A Tour of Youth Behavioral Health Services Landscape: Prevalence, Treatment, and the Workforce
Date:
Duration: approximately
minutes
Featured Speakers
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Janessa Graves, PhD, MPH
Associate Professor, Family Medicine
Director – WWAMI Rural Health Research Center -
Holly Andrilla, MS
Research Scientist
Deputy Director – WWAMI Rural Health Research Center -
Lisa Garberson, PhD, MBA
Research Scientist – WWAMI Rural Health Research Center -
Gina Keppel, MPH
Research Scientist – WWAMI Rural Health Research Center -
Natalia Oster, PhD, MPH
Research Scientist – WWAMI Rural Health Research Center -
Sara Woolcock, MPH, RDN
Research Scientist – WWAMI Rural Health Research Center
This webinar shared findings from multiple studies on youth behavioral health issues in the rural U.S., describing the prevalence of behavioral health conditions among youth, the youth behavioral health workforce, the behavioral health licensure and reimbursement policy landscape, and the provision of youth behavioral health services.
The full report, Access to and Provision of Child and Youth Behavioral Health Services in the Rural and Urban U.S., includes an executive summary of the complete project and summary findings of each research brief.
From This Webinar
Transcript
Per Ostmo: Thank you for joining us. My name is Per Ostmo and I'm the program director for the Rural Health Research Gateway. I'll drop my email into the chat, so please reach out if you have any questions. If you are unfamiliar with Gateway, we provide easy and timely access to research conducted by the Federal Office of Rural Health Policy funded Rural Health Research Centers. You can stay up to date on the latest rural health research by subscribing to Gateway's research alert emails or by following Gateway on social media.
During today's webinar, the research team from the WWAMI Rural Health Research Center will share findings from multiple studies on youth behavioral health issues in the rural United States. They will be describing the prevalence of behavioral health conditions among youth, the youth behavioral health workforce, the behavioral health licensure and reimbursement policy landscape, and the provision of youth behavioral health services. Please note that all attendees have been muted, but you may submit questions for our speakers using the Q&A function. Today's session will be recorded and posted to the Gateway website for later viewing.
So now, it is my pleasure to introduce our presenters. We have the WWAMI Rural Health Research Center team here today, which is led by Director Janessa Graves and Deputy Director Holly Andrilla. We also have the team of research scientists from WWAMI here today, and that includes Lisa Garberson, Gina Keppel, Natalia Oster, and Sara Woolcock. Now, this is a huge pool of talent and I'm not going to read everyone's bios, but I will say that you can search all of these researchers on Gateway and find all of their other FORHP funded rural health publications. So now I'm going to hand things off to the WWAMI team. I believe we're going to start with Director Janessa Graves.
Janessa Graves: Hello and good morning, or afternoon for some of y'all. Thank you for being here. And we're really excited to share this recent work out of the WWAMI Rural Health Research Center. We are going to cover a whole swath of information, but we're going to start off, I'm just going to give you a little bit of rundown of our team and the nature of this work. So we are a federally funded rural health research center supported by the Federal Office of Rural Health Policy, and this is one of the projects that we conducted as part of our work with HRSA and the Federal Office of Rural Health Policy.
That said, the information, conclusions, and opinions expressed here are those of ours and not endorsement of FORHP, HRSA, or HHS is intended to be inferred. It's a cooperative agreement that we have with them, and so it's a great work together, a collaborative work that we engaged, they identify some issues and then we seek to answer them. And so this particular project, we were really focused on youth behavioral health access. We have published a full report in May 2026, so relatively fresh off the presses last month, and you can use this QR code to access the report. This is what the front page looks like.
And what we've tried to do with this presentation is to give you more than just what's reported in the executive summary or the key findings, but give you a deeper look into some of our results that are still in the full report. And so please seek out that and access that. And that is located on the Rural Health Research Gateway. In terms of the topics that we'll cover today, we are going to start out with Gina Keppel, who will be talking about the prevalence of youth mental health or behavioral health concerns. So she'll be talking about depression, suicide, suicidal ideation, alcohol and marijuana use disorder, and then reported treatment, mental health treatment among youth.
I will be covering some of the information regarding the distribution of the behavioral health workforce. And then we'll be handing it off to Natalia Oster, who will be talking and speaking with you about interstate licensure agreements. After Natalia, Sara, we're just pokering. We're throwing it all over the place for y'all. She'll be covering DEA waivered clinicians, followed by Holly Andrilla and Lisa Garberson who'll be talking about treatment and access of Medicaid and commercially insured kids for opioid use disorder. And finally, Natalia, we'll come back to Natalia and she'll wrap up looking at reimbursement of services.
And so we're really covering the gamut from what's the distribution of the conditions that are facing kids, what does their access look like? What does the workforce look like? What are they getting? And then how is that paid for? And so to get us started, I believe the next slide is, I'm going to pass it off to Gina.
