Content notice: This article discusses suicide, suicidal ideation and suicide attempts. If you or a loved one are struggling, it’s OK to share your feelings, and there is free and confidential 24-hour support available in Spanish and English at the 988 suicide and crisis phone line. For mental and behavioral health services in Nevada, click here.

This is the fourth and final story in our multipart ‘We’ve got to talk’ series, which focuses on youth mental health in Nevada and is produced as part of the USC Annenberg Center for Health Journalism’s 2024 National Fellowship Kristy Hammam Fund for Health Journalism.

You can read the first story here, the second story here and the third story here.

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Once a week, Rachael Danielson and Wonha Kim pack their cars and drive almost an hour and a half from Reno to Fallon, where they provide counseling services to middle and high school students.

When Kim arrives at the Churchill County Middle School, she grabs keys from the main office and unlocks an often chilly sensory black room with a punching bag, balance beam and saggy couch. She settles in for a day filled with 45-minute counseling sessions. 

The students talk with her about their home lives, frustrations and experiences. Many are either bullied or bullies, reacting to feelings they’re struggling to name without one specific cause to blame.

“A lot of my students say that counseling is one of the few escapes that they have, or [where] they feel like they have any bit of control,” Kim said.

Kim and Danielson are pursuing master’s degrees in counseling and interning at the schools through UNR’s Downing Counseling Clinic. Their work is part of a research effort to break down stigmas surrounding mental health and address behavioral health needs in rural communities.

The sessions are part of a patchwork of community-based services aimed at allowing youth to work through their feelings in settings close to home and prevent mental health issues from escalating to the point that youth require hospitalization. 

But gaps persist.

In 2022, the U.S. Department of Justice concluded that the state was likely violating the federal Americans with Disabilities Act because its network of supportive services (such as therapy, crisis support, and behavioral support programs) was so inadequate that kids with behavioral health issues were often being institutionalized in facilities away from their families.

The state has been in confidential negotiations with the Department of Justice since the findings were published two years ago. The talks culminated in an agreement reached at the beginning of January establishing metrics Nevada needs to meet within five years to comply with the federal disabilities act. The agreement primarily addresses youth receiving Medicaid, but the state is approaching the requirements as a broader effort to reform Nevada’s overall behavioral health care system for youth — people between the ages of 15 and 24 make up the highest rate of suicide attempts in Nevada and for those between the ages of 10 and 35 suicide is the second-leading cause of death in the country.

As Nevada officials work to transform a hodgepodge of care options into a unified system, experts say officials can learn from other states that have had similar compliance issues. They note that the state needs to ensure:

• Equal access to services regardless of insurance type;
• School-based behavioral health support systems that can provide different levels of care; 
• Sustainable financial practices; 
• Communication between providers; 
• An umbrella agency with authority to design, fund, implement and evaluate a children’s system of care that allows local communities to shape services in line with national best practices.

“We really have to be thinking about, how do we take a tailored approach to meeting the needs?” said Stephanie Woodard, a licensed psychologist and a clinical associate professor at UNR’s School of Public Health. “Not just for this larger statewide community or even by county, but really even sometimes down to neighborhoods.”

Woodard and other experts said the state has already made strides — expanding its 988 suicide and crisis phone line and children’s mobile crisis services and better integrating care options into communities. The state also committed more than $200 million to overhaul Nevada’s behavioral health system and pay for services through the government-funded Medicaid insurance program.

“We have a lot of work to do,” said Nevada Medicaid Director Stacie Weeks, who played a key role in the negotiations. “But one thing that’s in our favor in Nevada is that we have the funding, we have committed individuals, committed organizations … and everyone at the table who are very passionate.”

Though House Republicans have included cuts to federal Medicaid funding on a list to help bankroll President-elect Donald Trump’s priorities, Weeks said that given Medicaid’s role as an economic engine and a driver of health care services, she hopes it will continue to be the program it is today.

“Regardless of whatever changes happen, if there are any, [state officials] will continue to have their obligation to help support this program, because without it, we can't comply with the Americans with Disabilities Act,” Weeks said.

Weeks said what keeps her up at night is the need for more providers.

Woodard said long wait times for diagnoses and insurance authorizations can lead to the need for intensive services and hospitalizations, further straining care systems, increasing costs and creating worse outcomes.

In its current form, Nevada’s care system is fragmented, with providers not communicating. This creates delays and stress on families. If a care system operates correctly, Woodard said there's no wrong door, and any provider a family finds can help guide them to the care they need most.

Transforming the children’s system of care

Danielson sits in a windowless room in the counseling office of Churchill County High School, which used to belong to the school resource officer. The cases Danielson works on are severe, including abuse, violence and suicidality.

“All I can do is try to build rapport with them, be an adult that they see in their life as someone that they can trust,” said Danielson, who grew up in a small rural town in Iowa where mental health was seldom discussed. “They do need a much higher level of care than I think I can provide. But also, what else is there?”

