Georgians for a Healthy Future (GHF), the Georgia Council on Substance Abuse (GCSA), and the Center for Pan-Asian Community Services (CPACS) are nonprofits focused on building healthier communities. We partner together to promote policies and systems that increase access to substance use and mental health prevention, identification, and recovery services for Georgia youth. 

The pandemic has dramatically shifted the lives of Georgia’s children and families. Children have faced inconsistent and uneven access to school, social isolation, and family stressors (from job loss, illness, or other changes). The potential impacts of these challenges are compounded for vulnerable youth, such as those in low-income families, in communities of color, or LGBTQ+ youth. The changes and challenges over the last year could result in or exacerbate mental illness or substance use disorders among Georgia students. 

According to the Centers for Medicare and Medicaid Services (CMS), COVID-19 has drastically reduced the utilization of mental health services among Medicaid & Children’s Health Insurance Program (CHIP) beneficiaries. In 2020, there was a 34% decline in the number of mental health services used by children under 19. Nationally, this decline means that 14 million fewer mental health services were provided to CHIP enrollees.1 The decline in services means that many fewer young people are receiving needed substance use and mental health services, leaving them ill-prepared to return or continue their educations successfully. Additionally, many students lost a critical lifeline for receiving mental health and substance use services during school closures.2 Prior to the pandemic, over one in three young people relied on schools as their primary source of mental health care. 

School-based substance use and mental health services are critical to ensuring that Georgia’s children have access to the services they need. Such school-based care is essential for ensuring young people are healthy and ready to learn, especially as we build back from the downstream effects of the COVID-19 pandemic. 

Georgians for a Healthy Future, the Georgia Council on Substance Abuse, and the Center for Pan-Asian Community Services offer the following comments with respect to the Georgia Department of Education’s utilization of ESSER funds to address the behavioral health needs of Georgia’s children, with a special focus on substance use prevention and treatment. 

Training School Staff on Substance Use and Mental Health 

School districts should train school health personnel and staff (i.e. school counselors, social workers, and nurses) to identify substance use and mental health needs as students return to the classroom and properly refer them to appropriate services, including community mental health and substance use providers. Identifying substance use and mental health issues early, allows students to get the treatment they need before the situation turns into an emergency. 

One evidence-based technique is SBIRT, which stands for Screening, Brief Intervention, and Referral to Treatment. SBIRT is low-cost, effective, and supported by the American Academy of Pediatrics. SBIRT helps trusted adults (like teachers, school nurses, or counselors) to have structured conversations that identify students’ drug or alcohol use and connects them to follow-up counseling or treatment if needed. Georgia policymakers have also demonstrated their support for SBIRT by adopting Senate Resolution 1135 during the 2018 legislative session, which endorses SBIRT as a “best practice to facilitate academic success and positive school climate.”3 SBIRT can also be combined with other screening tools that may only address depression, anxiety, or other mental health needs so that a student’s full spectrum of needs is addressed. 

Some related training for teachers and other school staff is beginning through the Opioid Affected Youth Initiative grant program from the Criminal Justice Coordinating Council (CJCC). With their OAYI grant, GCSA is already working with the Department of Education to identify high schools in each of the sixteen (16) RESAs that are most in need of training to have compassionate and constructive with their students who either experience overdose and come back to school, or with students who have friends or loved ones who do not survive overdose. This curriculum will serve as a foundation to build the strengths of each participating school, boost their confidence in having these difficult conversations with students about substance use, and lay the groundwork for similar trainings that focus on prevention and early intervention. The program is currently operating in 16 high schools throughout the state. With additional funds from ESSER, the program could be expanded to more schools, additional school staff could be trained, and participants could be trained for conversations that range from prevention to early intervention to support after overdose. 

Implementing SBIRT Pilot Projects 

Pilot projects to address students’ substance use and mental health needs are an innovative and effective use of the time-bound funding appropriated to the state through ESSER. Specifically, we encourage DOE to use the funding to implement SBIRT pilot projects in all Georgia high schools. 

GCSA has successfully implemented two SBIRT pilot projects, one at Marietta High School and one at Decatur High School, that demonstrated the effectiveness of providing SBIRT in high school settings. In both projects, local community members in recovery from substance use were embedded in the schools to lead the substance use screenings and conversations with students. 