Gina Keppel: Thanks, Janessa. I'm Gina Keppel, research scientist with the WWAMI RHRC, and I'm giving a very brief high level overview of some of our findings on prevalence of depression and suicidal thoughts and behaviors, alcohol use disorder and marijuana use disorder, and reported mental health treatment among adolescents and young adults in the rural and urban United States from 2021. Okay. There's a little delay there. So in looking at these topics, we know youth suicide mortality rates are higher in rural than urban areas as is the prevalence of depression and anxiety. We also know there's behavioral health workforce shortages in rural areas that can affect the ability of youth to receive treatment.
So for this analysis, we use the 2021 National Survey on Drug Use and Health, which surveys adolescents and adults to generate national prevalence estimates for non-institutionalized US civilians. And we calculated weighted frequencies and used chi-square tests to look at rural and urban categories and census divisions. And of note, there were some categories of rurality and census divisions where data were suppressed due to small sample sizes. To categorize rurality, we used the 2013 Rural-urban Continuum Codes and also used the five categories of rurality as listed here. Large metro, small metro, urbanized rural, less urbanized rural, and completely rural.
So the first analysis from this data is about depression and suicidal thoughts and behaviors among adolescents aged 12 to 17. So here's an overview of the findings. A significantly higher percentage of adolescents aged 12 to 17 in rural compared to urban counties reported they had serious suicidal ideation in the past year. And 18.2% of adolescents in rural areas and 14.8% of adolescents in urban counties reported serious thoughts of suicide, as well as 8.4% of rural and 6.3% of urban adolescents reported they'd had plans for suicide in the past year.
Regarding depression, one-fifth of adolescents met the criteria for having experienced a major depressive episode in the past year and there were no differences between rural and urban counties. However, the prevalence of major depressive episode in the past year varied significantly across census divisions, with the highest prevalence in the West North Central and Mountain census divisions, each around 25%, and the lowest at about 16% in West South Central census divisions. For experiencing a major depressive episode in their lifetime, the prevalence varied significantly by rurality, with the highest percentages in larger rural areas at over 30%, and the lowest in less populated rural areas, around 24%.
Okay. So the next analysis is about alcohol use disorder and marijuana use disorder among adolescents and young adults aged 12 to 24. So this analysis includes young adults. And alcohol use disorder and marijuana use disorder are clinical diagnoses that are related to impaired control over alcohol and cannabis use respectively. So the prevalence of past year alcohol use disorder among adolescents and young adults in this age group was 9.2% in urban and 8.5% in rural counties, which was not a statistically significant difference. The prevalence of past year alcohol use disorder was lowest in the rural West South Central census division at 6%, while the urban West North Central and rural counties of New England census divisions had highest rates, around 13%. And the prevalence of past year marijuana use disorder in this age group was 10% in both urban and rural counties.
So this did vary significantly across US census divisions overall and within both urban and rural counties by census division. So the lowest prevalence of marijuana use disorder was in the rural West North Central and the rural Middle Atlantic at just over 7%, and the highest was in the urban Mountain census division at 14.9%. And of note, also the highest in the rural Pacific census division where the prevalence was 25.3% in rural areas and then low at 9.6% in urban areas. And this was also a statistically significant rural urban difference within census division.
So finally for this data, we examined reported receipt of mental health services by adolescents aged 12 to 17. And of note, these are services for emotional or behavioral problems unrelated to alcohol or drugs. So in 2021, 18.4% of adolescents aged 12 to 17 in urban counties and 18% in rural counties reported receiving specialty mental health services in the past year. So the prevalence of receiving these inpatient specialty mental health services... Sorry, these specialty services in an inpatient setting was low with only 2.5% of adolescents in this age group reporting that type of mental healthcare in the past year. And there was no significant variation for rurality or census division.
But most specialty mental health services occurred in outpatient settings. So approximately one in six adolescents in this age group reported receiving specialty outpatient mental health services in the past year, which are services from a private therapist, psychologist, psychiatrist, social worker, or counselor. And there was no significant variation across the two categories of rural and urban, but some significant variation by rurality within the census divisions for receipt of outpatient specialty services, with significantly higher rates of reported receipt in urban compared to rural counties in the Mountain, Pacific and West Central census divisions.
So additionally, around 15% of adolescents in each rural and urban counties received mental health services in a non-specialty setting in the past year, which includes those delivered in education, general medicine, juvenile justice, or child welfare settings. There were no significant differences in the prevalence of these services by rurality or census division. So thank you. Now, I will hand it back to Janessa for the next topic.
Janessa Graves: Thank you, Gina. So youth can potentially carry a higher burden of mental health need, but we don't see in the data that we have a huge difference in the proportion of youth who are receiving services. And thank you, Gina, for covering that so well. With the higher needs in rural, it's really important to consider what the workforce is available to treat them, and so that's what I'm going to cover here. So here's the take-home message. The access to behavioral health treatment for youth is scarce. So if you take anything home with you today, that's probably should be that. However, you probably already know that that's why you're here.
