Author: Josh Ludwig

Background

Since the Covid-19 pandemic, there has been an increase in the prominence of telehealth services, especially for mental healthcare. As a result, previous government policies regulating telehealth have been reevaluated to consider the challenges surrounding the Covid-19 pandemic. 

Telehealth occurs in three categories: real-time communication (think Zoom, Google Meets, telephone, etc), store-and-forward (references the transmission of data, images, sounds, or video from one site of care to another site of care for evaluation), and remote patient monitoring (refers to collecting a patient’s vital signs or other health data while the patient is at home or another location, and transferring the data to a remote provider for monitoring and response as needed).

One argument for regulating telehealth is for privacy and security concerns. The Health Insurance Portability & Accountability Act (HIPAA) is a major concern for telehealth, especially telehealth for mental health (telemental health). The popular teletherapy apps BetterHelp and Talkspace collected and shared metadata with third-party vendors for targeted advertising, according to a recent report by Jezebel. HIPAA concerns are especially important for telemental health because of the sensitivity and confidentiality of the conversations patients have with their mental health providers. Additionally, another argument for regulating telehealth is that there are still debates about the efficacy of telehealth for mental health.

Recent Developments in Telehealth

1. Permanent telehealth policies (post-Covid): 37 states enacted 51 bills to make temporary flexibilities permanent post-Covid. These policy changes include Arkansas expanding the list of providers eligible to conduct telemental health for Medicaid recipients and required coverage for group therapy, crisis intervention services, substance use assessment, and other telemental health services.
2. Temporary telehealth policy changes: All 50 states, D.C. and Puerto Rico implemented some form of telehealth policy change during the Covid-19 pandemic. These policy changes include Connecticut enacting legislation to extend certain Covid-related changes until June 2023, including requiring payment parity (equal insurance coverage for in-person and virtual medical appointments) and expanding the list of providers eligible to use telehealth.
3. Non-legislative action (governors’ offices): Some states took non-legislative action—through governors’ offices, Medicaid agencies, licensing boards, and other state agencies—to make Covid-related changes permanent. These non-legislative actions include California’s Department of Health Care Services, which operates the state’s Medicare program, making Covid-related changes permanent by implementing payment parity for services delivered via telehealth in real-time and coverage for audio-only telephone visits.
4. Increased funding for new telehealth initiatives: The $2 trillion Coronavirus Aid, Relief, and Economic Security (CARES) Act passed by Congress included $200 million for the Federal Communications Commission to expand telehealth services across the country.

One argument in favor of deregulating telehealth is there is a shortage of mental health professionals, and bureaucracy makes it hard to offer telehealth between state lines. Additionally, the pandemic has made it harder for people to access their providers in-person. Currently, telehealth is inaccessible to many, due to the cost or lack of internet access. Deregulations for this inaccessibility could include forcing Medicare and Medicaid to adopt payment parity for telehealth and in-person medical appointments, reducing the cost, as well as subsidizing internet access for low-income folks.

Future developments in this issue include a further $100 million from the Universal Service Fund administered by the FCC which will finance a three-year Connected Care Pilot program to subsidize internet connectivity for healthcare providers (associated with CARES Act). Additionally, many states which implemented temporary telehealth policy changes will have to make decisions about which reforms to keep.

The heart of this issue is the government’s role in regulating vs. deregulating telehealth and telemedicine, and it comes down to the states mostly instead of the federal government. Will HIPAA privacy concerns stand in the way of telehealth accessibility, which is already inaccessible to many who lack internet access and economic capital? Will payment parity and the loosening of licensing restrictions for interstate telehealth appointments prevail over the questioned effectiveness of telehealth and telemedicine? Will the deregulations of telehealth that have already occurred be here to stay, especially once the pandemic is over? Is telehealth the future of healthcare, or are in-person medical appointments more effective?

The Government has the power to regulate and empower how colleges can respond to the college mental health crisis through funding for mental health resources, conducting surveys on mental health, and creating a national commission to study mental health on college campuses.

The college mental health crisis is happening for numerous reasons, but the Covid-19 pandemic exacerbated existing issues. Since the pandemic, college mental health resources have been stretched thin, resulting in longer wait times and less availability to meet with mental health professionals. This has resulted in increased deaths by suicide on college campuses.

Some argue that the government must hold these colleges and universities accountable for the college mental health crisis. One main reason in favor of this position is that untreated mental health issues at college-age can affect people throughout their entire lifetimes. Given the significance of the 18-23 age range in intellectual development, it might make sense for the government to become involved in this college mental health crisis. In addition, students with mental health disabilities are protected by national civil rights laws, so the government has a responsibility to advocate for these students. One option would be for the government to create a commission to study this issue, as little research has been done on mental health in higher education.

Four main pieces of legislation tackle the college mental health crisis, ranging from the state to the federal level, including from the White House.

