce
00:38:56.000 –> 00:39:02.000
They’re making reimbursement pathways to schools, meaning schools are becoming the new center of the mental health system.
00:39:02.000 –> 00:39:08.000
They’re creating ways for caregivers to get mental health services when they take their babies to the doctor. This is called biotic care
00:39:08.000 –> 00:39:17.000
And they’re maximizing federal investment because despite all of the changes to Medicaid under H.R. 1, no state, not a single one
00:39:17.000 –> 00:39:19.000
Cut Medicaid for children.
00:39:19.000 –> 00:39:23.000
All states still cover children under Medicaid
00:39:23.000 –> 00:39:31.000
And children in Medicaid have a unique status, which means that the federal government must match allowable expenditures.
00:39:31.000 –> 00:39:38.000
Let’s dive into this question of the workforce and behavioral health and why this is such an important and powerful moment to think about it.
00:39:38.000 –> 00:39:48.000
I’m showing you some California examples with four new provider classes were created in just the last two years. Community health workers, wellness coaches, doulas, and certified peers.
00:39:48.000 –> 00:39:53.000
So when you create a new provider in Medicaid, let’s just quickly say, like, what does that mean?
00:39:53.000 –> 00:40:03.000
Well, the first thing you have to think about is scope of practice, meaning what codes can they build in what setting and under whose supervision?
00:40:03.000 –> 00:40:10.000
The next thing that you have to define is the credentialing process. Who gets to say you are what you are?
00:40:10.000 –> 00:40:15.000
Like who in the system? Is it a community college? Is there a degree program? What’s the deal
00:40:15.000 –> 00:40:19.000
The third is paneling, meaning how do you sign up to get paid?
00:40:19.000 –> 00:40:27.000
Once I know what codes I can build, once I’ve gotten my certification, how do I sign up to get paid? And that’s a process that you have to understand.
00:40:27.000 –> 00:40:37.000
Payer, meaning which of the payers pays me? Is it the developmental disability system? Is the managed care plan? Who is cutting the check for my services? And then finally, what are the rates?
00:40:37.000 –> 00:40:46.000
And this is a really challenging issue, y’all, because the rates are low everywhere. 17 to 40 bucks is normal for these new types of providers for 30-minute interaction
00:40:46.000 –> 00:40:53.000
What’s fascinating is don’t peg this to red and blue, y’all. Like some of the states that are most are offering the best rates, Georgia
00:40:53.000 –> 00:41:05.000
are offering some of the highest rates for certified peers. So it’s not the stuff defies your political expectations, okay, y’all? Like, you got to dive in state by state to understand it
00:41:05.000 –> 00:41:10.000
And what this basically means is that if you’re a young person in a high school
00:41:10.000 –> 00:41:16.000
And high schools across the nation do this, meaning they train young people to talk to each other about health issues.
00:41:16.000 –> 00:41:21.000
And this is proliferating across the nation. It’s an evidence-based practice under SAMHSA. It’s an extraordinary effective tool
00:41:21.000 –> 00:41:26.000
But historically, when you said to that young person, hey, you know, you should be a mental health clinician
00:41:26.000 –> 00:41:31.000
They would say, what? Master’s degree? I’m going to be dead by 30. No way.
00:41:31.000 –> 00:41:36.000
But now, now that same young person could graduate and be a peer specialist
00:41:36.000 –> 00:41:38.000
Then they could go on and become a community health worker
00:41:38.000 –> 00:41:41.000
If they’re interested in birthing, they could be a doula
00:41:41.000 –> 00:41:45.000
If they went and got an associate’s degree, they could be a wellness coach or wellness coach two with a bachelor’s degree.
00:41:45.000 –> 00:41:51.000
And we’re now allowing interns and associates, meaning people who are earning their hours towards licensure, to bill in new settings
00:41:51.000 –> 00:41:56.000
So, this pathway doesn’t work, y’all, so this is an aspirational slide. I want to be really clear.
00:41:56.000 –> 00:41:59.000
Like, this is what we could build together.
00:41:59.000 –> 00:42:10.000
Which is a behavioral health career pipeline or pathway that leverages these changes to Medicaid, but also acknowledges that we’ve got to do something different, because what we’re doing with young people isn’t good.
00:42:10.000 –> 00:42:27.000
So what does this look like in practice? I just want to end here with a couple, this is what it actually looks like, which is how you do it. And I put a link to an article that Nia wrote about a project we did in Los Angeles where we went into the youth source centers, the employment and training hubs of the city of Los Angeles. We recruited three to five young people from each one of them
00:42:27.000 –> 00:42:30.000
Certified them as a peer and placed them in community.
00:42:30.000 –> 00:42:39.000
It was hard. Some things were great, some things didn’t work, but we learned a lot. We use WIOA dollars to pay for it. And it was a really, really important learning process.