So just a little bit of background. One element of context is the access to mental health facilities for rural youth, and there just simply aren't facilities in rural areas. So across all the United States, all US counties, roughly 64% of counties have a mental health facility that treats youth within that county. However, only 29.8% of rural counties have one of these facilities that will treat youth. Schools, while they're in nearly all communities, may not fully meet youth's needs either. Our previous work has shown that rural schools are 19% less likely to provide mental health assessments than city schools.
An obvious workaround could be telehealth, but that runs straight into rural broadband gaps. And I put data here from the 2024 census that shows that 75% of low-income rural households have broadband compared to 82% of urban households. So to see the full picture of the workforce, we needed to get a count of the providers everywhere. And so the objective of this part of the project, of this larger project, is to look at the distribution of child and youth behavioral health service providers across rural and urban areas.
So our approach is fairly straightforward. We turned to the National Provider Identifier Registry. So it's a registry of providers, essentially a billing fingerprint that every US provider carries, and pulled five provider types. And the way I thought of it was, these are folks who do both youth and children, youth, adolescents, kids, and then also do the mental health side of things. And so these are school counselors, school and family psychologists, youth and family mental health clinical nurse specialists, school social workers, and pediatric psychiatrists and behavioral pediatricians.
And we placed each provider in their practice county and then classified that county along the rural gradient using these Urban Influence Codes. From urban, all the way down to the most rural, small, remote communities that don't even have 5,000 people. And so we used that to calculate the supply per 100,000 youth aged five to 12. So what did it reveal? Here is the core finding. Urban counties have about 69 youth behavioral health clinicians per 100,000 young people, and rural counties have about 34. That's almost exactly half. The chart on the right gives you an idea of how the clinicians were classified. So we have on the left side people who care for kids, so that's the first three bars. And we do see a gradient there. The blue is urban. And then we get to micro and then non-core. So as we get more rural, we see fewer providers per 100,000 youth.
The second group are those folks who treat behavioral health. So behavioral health folks, we also see a gradient. And then on the far right, we see this youth behavioral health, which are far fewer, and that's part of the take home. And we still do see a gradient. So when we break down rural into layers, here on the left is that urban supply. And the supply erodes every time we step away from metro areas. So the further we get from metro areas, the less supply we have. The most remote counties, small, isolated, those counties without even a town of 5,000 people, those have 18 clinicians per 100,000 youth. That's barely a quarter of the urban figure.
And you'll see later that part of the issue here is that these are the children who face the longest drives and have the thinnest local infrastructure are the ones that could really benefit from having the providers near them. And you'll see later from some of our work that the driving is a significant barrier. So moving on to this next slide. This is looking at 50% of US counties. So half of counties don't have a single youth behavioral health clinician of any type. And in rural counties, let's see if our thing goes here. So in urban counties, 25% of them do not have a youth behavioral health provider. When we get to rural counties, it's 65%. So it climbs to nearly two thirds of that value.
When we get to the most rural counties, we're talking 87% of the most rural counties have no youth behavioral health clinician. And so the national numbers also tell us something about the regionality of what we're looking at. So here is a distribution across census divisions. And in case you don't know your census division, here's your country. And the colors correspond to where they are on the map. And what you can do is look at the rural South Central census divisions and the East and West South Central. They have about 10. So these bottom two, they have about 10 providers per 100,000. That's comparing that to New England that has 86 providers per 100,000 youth. And so that's a ninefold difference. Same country, same need potentially, wildly different reality.
And so a rural county in Vermont or Maine and a rural county in Mississippi, we know they're not the same. And maybe in workforce terms, they're entirely different planets. The deepest band we see, the deepest need band, are these gray counties in the center, and then this East South Central, which is this maroonish, brownish color. And so this scarcity tracks with geography. And so from a policy and intervention standpoint, we could use these data to target our efforts, and perhaps with different approaches in different areas based on their needs.
Now looking at this variation by provider type. So this is the number of specialized providers that are lacking in the county. And so this is dividing out, starting with youth mental health clinical nurse specialists, pediatric psychiatrists, school counselors, school social workers. And as we move down, what the availability in the percent of the counties that lack these provider types. And I think that the take-home message here is that 99% of rural counties lack some of these provider types. The best we're doing is the youth and family school psychologists, which is 75% of counties are lacking that provider type.
And so what do we actually do with all of this? I think that the most important... These are some of our take-home. The most important piece, I think, to think about is continued monitoring of the youth behavioral health workforce is essential. Efforts to address youth mental health access must account for the magnitude of the shortages and this geographic variation that I showed you with the census map. Certain areas and census divisions warrant targeted investment where rural counties have the lowest supply across regions. And shortages span multiple provider types, suggesting that there might be systemic barriers rather than isolated gaps. This is a systemic problem and it's an issue within the system, not necessarily an issue with a single county.
