By Abigail Kramer

After years of broken promises – and with billions of desperately needed federal aid dollars on the way – New York State has an unprecedented opportunity this year to patch up its broken system of care for kids with mental health problems. But with the State budget due on April 1st, even the best-case proposals now working their way through Albany offer limited hope that Governor Cuomo or the State Legislature will finally make good on their word. 

That’s not because anyone disputes that the system is woefully underfunded and inadequate. Long before the coronavirus arrived, suicide was the second-leading cause of death among the state’s adolescents, and the third-leading cause among kids aged 9 to 14. Because mental health care is reimbursed at chronically low rates – both by New York’s Medicaid program and, to an even greater degree, by the private insurance companies that the State is responsible for regulating – there is an extreme shortage of available care. Very sick children often sit on waitlists for months to see a therapist or psychiatrist.

In the past year, as the Covid-19 pandemic ground on, hospital psychiatric units have filled up with young people experiencing mental health emergencies – including many who’ve made serious attempts at suicide. Kids regularly spend days in emergency rooms, waiting for hospital beds to open up.

And when those young people are discharged from inpatient care, there are often no intensive outpatient programs to help them transition back home. According to State reports from 2019 (the most recent year for which such data are published), more than a third of young people discharged from an inpatient psychiatric stay at a general hospital end up back in an emergency room within 90 days. Nearly one quarter of those kids land back in an inpatient bed.

For sick kids and their families, the cycle can be brutal. AnnMarie Knox is a peer advocate who works with the families of kids with behavioral health problems on Long Island. Her own daughter, who’s now a young adult, was hospitalized close to a dozen times in her teens, only to be discharged without anywhere to turn for intensive follow-up care, Knox says. Once, she was sent home from a hospital with a care plan that instructed her, in case of emergency, to call a mental health facility that had been closed for more than 10 years. 

Many nights, Knox says, she slept sitting up on the sofa, with her daughter’s hair wrapped around her finger in case she got up to attempt suicide again.

Years of Broken Promises

Nearly a decade ago, when Governor Andrew Cuomo rolled out his massive, multi-year plan to overhaul New York State’s now $80 billion Medicaid program, his administration promised to resuscitate the mental health system, bringing new services and supports to hundreds of thousands of children and teens.

In reality, many mental health programs – including those that serve the sickest kids – have only grown smaller and harder to access. From 2012 to 2017, close to one in every six inpatient beds for kids in psychiatric crisis disappeared statewide, dropping from 1,786 to 1,488. About 20 percent of those closed beds were in private and public hospitals, which typically receive far less reimbursement for mental health care than for beds dedicated to medical procedures. 

The significant majority, however, were beds in State-run hospitals known as State Psychiatric Centers, designated for young people who need more than just a couple of weeks of inpatient care. Since 2012, New York’s Office of Mental Health (OMH) has closed more than 30 percent of State-run psychiatric beds designated for children, bringing their total count of kids' beds down from 460 to just 314, as of November 2020.

Under what the State calls its “Transformation Plan,” money saved by such reductions is supposed to be reinvested in community-based mental health programs. In February, OMH testified to the New York State Legislature that, since 2014, the State has reinvested more than $100 million from closed adult and child beds into community-based mental health services, including supportive housing and crisis intervention programs. However, the State does not report (and did not clarify, on request) how much of the reinvested funds go to children and adolescents – or what, precisely, the benefits are.

In fact, during the same period that the State has been shutting down inpatient beds, New York kids also lost slots in intensive outpatient programs, which – according to doctors around the state – typically have waitlists that last weeks or months, filled entirely with young people on the verge of a crisis that might put them in the hospital. Between October 2015 and December 2018, the state’s total intensive outpatient capacity dropped by 15 percent, from 3,636 to 3,105 slots, according to OMH data.

If all that sounds like scraps of scraps, the State’s reform plan promised to bring new community-based services to hundreds of thousands of kids. In 2017, OMH estimated that approximately 200,000 children would be eligible for a package of new “Children and Family Treatment and Support Services.” As of June 2020 (the most recent month for which reliable data is available) less than four percent of that number – just 7,300 children – were receiving services under the program, according to OMH documents.

Similarly, the State estimated that 65,000 children would meet criteria for a more intensive slate of “Home and Community Based Services” (HCBS) designed to support the highest-risk kids. As of June 2020, fewer than 7,000 children were enrolled in HCBS programs, and only 1,600 of those kids actually received any services during that month.

The programs are so poorly funded and difficult to run that dozens of nonprofit organizations have asked to be released from their State contracts to provide the new services. Since November 2020 alone, 46 community service providers for children have closed, reducing capacity in nearly every county in the state, according to a recent op-ed by Andrea Smyth, the executive director of the New York State Coalition for Children’s Behavioral Health, which represents dozens of behavioral health service agencies.

“The administration never invested into the community-based programs to which… New Yorkers turn when the residential opportunities are shut down,” Smyth wrote. “In other words, the Cuomo administration kicked countless young people with mental health issues off the island but never gave them boats to get ashore.”

Advocates Urge Increased Funding for Youth Mental Health Care

Mental health providers and advocates make the case that, this year, the New York State Legislature has the opportunity to make a serious investment in mental health care for kids.

The governor’s Executive Budget, proposed in January, laid out an austere spending. While children’s mental health services were exempted from a one percent cut to Medicaid services across the board, many of the providers who offer those services would be hit hard by the cuts to other funding streams. If adopted, The Executive Budget would also shut down a State Psychiatric Center for kids in the Hudson Valley, and pull back on the State’s obligation to invest funds from closed beds into community-based services.

This month, with higher-than-expected tax revenues and the infusion of billions of dollars in Federal aid through the American Rescue Plan Act, the State Assembly and Senate each passed one-house resolutions pushing back on Cuomo’s proposed cuts to Medicaid and public health programs, setting the stage for a battle in Albany between legislators and the beleaguered governor during the next few days.

As advocates point out, however, simply restoring proposed cuts will not be enough to rescue a system that has been debilitated by years of starvation. In a letter signed this month by close to 20 behavioral health provider organizations, advocates, and others (including the Center for New York City Affairs), members of the Campaign for Healthy Minds, Healthy Kids argued that the State has an imperative not just to hold services for children harmless, but to make a real investment.

Between the December stimulus package and the American Rescue Plan, New York State will receive approximately $300 million for mental health and addiction services. The funds can’t be used for services that are reimbursed by Medicaid, so they won’t repair the damage at the foundation of the mental health system. But they can be used to build wraparound supports and reach more kids, for example by starting new mental health programs in schools or bringing help to children who’ve lost a caregiver to Covid-19.

Crucially, advocates argue, half of the federal funds should be dedicated to services for children and families. “Only by investing in supports for the youngest New Yorkers can our state break the cycle of behavioral health crisis that turns struggling children into adults without recourse or adequate support,” the letter says.

"Over and over, we hear from state leaders about their concerns for the mental health of young people,” the letter says. “Yet when it comes to the State Budget – the primary place where our state can make a substantive difference in the daily lives of struggling children and families – we are forced year after year to oppose cuts rather than advance transformative investments in children’s behavioral health."

Abigail Kramer is a senior editor at the Center for New York City Affairs.

This brief is made possible thanks to the generous support of the New York Community Trust and The Child Welfare Fund, and is part of the Campaign for Healthy Minds, Healthy Kids.