Budget Battles: Mental-Health Care Seldom Comes Out Ahead
The high school needs a new roof. The teachers want a raise. Half the bus fleet needs a maintenance overhaul. Joey is depressed.
Which of these problems is a district most likely to tackle last? When most school boards debate their budget priorities, identifying children with mental-health problems doesn't generally rank high on the agenda. But the hidden costs of student woes hover like ghosts in the room.
Of the 21 percent of children in the United States who seek mental-health care, half get it at school. That's nearly 5 million students a year who seek refuge from their emotional problems in the company of teachers, coaches, and school counselors. A recent Connecticut study found that the No. 1 reason students visited the school health clinic was for mental-health or substance-abuse problems, not bloody noses or birth control. Most schools already are providing mental-health services, experts say; they just aren't getting fully paid for it.
A combination of factors—state and federal funding hasn't kept pace with students' escalating emotional needs, districts fail to lobby for such support, and the public is suspicious of school psychological programs in general—has resulted in a scenario where resources are stretched thin and students badly in need of help are often given cursory care.
'A Forest Fire'
Several studies have shown that screening teenagers for depression and other mental illnesses at school can help reduce the suicide rate. A majority of young people who commit suicide had histories of mental-health disorders.
In addition, the National Institutes of Mental Health estimates that 9 percent of the nation's students suffer from emotional or behavioral problems that pose a serious barrier to learning.
"This is a forest fire, and we are using buckets," said Kevin Dwyer, the president of the National Association of School Psychologists. Few districts calculate how much time their regular staff members devote to counseling students, making referrals, and processing related paperwork, and many don't keep track of exactly how much they spend on professionals to help students cope with extracurricular angst.
But Alan Odden, a professor of education at the University of Wisconsin-Madison and a leading expert on school finance, estimates that districts, on average, spend roughly 5 percent of their total budgets on "student support services," which include social workers and counselors, as well as safety personnel.
Gordon Wrobel, the health-care coordinator for the school psychologists' association, estimates that districts' mental-health costs balloon into the millions when one adds in the time that staff members of all kinds spend with troubled children on a daily basis. When schools have no personnel designated to provide mental-health services, everyone—teachers, principals, and coaches—takes a swing at the problem, he said.
"Education's contribution to [addressing] the national epidemic [of teenage suicide] would stagger even the most liberal politicians," Mr. Wrobel said.
But because more school employees than private physicians or psychologists serve as de facto therapists to the nation's adolescents, their ranks are woefully inadequate to meet the demand, Mr. Wrobel said. A NASP survey found that the average school psychologist had a caseload of 1,500 students; NASP's recommended ratio is 1-to-1,000.
School psychologists earn an average of about $49,000 a year, a low salary compared with what their private-sector counterparts can make. That makes it hard to attract and retain qualified professionals.
Yet a lack of trained personnel can, in itself, prove costly. Several districts in the past two decades have been hit with negligence lawsuits for failing to refer students who had expressed suicidal intentions for professional help.
Though no one tracks exactly how much states and the federal government spend on school-based health care, experts estimate that it's less than a fraction of 1 percent of their revenue.
Spending varies widely from state to state; such expenditures are often governed by how wealthy a state is and how disposed its residents are to paying for such programs. As a result, some states opt to pay for psychiatrists to work in state-of-the-art mental-health clinics in schools, while others choose not to fund even guidance counselors.
While many factors can influence how many teenagers in a given state commit suicide, one long-term study found that public investments in social services can reduce the suicide toll in general.
A University of Minnesota study published in 1990 compared states' suicide rates with their spending on Medicaid and other public-welfare programs over a 30-year period, with factors such as divorce rates, population density, race, and gender all being equal. Shirley L. Simmerman, a professor of social science at the university and the lead author of the study, found that suicide rates were higher in states that spent less on public-welfare programs compared with those that spent more "to meet the needs of people."
For instance, South Dakota, which in 1997 spent $54 per capita on mental-health services overall—well below the national average—has the third-highest teenage suicide rate in the nation. By comparison, Connecticut, which spent $99 per capita that year on mental-health services, ranked 46th in adolescent suicides. Some officials, meanwhile, argue that the federal government hasn't provided enough aid to help schools prevent suicide.
From 1969 to 1994, federal spending on all mental-health services rose just 5 percent after adjusting for inflation, according to a report by the federal Substance Abuse and Mental Health Services Administration. During the same period, the rates for depression and suicide among youths tripled.
"There's been money spent, but not a lot," said Michael J. English, the director of the division of the agency that oversees youth programs. "No one would suggest we have been close to meeting the needs of children with mental-health disorders."