And these findings point to both supply and geographic distribution, and we need to think about that when we're thinking about strategy. So we might want to consider more providers expanding training pipelines in rural serving programs across all five types. We need to extend the reach of telehealth, but pair it with broadband to make it real. We need to target the places for this behind and look at these regional disparities. And we should build on what already works. So we know that school-based providers often reach kids in places where there are no clinical specialists might exist or there's no clinical site, and that might be a really apt place to leverage. The point is that the supply and the distribution have to be solved together. It's not just one or the other.
And so for my last slide, this is what the take-home is, is that youth behavioral health clinicians, there's a low supply, but it's in a context... Oh, sorry. Next slide. I have the wrong button. Lower supply in the context of greater need. And so that's what we need to take forward with us as we think about these things. And so I'm going to pass the torch on to Natalia, who's going to talk a little bit about interstate occupational licensure arrangements. Thank you.
Per Ostmo: Janessa, can I jump in here really quick with a question?
Janessa Graves: Mm-hmm.
Per Ostmo: So a couple slides back, there was a map showing the different regions, and then I think it was the number of youth behavioral health providers per county. Was there adjustments for the difference in population for those regions?
Janessa Graves: Yeah. So that's adjusted for. The denominator is the number of youth, per 100,000 youth aged five to 17 in that region. So it's all adjusted for population size.
Per Ostmo: All right. Wonderful. Thanks, Janessa.
Natalia Oster: All right. Awesome. Thank you, Janessa. And hi everyone. I'm Natalia Oster and I'm going to be talking about interstate licensing models. Oops. Sorry. Jumped ahead. Okay. So for background on this topic, most interstate licensing agreements take place through interstate compacts. And for a definition, interstate compacts are legal agreements between states to work together to address a variety of shared policy issues. So compacts are really used for a wide range of cross-state issues like emergency management services, foster care services, adoption, shared water resources, and many other things. States are also using compacts to make it easier for licensed professionals to practice across state lines through professional licensing compacts.
And a key reason for these arrangements is that occupational licensing is usually very fragmented across the states. So states typically have different requirements for education and training for supervised clinical experience, background checks, and continuing education among many other things. And that variation can really make transferring a license complicated and time-consuming. So the goal of compacts is to simplify the process of transferring a license from one state to another or practicing potentially in multiple states.
So our study objectives were to describe state policies that expand behavioral health services through interstate occupational licensure arrangements. And for our methods, we reviewed professional association websites and the literature to summarize licensing models for five specific behavioral health professions. So we looked at psychologists, social workers, licensed professional counselors, marriage and family therapists, and school psychologists, we chose those behavioral health professions because each has either an active or developing compact arrangement or a portability initiative.
So then moving into the results, we found that interstate licensing models really fall into two categories. The most common being, by far, compact agreements, and then the other are licensed portability laws. In occupational licensing compacts, participating states adopt identical licensing laws in each state, and that allows behavioral health workers, for example, a social worker with a license in one compact state, to practice in another participating state without needing to get a separate license.
So in the context of these five professions that we're talking about in this presentation, the compact model is being used by psychologists, social workers, licensed professional counselors, and school psychologists. And then rather than developing a compact, the American Association for Marriage and Family Therapy (AAMFT) is focused on developing license portability laws. And in contrast to compacts, license portability allows states to retain their own licensing standards, but it really streamlines the process for becoming licensed in another state.
All right. Let's see. Sorry. I'm having some problems progressing. All right. So the next four slides show maps of states participating in each of the active or developing compacts. And I use maps directly from the individual compact commission websites, which are current as of now, as of June 2026. And as you'll see, as we walk through these slides, the compacts really are in various stages, so ranging from very early development to operational. The most developed compact is the PSYPACT. That's the compact for psychologists and that's the map that's shown here.
And at the moment, 41 states and Washington DC that are shown in dark blue are participating in the compact. And then two additional states, Louisiana and Iowa, which are in light blue, have an active legislation, but they're not yet up and running as part of the compact. And then four states that are shown in black, Alaska, Hawaii, Massachusetts and New York have introduced legislation, but they haven't passed the legislation yet. And then the three states that are shown in gray, they have no active legislation.
All right. Then moving to the compact for licensed professional counselors. This compact is active in six states, and those states are shown in green. Then 32 states and Washington DC that are shown in dark blue have passed legislation, but they're still working out logistics. For example, integrating their state license databases with the national compact database. That actually takes several years potentially for states to get up and running. And then legislation has been filed in Pennsylvania, New York, and Michigan, and that's shown in yellow. And then nine states don't have any active legislation, and that is shown in gray.
All right. So then moving to the social work compact. This compact is still in development. As of June 2026, 32 states have passed legislation, and that's shown in dark blue. And then New Mexico shown in yellow have passed a modified version of the compact legislation, but it's not yet a full compact member. And then legislation is pending in four states and DC shown in light blue. And then the gray shows 13 states with no active legislation. And this compact is expected to go live in about a year in the spring of 2027.
All right. So then moving to the final compact. This is for interstate school psychologists. It's the newest compact and it is really just getting organized. So as of June 2026, legislation has passed in eight states and has been filed in five states. And then all the states that are shown in light green don't yet have legislation passed.
