HBX requested that Children’s National Hospital assist in the identification of specific behavioral health diagnoses, along with the therapies, medications, and related care that would improve access to mental health services for children and adolescents with those conditions. Special attention was given to meeting the needs of Black and Brown children in the District. A collaborative team of hospital clinical, operational and policy experts was convened by Tonya Vidal Kinlow, Vice President of Community Engagement, Advocacy, and Government Affairs, and strategies were developed to glean information that would lead to beneficial solutions to the children insured through products on the Health Benefit Exchange and address racial and ethnic disparities in access to care. 

Data on most common behavioral health diagnoses informed early conversations, and soon led to the development of proposed treatment scenarios for the top diagnoses for outpatient children with private insurance seen by Children’s National clinics. Clinicians’ expertise shaped treatment scenarios that included initial and ongoing therapy sessions, medication management visits, related lab work, and appropriate medications for each condition. These scenarios were then synthesized and shared with HBX, who confirmed the recommendations as standard practice and prepared actuarial calculations in accordance with the insurance industry. 

While there will always be differences in opinions when theorizing the best approaches to changing health care delivery, there was no disagreement that children’s mental health was suffering and continues to do so. Solutions that prioritized increasing access and reducing barriers remained the primary objective in this effort. Concerns were highlighted, including: potential reduced access to mental health services for Medicaid and other populations from under-resourced communities at the expense of increasing access for patients insured through DC Health Link, unintended emphasis on medication over therapy treatment, whether financial barriers were the most burdensome of barriers to care, and others. And while these concerns all warrant real attention, the very real crisis of children’s mental health mandated that initial action should be taken. Children’s National clinical leadership and staff continued to advise the HBX Standard Plans Working Group on the needs of children in the District and best practices throughout their deliberations.  

After much thoughtful discussion amongst HBX Standard Plans Working Group members Committee members, the HBX Executive Committee voted unanimously to adopt recommendations that help address health disparities in pediatric mental health treatment. Starting in Plan Year 2024, children covered by a standard plan on DC Health Link will only have a $5 copay, with no deductibles, for outpatient mental health visits, including specialist visits, and no limit on the number of visits. Additionally, prescription copays for child mental health care are reduced to $5, with no deductibles.   

This is inclusive of all primary behavioral health conditions (based on ICD-10 F-code documentation) and includes visits such as initial evaluation, therapy, medication management and certain lab work, and covers children up through age 18.  This is a significant cost-sharing reduction – current plan copays range from $20-45 per outpatient visit – and a huge step forward in reducing the financial barriers to mental and behavioral health care. From our first internal meeting in August 2022 until the passage of this recommendation in November 2022 was a very brief 15 weeks. While that may seem like an eternity in some environments, this is an impressive turnaround for policy work. There are examples of legislation that take years or even decades to come to fruition. In just one example, mental health parity was first mentioned as early as the 1960s, with various federal laws enacted through 2008 still codifying this important principle.   

Policy work is not for everyone; it sometimes takes a strong stomach and fortitude to withstand the currents. Indeed, the lawyer-poet John Godfrey Saxe alluded to laws being like sausages, and not enjoyable to see being made. But once in a while, you can witness something quite extraordinary in front of your own eyes. I am sure the clinicians administering the first mass vaccination clinics against polio felt similar exhilaration. And I hope you can experience this, too.