Even when the federal government does promise money, it doesn't always come through, Mr. Wrobel said.
Though Washington in 1975 required schools to conduct psychological evaluations of students who seek special education services under what later became the Individuals with Disabilities Education Act, which includes children with mental illnesses, the government has paid only a portion of the tab. Congress originally authorized IDEA to be funded at 40 percent of schools' costs, but the federal contribution has never exceeded 12 percent, according to Mr. Wrobel.
One result of the financial strain on school budgets is complaints from parents about shoddy service, some mental-health advocates say. In a report last year, titled "A School System in Denial," the National Alliance for the Mentally Ill contended that students with mental illness weren't getting the help they are entitled to by federal law.
The Arlington,Va.-based advocacy group for people with mental illness surveyed parents of such students about their schools' services, and found that 46 percent of the parents believed that their schools "resisted identifying children with mental illness." And 60 percent maintained that the schools' individualized educational plans—required for students with disabilities—failed to meet their children's psychological and medical needs.
A complicated bureaucracy also frequently comes between schools and their money. Districts can apply for mental-health revenue for suicide prevention, for example, from an array of sources: the federal Medicaid program, the federal Maternal Child Health Block Grant, the state education department or health department, the state legislature, private foundations, and local governments.
Mr. Wrobel of the NASP calls that the "bake sale" model for funding, in which schools get little bits of money here and there and attempt to put together a service: "The patchwork of funding sources has created a labyrinth that befuddles even the most sophisticated financial analysis."
Another obstacle to financing school mental-health services is that Medicaid reimbursements for school clinic care create snarls of paperwork. That means only the schools that can spare the personnel to do the administrative tasks can benefit from the program.
Julia Lear, who runs Making the Grade, a Washington-based program that provides support to the country's more than 1,000 school-based health clinics, contends that the federal government has purposely made the system of reimbursement for health services so complicated to discourage billing that would drive up Medicaid costs. "They've made it hard for schools, and it wasn't an accident," she asserted.
For their part, federal experts say that schools have taken advantage of the Medicaid program and billed for services that weren't health-related.
States such as Montana that have tried managed-care systems to help contain medical costs also have made providing mental- health care for students harder, said Doug Cockran-Roberts, a psychologist at Corvallis Primary School in Corvallis, Mont. "The managed-care company put a lid on money spent, and the quality suffered," he said.
But districts sometimes erect their own barriers to getting the financing they seek, said Kathy Christie, a policy analyst for the Education Commission of the States in Denver.
With many items on their wish lists, education groups from the teachers' unions to the superintendents' associations seldom lobby for mental-health care the way they would for building repairs, metal detectors, or higher teacher salaries, she said.
And because constituents in many states are dubious about using tax dollars to subsidize school mental-health counselors, schools need to explain to legislators why they should care, Ms. Christie said.
Mr. English of the SAMHSA advised that if educators want more money for such services, they need to tuck mental-health funds into their traditional package of requests when they lobby the federal government for assistance. "Kids are not going to stand up and say, 'I have a mental problem. Come help me,' " Mr. English said.
One effective lobbying tactic that has won revenue to combat smoking, teenage pregnancy, and AIDS is the argument that cash up front saves more money down the road.
Mental-health screenings, in particular, can be cost savers, research has found. Students whose depression is detected and who are then referred for treatment are 50 percent less likely to attempt suicide, preliminary data from a University of Washington study has found. Experts estimate the average cost of an emergency room visit for a suicide attempt to be about $33,000.
Alex Berman, the executive director of the American Association of Suicidology, estimates that each teenager who commits suicide costs society, in terms of lost wages and productivity for an average life span, about $500,000.
Dr. David Satcher, the U.S. surgeon general, is drilling this prevention calculus into congressional leaders these days. This past summer, Dr. Satcher and Tipper Gore, the wife of the vice president, unveiled the nation's first comprehensive suicide-prevention strategy. It calls on Congress to enact legislation that would put money into research on the most effective suicide-prevention techniques, help reduce the stigma associated with suicide, and foster the availability of state-of-the-art mental-health care.
"The federal government isn't spending enough to help kids," Sen. Harry Reid, D-Nev., who is backing a Senate bill to boost suicide-prevention programs, said in a recent interview. "We spend a lot of money advertising the dangers of AIDS and tobacco, but we need to educate young people on the dangers of suicide."
Mr. English acknowledged that such an initiative could encounter resistance on Capitol Hill. "But if we can bring people to the bottom line—how do we save our children—then people may start thinking about what this is really about," he said.
Vol. 19, Issue 32, Pages 30-31Published in Print: April 19, 2000, as Budget Battles: Mental-Health Care Seldom Comes Out Ahead