All right. Sorry. I apologize about my slides that they're not quite progressing right for me. So then just a final slide on marriage and... Actually, let me just go back so that you can see the school psychologist. I'm not sure if you actually saw that. So again, a compact that's very much in the beginning stages.
All right. So then moving into our final slide on marriage and family therapists. So as we briefly talked about before, rather than developing a compact, the AAMFT has developed model portability laws. And at this point, 16 states have passed this model legislation. And then seven additional states have passed laws that are similar to the model legislation and are considered portability friendly. And then there are efforts in four states to develop legislation, and that includes California, Michigan, Pennsylvania, and Rhode Island. And then no current efforts in the remaining 23 states.
Sorry. I do have one more slide. Okay. So just to recap the main points, interstate licensing arrangements for behavioral health providers really are in the early stages. Future evaluations will definitely be needed to really understand how these licensing models impact cost, access, and quality of behavioral health services. All right. That's all for me and I'm going to pass things on to Sara.
Sara Woolcock: Great. Thanks, Natalia. So my name is Sara Woolcock. I'm also a research scientist at the WWAMI Rural Health Research Center. I'm going to briefly be sharing the results of a data brief that we did as part of this project to describe the supply of clinicians with a DEA waiver to prescribe buprenorphine. So to start with a bit of background, one of the barriers that youth face in accessing care for opioid use disorder is the limited availability of clinicians who provide opioid use disorder treatment to youth. And one form of treatment for opioid use disorder in adolescence includes medication treatment for opioid use disorder. And buprenorphine is one of the recommended medications for treating opioid use disorder in adolescents.
So on this slide, this is a timeline showing the legislative changes that have happened in the past 25 years to expand the workforce who can prescribe buprenorphine. Until recently, eligible clinicians had to complete training and then apply to the DEA to attain a specific X waiver before they could prescribe buprenorphine for opioid use disorder. But most recently, this requirement to obtain a waiver was eliminated starting in January 2023. So that was great for clinicians. They had one less barrier to start providing this care to their patients. But with that, it also eliminated the registry that the DEA kept that tracked the eligible workforce that can provide buprenorphine to their patients.
So for this project, we wanted to take a last opportunity to describe the availability of the workforce that's eligible to prescribe buprenorphine before that waiver requirement and that registry went away. So to do this, we used data from the DEA from 2017 to 2022 to provide a five-year lookback. And we assigned all clinicians in the registry to their county and then classified counties based on the USDA Urban Influence Codes, the same classification Janessa talked about. And then we broke down the rural counties by UIC into three separate categories. And UICs use the closeness to a metro area and population size to classify counties as more small and more remote rural counties.
And then in each county, we calculated the counts of clinicians in each county and also adjusted for population, the clinicians per 100,000 population. Oh, and one limitation I just want to note before I jump into the results is, with the DEA registries, with this data source, we can't specifically determine which clinicians in the registry specifically treat youth and adolescents, but it does give us a general idea of the available workforce that could potentially do that.
All right. So this is that last snapshot from 2022. This chart is showing the percent of counties with and without a DEA waivered clinician in 2022. The urban counties are in that first blue bar and all the rural counties combined are in that dark green bar. And then the subsequent green bars are showing the different levels of rural broken out. So we see that, in total, of all rural counties, about 30% of rural counties did not have a DEA waivered clinician in 2022 before the waivered requirement was eliminated. That's in comparison to urban, that only about 10% of them did not have a DEA waivered clinician.
And then looking at the different categories of rural, we see, again, that the small and remote rural counties have the least access, where only about 60% of those counties have access to a DEA waivered clinician. And this chart is showing... We also looked at the change in the supply of waivered clinicians in the five years before the waiver requirement was eliminated. So this is showing the population adjusted supply of clinicians from 2017 to 2022. And we can see in all five years, rural counties had a lower supply compared to urban counties in the number of clinicians per population. But over that time period, five years, the growth in rural counties was slightly higher. Rural supply per population grew 320%. Whereas urban, it grew 268%.
And then we also, again, looked at the availability of waivered clinicians regionally. So this is a map showing the supply of waivered clinicians just in the rural counties. All the urban counties are whited out. The red counties are counties without a waivered clinician. The yellow counties are rural counties with only one wavered clinician. So they would be at risk of potentially losing their one single provider if that provider stopped providing this treatment service for whatever reason. And then all the blue counties are showing different levels of supply. So the lightest blue have two to three clinicians and the darkest blue have the most.
So we do see that in the central mountain states, up from Montana, North Dakota, down to Texas, there is a lot of area there where there are a lot of counties that either don't have a provider or they have very few. So those are places that would have major implications for access to treatment with buprenorphine in those particular areas.
All right. Thanks so much. So now I'm going to pass it on to Lisa and Holly.