SBIRT pilot projects would allow schools to screen students at risk for substance use; provide opportunities for school staff to learn strategies and interventions for addressing substance use; tailor the screening and brief intervention model to the specific needs of a school; capture data and lessons learned for implementing the program successfully throughout the state; and allow schools to adopt sustainable funding mechanisms to support the programs long-term.4 

Sustainable Investments in School-Based Health Services to Address Substance Use 

In 2018, Georgia submitted a State Plan Amendment (SPA) to CMS to remove the Individualized Education Program (IEP) requirement for school nursing services and allow school districts to bill for school nursing services provided to all Medicaid-enrolled students. Implementing this SPA would bring in additional revenue from the federal government and increase resources for schools to address student substance use.5 For example, if the SPA were implemented and the SBIRT pilot projects were successful, school Medicaid reimbursements could cover the cost of sustaining the program. The SPA is currently on hold, but if the state revived it, ESSER funds could be used to cover the costs of setting-up the program, thus making the funding more sustainable. We encourage DOE to collaborate with the Department of Community Health to revisit the SPA and leverage ESSER funds to implement the change. 

During the 2020 Georgia legislative session, House Health & Human Services Chairwoman Sharon Cooper sponsored HB 1114. The bill allows eligible mothers to receive Medicaid coverage for six months after giving birth, up from the current 60-day limit.  

Currently pregnant women and new mothers are covered by Medicaid only up to 60 days after their birth or miscarriage. Georgia has very strict Medicaid eligibility rules for Georgia parents outside of this 60-day period and Georgia has not expanded Medicaid to other low-income adults. For these reasons, many mothers who try to apply for Medicaid after the 60-day period are ineligible and become uninsured.

Georgia’s alarming maternal mortality and morbidity outcomes prompted Georgia leaders to examine the problem and propose solutions. State leaders agreed that extending Medicaid coverage from 60-days postpartum to six months for women with incomes at or below 225% of the federal poverty level (FPL) would be a step in the right direction. This move improves access and consistent care during the more of the postpartum period.

Georgia’s Department of Community Health invited public comment on the proposal from October 8, 2020 to November 9, 2020. During this comment period, individuals and organizations were able to provide their input at two public hearings or in writing.

GHF offered its qualified support of the proposal. GHF urged the state to to go further by extending coverage to twelve months. We also recommended an expansion of Medicaid to all low-income adults. Both of these moves would optimize Medicaid’s benefits and access to care for women throughout the postpartum period and beyond. You can read GHF’s full comment letter here.

On Friday, July 13 the Georgia Department of Community Health (DCH) announced plans for next steps in the “Medicaid Redesign.”  Over the past several months, DCH has convened task forces comprised of stakeholders and advocates to formally provide input into this process. At the same time, advocates have come together as the CARE-M coalition to develop recommendations based on best practices for vulnerable populations. This redesign process is separate from but parallel to the conversations currently taking place regarding whether or not to move forward with implementation of the Medicaid expansion authorized by the Affordable Care Act. Ultimately, both processes will have a big impact on coverage and access to care for health care consumers throughout Georgia.  In a press release, DCH said:

“Today, the Georgia Department of Community Health (DCH) announced that it will move forward with implementing key recommendations from its Medicaid and CHIP (Children’s Health Insurance Program) Redesign task forces and workgroups. It will not, however, pursue wholesale restructuring of Georgia’s Medicaid program at this time because of increasing uncertainty at the federal level.”

According to DCH, the changes that the state will move forward with include: 

• Proceeding with at-risk managed care to serve Georgia Families members

• Transitioning children in foster care to one designated vendor statewide within the new Georgia Families program

• Maintaining Georgia’s current Fee-For-Service structure for ABD populations and services

• Moving forward with Home and Community-based Services Rebalancing. This rebalancing will help move patients from skilled nursing facilities to home and community based services.

• Begin utilizing a value-based purchasing model. Value-based purchasing will allow DCH to continuously improve the quality of care for our members while better engaging our providers and ultimately containing costs.

• Creating a one-stop portal will improve accountability and efficiency. Specifically the portal will give health care providers better information about their members and their medical history, streamline their credentialing process, and present providers with a measurement of key performance metrics and allow them to monitor quality and outcomes compared to their peers.

• Creating a Common Pharmacy Preferred Drug List that will simplify the program and reduce administrative burden on providers

The Department has committed to continuing its work with the task forces and work group through the RFP process and past the go-live date.  As members of the Children and Families Task Force and Substance Use and Mental Health Working Group, Georgians for a Healthy Future staff will continue to provide a consumer voice in these discussions and will continue to advocate for greater access to care for Georgia’s most vulnerable citizens.  For more information about the redesign process, visit https://healthyfutprod.wpengine.com/issues/medicaid-and-peachcare-redesign.