Dear Governors:

We are writing today to share information regarding current and upcoming federal resources to help you better support the mental health of your students. As you know, our country faces an unprecedented mental health crisis among our children and youth in the wake of the COVID-19 pandemic. Over 40 percent of teenagers state that they struggle with persistent feelings of sadness or hopelessness, and more than half of parents and caregivers express concern over their children's mental well-being. Between March and October of 2020, the proportion of emergency department visits by children with mental health emergencies rose by 24 percent for children ages five to 11 and by 31 percent for children and youth ages 12 to 17, compared with the same time in 2019. As of June 2021, approximately 140,000 children had lost a parent or grandparent caregiver to COVID-19i, and one year later this number is certainly much higher.

In light of this crisis and as part of his Unity Agenda, President Biden has called for a major transformation in how mental health is understood, accessed, treated, and integrated— in health care settings and in communities, including in our schools. Providing essential health care, including mental health services, in schools can reach children and youth where they are and help ensure that they get the care they need.

The President's Unity Agenda builds upon the investments the Biden-Harris Administration has made to support student mental health through the American Rescue Plan Act of 2021 (ARP; P.L. 117-2) and previous guidance. More than $120 billion in funding has gone to schools and school districts to support COVID-related activities that can include the hiring of more school counselors and building a sustainable infrastructure for school-based mental health programs and services. With the help of the ARP, public schools have seen a 53% increase in the number of social workers and an 18% increase in the number of counselors since the years before the pandemic.

Additionally, in October 2021, the Department of Education (ED) released *Supporting Child and Student Social, Emotional, Behavioral, and Mental Health Needs* to provide information and resources to enhance the promotion of mental health and the social and emotional well-being among children and youth who are students across early childhood, K-12 schools, and higher education settings.
Since our March letter, ED and the Department of Health and Human Services (HHS) have continued to work closely together to improve the health and well-being of children and youth by ensuring they have the physical and behavioral health services and supports they need to build resilience and thrive. For example, Health Resources and Services Administration awarded nearly $25 million in grant funding to community health centers to increase and improve access to school-based health services, including mental health services. Additionally, the Substance Abuse and Mental Health Services Administration (SAMHSA) awarded $119 million in grant funding to develop a sustainable infrastructure for school-based mental health programs and services. The Departments have also jointly developed a webinar series to help schools and health centers better partner together to deliver high quality, accessible, school-based health care, including mental health care, to students.

Our work together is just beginning, and we are excited to announce forthcoming guidance and other actions that will both help schools sustain their ARP investments and implement several provisions of the Bipartisan Safer Communities Act (BSCA; P.L. 117-159), including through better utilization of the Medicaid program to support the delivery of mental health services to students, such as students affected by school shootings and daily acts of gun violence in our communities.

Improved utilization of Medicaid complements the BSCA's robust investments in youth mental health, such as $1 billion in funding for ED's school-based mental health programs, $240 million in additional funding for Project AWARE to support trauma care services in school- based settings, and the reauthorization of the Pediatric Mental Health Care Access Program, which supports state and regional networks of pediatric mental health care teams available to schools through teleconsultation, training, and technical assistance for diagnosing, treating, and referring children with mental health conditions.

Later this summer, the Centers for Medicare & Medicaid Services (CMS) will issue guidance to states encouraging them to leverage Medicaid's existing "free care" policy so more schools can receive Medicaid funding for the array of covered health care services, including mental health treatment, they provide to children enrolled in Medicaid. This is the first of several steps CMS is taking, in partnership with ED, to provide states, local educational agencies, and other stakeholders with guidance and technical assistance to promote the availability of Medicaid services, including mental health treatment, in schools. For example, CMS will issue additional guidance and new tools for states to make it easier for schools to bill Medicaid for direct health care services furnished to beneficiaries and associated administrative costs. Finally, ED is currently reviewing regulations to determine how the Department can help schools expand and sustain the delivery of mental health and other health care services to students.

CMS will also issue guidance and best practice information for State Medicaid Agencies regarding Medicaid's Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit. Similarly, this guidance is the first in a series of actions CMS will take to ensure EPSDT is working as intended—to provide comprehensive and preventive health care services, including behavioral health services, to children enrolled in Medicaid. CMS will also provide technical assistance to state Medicaid agencies to support them in addressing gaps and deficiencies in the provision of the EPSDT benefit.

On July 16th, our nation transitioned to the 988 Suicide and Crisis Line. As it becomes the nation's new "go to" number for suicide and crisis care, we will be directing our Departments to advance resources and efforts to address the youth suicide crisis. In recognition of the role adverse childhood experiences (ACEs) play in overall and long-term youth health outcomes, including mental health outcomes, the Centers for Disease Control and Prevention will issue new training on ACEs for staff who work in schools. The Administration for Children and Families' Office of Early Childhood Development and ED plan to release a joint letter on their commitment to ensure that all young children and their caregivers have access to high-quality resources that equitably support social-emotional development and mental health. SAMHSA will also award a new Center of Excellence on Social Media and Mental Wellness to develop and disseminate information, guidance, and training on the impact of youth social media use (benefits and risks), especially the potential risks social media platforms pose to their mental health.

This fall, ED will also release notices inviting applications for two programs dedicated to increasing school-based mental health capacity. ED will award over $140 million in grants for the School-Based Mental Health Services Grant Program, which provides competitive grants to increase the number of qualified mental health service providers that provide school-based mental health services to students in districts with demonstrated need. An additional $140 million in grants will be competed for the Mental Health Service Professional Demonstration Grant Program, which provides grants to support innovative partnerships to train school-based mental health service providers for employment in schools and districts. These awards will add capacity and contribute to President Biden's commitment to double the number of school-based mental health professionals. Plus, the competition for the Full-Service Community Schools GrantProgram, which ED announced last week, will provide resources to support community schools and wraparound services, which can include mental health and social-emotional supports. Finally, ED is currently reviewing regulations to determine how the Department can help schools expand and sustain the delivery of mental health and other health care services to students.

We are excited to work with you to improve the health and well-being of our students, and we encourage you to reach out with ideas and suggestions so we can continue to work together to make quality health services accessible in schools for the children and youth who need them.

/s/
Xavier Becerra,U.S. Secretary of Health and Human Services
/s/
Miguel A. Cardona, Ed.D.,U.S. Secretary of Education
i Hillis, S. D., Blenkinsop A., Villaveces A., Annor F. B., Liburd, L., Massetti, G. M., Demissie, Z., Mercy, J. A., Nelson, C. A., Cluver, L., Flaxman, S., Sherr, L., Donelly, C. A., Ratmann, O., & Unwin, J. T. (2021). Covid-19- Associated Orphanhood and Caregiver Death in the United States. Pediatrics. DOI: 10.1542/peds.2021-053760i
  Last Modified: 07/29/2022