1. Higher Education Mental Health Act of 2021: This legislation would require the Department of Education to create an Advisory Commission for supporting college students with mental health disabilities. The commission would report on the quality and efficacy of mental health resources for college students with mental health disabilities, the impact of policies (reasonable accommodation and disciplinary policies) that either help or hurt the goal of equal opportunity for these college students, the use of protected health information of college students by their institutions of higher education, the impact of providing these resources on a student’s level of success in college (academic, well-being, and completion status), conclusions on the major challenges facing these students, and recommendations to fix this issue/improve the outcomes for these students.

Strengths: This piece of legislation is comprehensive and tackles many aspects of the college mental health crisis. Even less-talked-about parts of a college student’s mental health, such as accommodation and discipline, are taken into account in this legislation, which can impact a student’s chance of success in college. For example, if a college student is in a class where the professor penalizes absences, a student going through documented mental health issues that require them to miss class won’t be able to succeed. Similarly, if a college student is disciplined for a mental health crisis, such as for showing up to a class intoxicated continually, that student won’t receive the help they need for a possible alcohol abuse disorder diagnosis.

Weaknesses: By focusing on students with documented mental health disabilities, this piece of legislation doesn’t account for someone going through their first mental health issue or crisis that may not be documented by a mental health professional. Those without a documented mental health condition are left out of this piece of legislation.

2. Enhancing Mental Health and Suicide Prevention Through Campus Planning Act: Representative Susan Wild introduced this bipartisan legislation with Representative Fred Keller. This legislation would amend the Higher Education Act to promote positive mental health among college students and encourage comprehensive planning on college campuses to prevent mental health crises. The legislation provides for more coordination between federal agencies and colleges to develop and implement mental health and suicide prevention plans, increasing student access to mental health resources. The Act would require the Department of Education to work alongside the Department of Health and Human Services to incentivize colleges and universities to tackle the college mental health crisis.

Strengths: This piece of legislation improves on the weakness of the Higher Education Mental Health Act of 2021 by promoting positive mental health among all students, not just those with documented mental health conditions. Additionally, this Act would increase coordination between the Department of Education and the Department of Health and Human Services, both integral departments when talking about college student mental health.

Weaknesses: While this act deals with the prevention of mental health crises, it does not discuss how to manage mental health crises that aren’t prevented. For example, a college student who does not receive the mental health care that they need may have a mental health crisis, and may require hospitalization. This example wouldn’t deal with the prevention of mental health crises but would deal with the management of active mental health crises.

3. NY Senate Bill S7659A: This statewide bill would require SUNY (The State University of New York) and CUNY (City University of New York) to adopt specific provisions concerning college student mental health such as administering mental health climate surveys, establishing a mental health committee, providing mental health training to faculty and staff, and improving college policies in general regarding mental health.

Strengths: Something unique to this bill is that it would provide mental health training to faculty and staff, while other pieces of legislation focus on the hiring of mental health professionals. This is effective because faculty and staff are at the forefront of the fight against mental health crises on college campuses, and they can refer students to mental health resources before a crisis occurs. When other bills focus on mental health professionals but do not take into account faculty and staff, such as Professors and Resident Assistants (RA’s), the focus goes to the management of mental health crises rather than preventing them, and both are important.

Weaknesses: At the same time, this bill does not discuss the funding of mental health professionals. On the opposite side of the strength of training faculty and staff for the prevention of mental health crises, by not putting that same amount of resources into mental health professionals, this bill ignores the management of active mental health crises.

4. Higher Education Emergency Relief Funds (HEERF): HEERF can be used to invest in evidence-based mental health supports for students and connect the campus community to providers and care (White House/Executive Branch Legislation).

Strengths: Not all mental health supports are created equal, and by focusing on evidence-based mental health supports, this piece of legislation is strong.

Weaknesses: This piece of legislation is vague and does not define what these evidence-based mental health supports are nor does it explain how it would connect the campus community to providers and care. Additionally, many college students complain that they are always referred to community mental health professionals by the campus mental health services, which aren’t always accessible to low-income students. It might be more effective to fund and train more mental health professionals on-campus rather than refer students off-campus.

There are arguments against the government regulating colleges’ responses to the mental health crisis, including that this would be expensive in a time with high inflation and an at-risk economy. Additionally, it would be time-intensive, and there is a chance that it might not work. Some might argue that it’s not the government’s job, and either to leave it up to the colleges to decide how best to serve their students or leave it up to the students, as they will be on their own to seek mental health resources once they graduate from college. From the colleges’ perspectives, a federal commission could also hurt the colleges’ public perception, possibly dissuading parents from letting their children attend a college where so many students suffer from mental health conditions and don’t receive adequate support. Or, in other words, it would open up the colleges to talk about an issue that would put them in a negative light and hurt their business model.

Future developments in this issue include a federal commission to study mental health concerns on college campuses and periodic campus climate surveys on the mental health of college students. 

The key question here is should the federal and state governments get involved in the regulation of colleges’ responses to the college mental health crisis, a crisis that is worsened by the Covid-19 pandemic and comes at a pivotal age of development (young adulthood)? Or, do the colleges know best how to serve their students and an investment by the government would be a waste of federal and/or state resources?