Lisa Garberson: Thanks, Sara. My name is Lisa Garberson. I'm a research scientist with the WWAMI RHRC. And today, I'm going to talk to you about two of our studies. We looked at the rural-urban variation in the distance traveled for care by children and adolescents with an opioid use disorder diagnosis. For youth with OUD in rural communities, there are fewer treatment options and a number of barriers to getting that treatment. So for our studies... Oops. Sorry. There's a little bit of delay. For our studies, we looked first at the commercial claims, and then Medicaid claims, and they were both for calendar year 2019.
There we go. And so our sample was children and adolescents aged zero to 17 who had a claim with a diagnosis code of opioid use disorder or opioid overdose. And on the bottom of the slide there, you can see the... Oh, sorry, the number of enrollees we had in the commercial sample and the number of beneficiaries in the Medicaid sample. We defined a single visit by rows of data with the same patient and bene ID, visit date, and servicing provider NPI number. We used ZIP codes to calculate one-way driving distance and travel time between the patient location and the servicing provider practice location. We used the practice location as a proxy for place of service because we did not actually have a ZIP code for the place of service in the data we used.
But one thing... Sorry. I'll go back to the next one. We could not calculate driving distance for beneficiaries and patients who are in the same ZIP code as the provider. So for those, we imputed zero for one-way driving distance. In the policy briefs for both of these, we provide the imputed values and with the imputed zeros, the distance numbers with the imputed zeros and without the zero, so you can see both of those. This was a county level analysis. So we used the 2013 Urban Influence Codes. We had metropolitan urban and non-metropolitan rural. And now, I'm going to hand it off to Holly to walk you through some of our results.
Holly Andrilla: Thanks, Lisa. So I'm going to just share findings from one piece of these two studies. And to start, I want to just orient you to this particular slide because I'm going to look at it a bunch of different ways. On the left-hand side, you see all those beneficiaries and enrollees for commercial insurance. And on the right-hand side, you see the numbers for the beneficiaries with Medicaid insurance. And then within each of those broader columns, you see the rural, urban columns individually. So let's start with comparing within patients with commercial insurance, how far does a rural patient, and these are all for youth, have to travel as compared to an urban.
So on average, rural patients travel 23 miles compared to 12.9 miles for urban. So about twice as far. And it probably actually is twice as far because I am reporting findings that have those zeros included. So anytime somebody got care in the same ZIP code as they lived, we have to count that as a zero. And we did include those because the differences look bigger if you exclude all the close visits. And there are more rural people that see a patient in the same ZIP code. So it's about twice as far as the take-home message.
And if we look at the same thing for Medicaid, we see a similar pattern. Rural beneficiaries with Medicaid insurance travel, can you believe it? Almost 81 miles on average for care for opioid use disorder as compared to 45. And I think 45 is huge as well. Now, the next logical comparison to look at is, what about if you are comparing types of insurance and ignore the rurality for a minute. So urban beneficiaries with Medicaid insurance travel on average 45 miles as compared to urban commercially insured patients about 13 miles, about three and a half times farther. And we see that same... It's a little slow to move ahead. You see that same pattern when you compare rural Medicaid insurance patients to commercial insurance. They travel about three and a half times farther.
And we've got the times there too if you're interested. If you take those... Let me go back one slide for just a minute. If you take those rural patients that traveled 80 miles on average and you just look at them and you just look at the Medicaid. So this next slide is just the Medicaid enrollees and just the rural. And you look at it across the rural continuum, you see that the 80 is true overall. But as you move from left to right on this slide, you move from the, I'll say, least rural to the most rural, that is, you move from counties that are adjacent to a metropolitan county, to small and remote counties that are not adjacent to a metropolitan or a micropolitan. So really the smallest places. And look what happens to the average. It just steadily climbs. So the story of 80 is true for a lot of people. But it's even more, even a farther distance for people in the most remote places. So what's the take-home.
And rural children and adolescents travel twice as far as their urban counterparts regardless of their insurance. But rural children with Medicaid insurance carry the largest travel burden. They travel twice the distance as their urban counterparts and more than three times, about three and a half times farther than commercially insured rural children. So why is that? We have some ideas. Stigma is one of them. Providers don't always want to provide care. But this group is interesting because there's also a big problem with the lack of available specialty care.
In the rural population that we looked at, we could tell the specific age of the patients. And about 10% of that sample were babies, less than one year old. And then about almost another 20% were one to four year olds. So that group of patients were people that were born with opioid use disorder because their mother was using drugs during pregnancy. And so the level of specialty care that they need is likely not available in a rural place. For older kids, there's a concern about for families maintaining anonymity in a rural community. And if you live in a rural community, you're familiar that everybody knows your business and maybe this isn't business that you want everybody to know.
However, if that was the only reason, if those were the reasons, we wouldn't see the big additional disparity between commercial and Medicaid insurance. And so likely, the very low reimbursement rates for the Medicaid population is contributing that providers can't afford or choose not to afford to provide services when the reimbursement rates are so low. And Natalia's going to, I think, finish us off with talking about some of those reimbursement rates.