00:42:39.000 –> 00:42:48.000
But we also did a project with 60 six 0 community-based organizations that work with kids coming back from detention.
00:42:48.000 –> 00:42:50.000
And what we did
00:42:50.000 –> 00:42:59.000
We identified community-based organizations that had these type of professionals, community health workers, peer counselors, and then we helped them get certified
00:42:59.000 –> 00:43:01.000
And we fund them
00:43:01.000 –> 00:43:04.000
to learn how to walk the path of Medicaid.
00:43:04.000 –> 00:43:10.000
And our goal was to create 5 million in ongoing revenue, and we’re going to blow that out of the water. We’re already at 7 million annually
00:43:10.000 –> 00:43:15.000
of ongoing revenue across these 60 organizations of new Medicaid revenue
00:43:15.000 –> 00:43:23.000
And then finally, an aspirational project we have in New York City is called School Wealth Force New York. This is just attracted a significant investment from philanthropy
00:43:23.000 –> 00:43:29.000
What we’re going to do in the Bronx, District 9 in the Bronx, where over 90% of all children there are eligible for Medicaid
00:43:29.000 –> 00:43:31.000
It’s a five-year
00:43:31.000 –> 00:43:38.000
process, five-year pilot in the Newark Public Schools, where we’re going to try to train and place people who live in the Bronx
00:43:38.000 –> 00:43:43.000
As peer counselors and wellness coaches, and work in District 9 schools in the Bronx
00:43:43.000 –> 00:43:57.000
It’s we’re hiring from the community with people who can build trust and relationship with young people. We’re teaching them how to screen and assess and do psychoeducation, not be therapists. They’re not therapists, but they work under the supervision of a licensed professional.
00:43:57.000 –> 00:44:03.000
We teach them how to bill Medicaid, and we integrate with the existing infrastructure of New York’s Medicaid program.
00:44:03.000 –> 00:44:05.000
Finally
00:44:05.000 –> 00:44:10.000
Oh, this is a little bit more about school welfare New York and our partners.
00:44:10.000 –> 00:44:19.000
Finally, I’m going to end with a relevant project because if you invite me to a webinar, it’s an occupational hazard. You have to hear about this program
00:44:19.000 –> 00:44:25.000
When I was leading a large health system, we had one of the busiest 911 systems in America
00:44:25.000 –> 00:44:30.000
Literally 500 ambulances. And we had a lot of trouble staffing
00:44:30.000 –> 00:44:37.000
our EMT level service. And this is a national crisis. You can Google the name of the State you live in, followed by the words
00:44:37.000 –> 00:44:41.000
Emergency medical technician or EMS workforce shortage
00:44:41.000 –> 00:44:52.000
An up-comer story from your state or the community you live in in the last 66 months that talk to this critical staffing shortage in our most popular public service in the history of America is 911.
00:44:52.000 –> 00:44:57.000
And in 2012, we started training young people who had faced adversity
00:44:57.000 –> 00:44:59.000
to work in our EMS system
00:44:59.000 –> 00:45:09.000
And we did lots of things wrong, so again, I don’t want to pretend like it was an easy thing, and it all worked out. We had to listen and learn and get better every… over time. But here we are 12 years later
00:45:09.000 –> 00:45:20.000
And we have 10 new programs after the original one born in Oakland. We have 10 new programs in California, a new site in New Mexico, new site in New Orleans, new sites
00:45:20.000 –> 00:45:24.000
I’m coming in Atlanta and Baltimore this year, a new site in New Jersey
00:45:24.000 –> 00:45:28.000
New sites in Baltimore, New Jersey, and
00:45:28.000 –> 00:45:33.000
By the end of 2026, we’ll have 18 sites operating across six states.
00:45:33.000 –> 00:45:40.000
So my point here is that we have demonstrated that when we put our time and energy to it, and admittedly, this was a decade-long process.
00:45:40.000 –> 00:45:44.000
When we put our time and energy to it, we can integrate
00:45:44.000 –> 00:45:53.000
workforce new folks into the emerging healthcare workforce opportunity. It just takes dedicated funding and resources and a lot of time and learning
00:45:53.000 –> 00:45:58.000
Thank you.
00:45:58.000 –> 00:46:14.000
Right. Thank you, Alex. And if you want to go ahead and stop sharing your screen. And we’ll open it up for questions again. So if you have any questions for either Nia or Alex, please feel free to put those into the chat box.
00:46:14.000 –> 00:46:31.000
And I’ll start off with a question because it’s been some great information. So Neil, when you started with the poll at the beginning of rank yourself from one to five, I was definitely at a one with my knowledge of Medicaid. So you did a great job of explaining that. And I also see that
00:46:31.000 –> 00:46:44.000
We have the Medicaid explainer, it’s in the chat box, and I will email that out to you as well, to everyone. But I think what my question is, you know, as we’re thinking about healthcare or healthcare apprenticeships
00:46:44.000 –> 00:46:51.000
For somebody, for a workforce board or organization who is interested in doing this, where would you say, where do you start?
00:46:51.000 –> 00:46:52.000
What’s step one
00:46:52.000 –> 00:47:06.000
Yeah, and I think Alice can answer this question as well. I think he could probably share some more details about some of those programs he mentioned at the end, who really have gone through the process. But again, the step one, and Alex said this too, is
00:47:06.000 –> 00:47:22.000
Everybody on this call has taken the first step today, trying to move that one up from a one is the absolute necessary 1st step. One of the interesting things about focusing on a population in your work and the way that we do right is that young people don’t live single issue lives. So yes
00:47:22.000 –> 00:47:38.000
They need jobs, they are in the workforce space, but their mental health is there, their, you know, family is there, their income is there, like, all these other issues are there, all the time, all together. And what is so unfortunate about the way that so much of government functions
00:47:38.000 –> 00:47:53.000
is that these issues are siloed, right? So sometimes even within sort of similar areas that people don’t talk to each other, never mind folks from workforce talking to people in the mental health department. So I’d say the next step
00:47:53.000 –> 00:48:10.000
After you get a little bit comfortable is figure out who are the mental health folks in your community and how can I start to get connected with them? Who are the Medicaid point people in my state? And what are ways that I can start to get connected with them
00:48:10.000 –> 00:48:26.000
Because, like I said, getting all those gears working together is not a short-term project, it’s not a quick journey, but we got to start. And it starts with starting to make, like, the gears are just totally separate right now. At least we start to try and bring them together and get them interlocking
00:48:26.000 –> 00:48:29.000
Before we get them rotating and all working together. And Alex, I’m sure you got more practical advice
00:48:29.000 –> 00:48:38.000
I love it. And I dropped them in the chat. My kids tell me uninvited counsel is the worst, but I think this is invited. Okay.
00:48:38.000 –> 00:48:39.000
He survived it
00:48:39.000 –> 00:48:43.000
All right. First, don’t be afraid of Medicaid.
00:48:43.000 –> 00:48:46.000
It covers half of all kids
00:48:46.000 –> 00:48:50.000
and it is a dominant dominant economic engine in your state.
00:48:50.000 –> 00:49:05.000
And it is a dominant factor in your state’s budget. One of the heaviest single pieces of the pie is your Medicaid budget. So don’t be afraid of it and know that it has massive workforce needs and challenges, particularly in behavioral health. So that’s number one
00:49:05.000 –> 00:49:07.000
Be Medicaid curious
00:49:07.000 –> 00:49:15.000
To learn the new provider or workforce classification landscape in your state
00:49:15.000 –> 00:49:25.000
Are you one of the 28 states that have a community health worker state plan amendment? Do you reimburse or certified peer counselors? Is there a wellness coach or behavioral health tech? Learn it.
00:49:25.000 –> 00:49:35.000
find out what happens in your state for these… this new emerging workforce classifications. Nia’s map is a good place to start. Send us emails if you need more information.
00:49:35.000 –> 00:49:41.000
3. Understand the specifics of the credentialing pathway.
00:49:41.000 –> 00:49:48.000
Most certified peer trainings average between 40 and 70 hours, up to 90 hours of training
00:49:48.000 –> 00:49:56.000
Community health workers average 80 to 150 h of training. Your historical providers tend to be your community college
00:49:56.000 –> 00:50:01.000
infrastructure, though there are others who do it
00:50:01.000 –> 00:50:18.000
And sometimes states have different credentialing processes or authorities, like an entity who credentials the curriculum of a certified peer counselor program. In Georgia, this would be the Department of Behavioral Health and Developmental Disability. In California, it would be Cal Mesa
00:50:18.000 –> 00:50:27.000
So understand the details. How many hours is it? What’s included in the curriculum and who provides that training? And then four, learn the provider landscape.
00:50:27.000 –> 00:50:35.000
Meaning, who are the community mental health agencies who contract with Medicaid to deliver services? Who are they?
00:50:35.000 –> 00:50:38.000
And like
00:50:38.000 –> 00:50:41.000
little agencies
00:50:41.000 –> 00:50:44.000
Struggle with this. Okay, let’s just name it
00:50:44.000 –> 00:50:47.000
you’re high. You got less than 10 or 20 employees.
00:50:47.000 –> 00:50:52.000
you’re unlikely to be successful billing Medicaid because it’s a volume game. Are you with me?
00:50:52.000 –> 00:51:02.000
Like you get paid and how many widgets you deliver. Okay, what we call CPT codes. How many of these encounters can you document in an electronic health record and submit to the plan for payment
00:51:02.000 –> 00:51:10.000
And remember how I said they’re between 17 and 40 bucks for 15 or 30 minute interval? It takes a lot of those to cover costs.