Natalia Oster: Yep, that's right. Thanks, Holly. All right. So I'm going to be talking about Medicaid reimbursement for youth behavioral health services. And so for background on this topic, as all of you will know, youth behavioral needs are rising at the same time that we have a lot of behavioral health provider shortages. And a key workforce piece is really how providers are reimbursed. Medicaid is the single largest both provider and funder of behavioral health services in the US. It covers about 20% of US residents. However, it does cover a disproportionate number of rural children. Research suggests that about 47% of rural children are covered by Medicaid and CHIP versus 40% in urban areas.
So just continuing with some brief background on Medicaid funding and administration that's relevant here. Medicaid is jointly funded by states and the federal government, but it's administered by the states. So states determine billing, reimbursement, coverage policies and other things. And this results really in 56 distinct Medicaid programs, so the 50 states, plus DC, and the US territories. And then adding to that variability, Medicaid reimbursement policies also vary by the patient's age, by care setting, and by eligibility criteria. So because of this state-by-state variation and reimbursement and coverage policies, the goal of our study was to summarize reimbursement for behavioral health services for Medicaid beneficiaries ages zero to 24 in all 50 states and the District of Columbia.
Moving to the methods, we reviewed Medicaid provider and billing manuals for all 50 states and DC for three specific behavioral health occupations. So we looked at social workers, marriage and family therapists, and psychologists. And then we also separately reviewed individual state reimbursement policies within school-based Medicaid programs for school psychologists. And the reason for doing that is that school psychologists typically are not enrolled as independent Medicaid providers. Instead, they're typically reimbursed through school-based Medicaid programs.
All right. So then just moving into our main findings. This is as of November 2024. I should say that the policies change frequently. So this is as of 2024. Medicaid reimbursement was available in both community and school-based behavioral health services for psychologists and social workers in all 50 states and DC. I don't know if you can see my cursor, but you can see this in the second and third column that psychologists and social workers are fully covered for both school-based and community-based.
Less coverage, for sure, for marriage and family therapists. So in contrast, marriage and family therapists were reimbursed in school-based settings in 34 states. And then 16 states and DC did not provide coverage. And then looking at the bottom right cell, MFTs could bill Medicaid for community-based services in 48 states and DC. And those two exceptions, the two missing states were Pennsylvania and West Virginia, which, at the time, did not reimburse marriage and family therapists for community-based services. But since then, West Virginia has actually begun reimbursing MFTs and Pennsylvania does offer now some limited coverage through certain managed care programs.
All right. Then just final results that I'll be sharing here. Medicaid billing and reimbursement policies vary very widely both between and within states. So for example, some states offer multiple Medicaid plans such as a fee-for-service and other managed care plans. Some providers are covered by some Medicaid benefits and not others. And then interestingly, I thought it was interesting at least, benefits are also sometimes differ by provider settings. So in some states, reimbursement is restricted to services provided in a clinic or community mental health center or another institutional setting.
So just to recap in conclusion, most states provide some level of Medicaid reimbursement for youth behavioral health services for social workers and psychologists and MFTs. Fewer states do cover MFT reimbursement for school-based Medicaid programs. And I believe that's my last slide. So thank you so much. And I'm going to be passing things back to Janessa.
Janessa Graves: Thank you. So before I pass it back to Per, and we're happy to answer questions, so please put them in the Q&A. Just as a summary statement, the challenge that we've cited here from our work is not that it's simply one need or one workforce. It's a mismatch between where the youth need services and where the services actually are. And so rural communities face potentially higher burdens of some behavioral health outcomes, while they simultaneously have to navigate having fewer local resources and greater barriers to care, like the driving times that we talked about.
So improving youth behavioral health in this context in rural America does require some targeted place-based solutions that expand workforce capacity, that reduce access barriers, and ensure that all youth can receive timely appropriate care regardless of where they live. And the link to our policy report, I believe, is in the chat. And I am curious if there are any questions. All of our work can be found at the Rural Health Research Gateway.
Per Ostmo: Thanks, Janessa. So we do have a few minutes. While everyone takes a couple minutes to type their questions, I'll go over, review a couple housekeeping items. The recording transcript and slide deck will be available, if not Friday, then next week, Monday. If you have questions about anything you've heard today, you can feel free to send an email to the researchers. All of their contact information is on Gateway. Or you can send an email to me or the Gateway general inbox. If you don't know who to reach out to and you have a question in general about rural health research, always feel free to email Gateway and I can connect you with a researcher who specializes in whatever area that you're interested in.
So thank you to our presenters for presenting and to anyone asking questions. We'll check the QA one more time.
Janessa Graves: I have a question. Can I ask?
Per Ostmo: Yeah. Janessa, go ahead.