00:51:10.000 –> 00:51:17.000
So you want to find an organization who has some administrative depth and sophistication and scale
00:51:17.000 –> 00:51:20.000
to partner with to grow these programs.
00:51:20.000 –> 00:51:24.000
That was a lot, okay, you guys want to say? But
00:51:24.000 –> 00:51:32.000
I think those four steps is what I would recommend. And I just want to say, too, like to the workforce folks in the room
00:51:32.000 –> 00:51:47.000
us Medicaid and mental health people, we need you so desperately. Like, I can’t even tell you how desperate it is. And Nia showed that slide where some of the organizations that do this work are struggling financially. So there’s work on our end. We got to make those organizations thrive and survive better
00:51:47.000 –> 00:51:58.000
better reimbursement rates, more hand-holding electronic health records that are easier to use. So there’s a lot of work on my side that has to be done. But we need people to produce these folk while we build the field
00:51:58.000 –> 00:52:02.000
So we could do things different in mental health. Thanks.
00:52:02.000 –> 00:52:22.000
Yeah, and one addition, because I don’t see any other questions come into the chat yet, which, you know, Alex started with the really powerful set of statistics around the challenges that young people have been facing, continue to face around their mental health in this time. But the other thing that he alluded to with EMS Corp, but I’m just going to say even more strongly
00:52:22.000 –> 00:52:25.000
is that young people want to go into these lines of work
00:52:25.000 –> 00:52:40.000
And this is how young people want to receive mental health support. Like there’s a beautiful alignment here between what young people want to do and are strong at doing and what young people want to receive and how they want to get support.
00:52:40.000 –> 00:52:59.000
And so again, it’s going to be a long slog, but there’s so much potential and so much benefit of getting all of these gears working together to address so many challenges that are sort of it’s mutually beneficial in so many different ways
00:52:59.000 –> 00:53:00.000
Awesome.
00:53:00.000 –> 00:53:02.000
Yes.
00:53:02.000 –> 00:53:04.000
Thank you.
00:53:04.000 –> 00:53:05.000
Okay.
00:53:05.000 –> 00:53:06.000
Yeah, I’ll make sure Kim has our slides
00:53:06.000 –> 00:53:12.000
And I just want to say from the Public Works Alliance perspective, you may copy, paste, rebrand and use our slides however you deem fit
00:53:12.000 –> 00:53:21.000
We don’t believe in intellectual property in this kind of work, so anything you get from us, you may use and reproduce as you choose
00:53:21.000 –> 00:53:44.000
Perfect. And thank you for laying out both of you. Thank you for laying out those next steps because it’s a lot of information, a lot of great information. And sometimes it can get overwhelming where we like, okay, we see the end goal, but what’s the next step? So thank you for laying that out. We definitely appreciate it. What a wonderful hour this has been of information. I have learned, I’ve learned so much and we appreciate both of you
00:53:44.000 –> 00:53:59.000
So I see a couple of people ask for your contact information. So again, this will be available on our website. I’m also going to email it to you, and I see Alex has put his information in the chat, but you will definitely have access to that.
00:53:59.000 –> 00:54:03.000
And we do have one more slide that I need to share with you all.
00:54:03.000 –> 00:54:09.000
And are you able to see my screen?
00:54:09.000 –> 00:54:15.000
Not yet
00:54:15.000 –> 00:54:38.000
And the product was created by the recipient and doesn’t reflect the official position.
00:54:38.000 –> 00:54:43.000
Kim, I think you may be froze for a minute, so that screen didn’t show, but
00:54:43.000 –> 00:55:00.000
Oh, okay. Sorry about that. So, okay, so I am going to just close that. So we have we do have a disclaimer, and it’s going to be on the last. So when I email you, you’ll see the disclaimer on the slide deck. So I apologize for that. But the slide deck or the disclaimer basically says that
00:55:00.000 –> 00:55:17.000
What we said here is not necessarily endorsed by the U.S. Department of Labor. So it’s just a DOL disclaimer. So that is all that we have for you today, and I don’t see any other questions in the chat box
00:55:17.000 –> 00:55:30.000
Again, you can look for this in the next couple of days sent to your email, and if you have any other questions, any anything else we can help you with regarding this webinar, feel free to reach out to us. You will have all of our contact information.
00:55:30.000 –> 00:55:46.000
So again, we appreciate you all for joining us, and if there’s no other questions, I see a lot of thank yous coming up. So again, thank you, Alex. Thank you, Nia, for presenting and I hope you all have a wonderful rest of your Thursday.
00:55:46.000 –> 00:55:52.000
Take care, everybody. Thanks.