Janessa Graves: I'll just fill up the world with questions. So this question is for Holly and Lisa. Rural Medicaid youth travel the furthest of any group, and I think of driving time all the time because I live in a very rural area and also have to drive. In my case, that's 65 miles one way. Given the possible drivers that you listed, so you talked about stigma, specialty care, scarcity, anonymity concerns, reimbursement, which lever do you think would reduce that travel burden the most? And, is telehealth a realistic substitute for that population?
Holly Andrilla: Okay. Unless you're dying to take it, Lisa, I will.
Lisa Garberson: No, go ahead.
Holly Andrilla: So for me personally, I think that the most realistic, quickest lever is improving reimbursement. I think that that is a huge barrier for rural populations for providers. However, it only matters if there's a provider there to improve the reimbursement for. And so I think expanding our workforce is really key. There has been a huge increase. And I reported the findings for opioid use disorder, but there's lots of other things that people need help for. But there's been a huge improvement in the workforce in, I will say, the last 10 years that can provide care for opioid use disorder. So I would love to see. And we've seen the expansion of marriage and family therapists, their billing capacity.
So I think expanding the workforce and removing some of those barriers to providing care for people, having practitioners work at the top of their scope is going to be really key. When you say broadband improvement, or telehealth, that goes hand-in-hand with broadband. You know. You live in a rural place. A lot of people say, "Oh, we can just use telehealth." But that isn't a realistic solution at this moment for rural communities. So that's another thing that the federal government and others have been talking about for a lot of years. But we definitely need to improve that if that's going to be our go-to answer.
Janessa Graves: Fantastic. Thank you. There is a question in the chat. "Would you please detail," this is from Meredith, "What you would see as potential solutions to these issues and as specifically as possible?" And there are a lot of solutions. So I would say, first, check out our report because we do talk about some solutions in the key findings. And at the end of the policy reports, we have some suggestions or some considerations. I think, personally, one thing to think about is that these are some structural challenges that we are facing.
And so, instead of building something new in a community is leveraging the structures that are already there. So be it a really active youth center or senior center or schools, because that infrastructure already exists, and could we leverage that infrastructure to get something off the ground more quickly than, say, building a whole clinic or something. Similarly, pipeline and pathway programs matter and they're very important. They do take some time. I think working on different timescales. If you're working in the long timescale, think about pipeline and pathway programs, which are critical. But also thinking about the shorter terms and what sort of changes can be made around reimbursement or the way care is delivered, whether we're leveraging schools or leveraging other community resources can be a quicker component to address some of the challenges that youth are facing.
But there are a lot of different potential policy levers or interventions that could be employed. And please send us an email. It's really fun to talk about this stuff and I'd love to chat more, if that's something you're interested in, Meredith. And then Alejandra says, "What are your thoughts on helping potential providers of behavioral health services with billing and Medicaid reimbursement given the climate of the Medicaid budget?" And so I am not sure if this is the technicalities of reimbursement and how to handle billing and reimbursement, or if it's the entire climate of this as a potential source of services or a reimbursement of services is potentially going away with some circumstances.
For the former, I think there are technical assistance services out there that can help with billing for billing Medicaid and being able to do that. And then for the latter, I might pitch it to Holly because I know she has a million great ideas. And she might have a better idea on... She's laughing right now.
Holly Andrilla: Thank you. Thank you. I was trying to see the question. For some reason, I can't see the question.
Janessa Graves: It says, "What are your thoughts on helping potential providers 'of behavioral health services' with billing and Medicaid reimbursement given the climate of Medicaid budget?"
Holly Andrilla: Yeah. Well, what will I say? Yeah. I do think that the technical support is important. But as Janessa said, I do think a lot of that exists. Of course, it's different for every state because Medicaid is a state-federal partnership. And so that further complicates it. In my interactions with clinicians that are hesitant to use Medicaid or to accept Medicaid, it's not so much that they don't know how to bill it. It's that the amount that they are getting is very small and the time that it takes to get it, both in terms of paperwork and then actually getting paid, having the money is so long that they just say, "It's not worth it. I've got people that can pay me more in a more timely fashion. I don't want to sign up for this extra administrative burden and the wait time for the money."
So I think that we really do need to address that, or we need to figure out ways to, I will say, have a larger share of the clinician population or provider population, whatever you want to call them, participate. Because if everybody did a little, of course, it would be workable. It's that everybody doesn't do a little, and then that makes the burden really fall heavily on some groups.
Janessa Graves: Yeah. We have some other work looking at how Medicare expanded the workforce to include and be reimbursed for marriage and family therapists and mental health counselors. And one of the challenges in some interviews we've conducted with key informants is the administrative barriers and these challenges with billing Medicare. Certainly, it's potentially even more complex with Medicaid. And so one of our suggestions or considerations for that was trying to address some of these administrative challenges to make it easier for folks to serve those kids or folks.
Per Ostmo: Well, thank you. We don't see any other questions in the Q&A. So a big shout-out to the WWAMI Rural Health Research Center team for presenting here today and a big shout-out to all of our attendees for asking such excellent questions. I hope to see everyone at future Gateway webinars, and have an excellent day. Thanks again. Bye everyone.