In a state where distance and workforce shortages complicate mental health access, unstable funding sources and isolated efforts have made meeting young people’s mental and behavioral health needs challenging and led to a fragmented mental and behavioral system that experts say is often difficult to navigate. 

This combination has contributed to Nevada ranking last in the nation for children’s behavioral health outcomes for the past seven years.

“We chose incarceration versus resources and help for the youth,” Nevada’s Republican Gov. Joe Lombardo said last March, referring to the Department of Justice’s findings on Nevada’s system of care for youth. “We're going to have to make some significant changes as a result of that.”

As part of the 44-page agreement reached this month, the state committed to ensuring children who may have a behavioral health disability have access to assessments to diagnose them and a facilitator who, as part of a broader team, helps connect children with services and support.

Weeks said the agreement provides a foundation and a set of guardrails as the state works to reduce the need for institutionalization and keep children in their home communities. She noted that a working group will guide the agreement's implementation and ensure its compliance with federal and state laws.

She said the division plans to add respite care to offer caregivers a break and a wraparound service coordination program in a way that hasn’t been done before in the state. Officials are also planning to figure out how to cover children who may be at risk or need early childhood intervention services, which help families address developmental delays, Weeks said.

“Those two things together, plus all of the other rate increases we’re putting into the system, I’m hopeful that families will start to see that they have support at home, that they don’t have to go straight to the ER,” Weeks said. 

Tackling potential insurance disparities

Roughly half of children in Nevada are on Medicaid, which primarily serves low-income families, but Weeks said the changes should have benefits that expand beyond Medicaid participants. For example, when Medicaid starts covering a service, Weeks said that it builds a market and a provider network that private insurers can tap into.

Woodard cautioned that Medicaid can’t be the only solution source, and there needs to be a way to ensure that children not on Medicaid receive the services they need.

It’s often more challenging to get coverage for mental health and substance abuse disorders than for physical ailments in insurance plans overseen by Nevada’s Division of Insurance, Woodard said. This can lead to lower reimbursement rates, burdens on providers trying to get paid and delays in care. 

It’s a problem community leaders have echoed. 

In 2021, Dan Musgrove, the chairperson of the Clark County Children’s Mental Health Consortium, sent a letter to the Division of Insurance noting that the baseline set of services the state requires insurers to cover does not include forms of cognitive and behavioral therapy, counseling and care for issues common among children, including learning disabilities and personality disorders.

More than three years later, those exclusions are still in place. 

In an interview, Nevada Division of Insurance commissioner Scott Kipper said the exclusions refer to the need to get prior authorization from insurance for those therapies. Nevada’s time frame for acquiring prior authorization — which is when an insurance plan requires approval for certain treatments or prescriptions — is up to 20 business days, one of the country's longest wait times, he said.

New federal prior authorization standards for the Centers for Medicare & Medicaid Services (CMS) that will go into effect in January 2026 will set a seven-calendar-day time frame for standard requests and a 72-hour time frame for expedited requests in programs CMS oversees.

Kipper said the division used its one bill draft request for the upcoming legislative session to propose reducing the time window for prior authorizations from 20 business days to five and, in emergencies, two business days.

“I think that 20 day timeframe may have been overly accomodating for carriers in the state,” Kipper said. A shorter window is “more in line with the norm across the country.”

In September, the federal government released new rules prohibiting health plans from imposing barriers to mental health and substance abuse care as part of the Mental Health Parity and Addiction Equity Act (MHPAEA). Nevada’s Division of Insurance oversees about 25 percent of the state’s insurance marketplace, while Medicaid and the insurance program that covers state employees regulate the rest of the market.

The Division of Insurance received a federal grant to help bring the state and insurers into compliance with the act. The division can only regulate the insurance companies it oversees, making achieving equal insurance conditions challenging. 

“With the federal government working with MHPAEA, that does provide a little bit of incentive for the non-DOI-regulated entities to come into compliance,” Kipper said.

Navigating the system

Since Barbara J. Stoll, a licensed clinical social worker, moved to Elko in 1993, she’s seen a rise in anxiety and depression among children, exacerbated in part by the pandemic. 

“Some of that is the competitive nature of society today. I think it's social media, I think just access to information, which has its positives, but also can have its negatives,” Stoll said.

Stoll started her practice, the Elko Family Wellness Center, in 2009 and has become intimately familiar with the community, which can be transient. Residents moving from elsewhere can have their care disrupted and be far from extended family support, and the community has fewer long-standing grassroots organizations compared with her home state of New York.

Though Stoll and her staff make every effort to meet their clients' needs, she said there are situations where families face frustrations about children not making academic progress or not receiving needed services. 

In those instances, Stoll or her staff connect the families to Nevada PEP, a statewide nonprofit serving families of children and youth with disabilities and behavioral health needs.

Nevada PEP Executive Director Karen Taycher said there are long wait lists for mental health services or services for children with autism, waiting lists to be assessed and eligibility criteria that can be challenging to navigate. The grassroots organization supports families who do not know where or how to get services.

Taycher founded PEP after struggling to find help for her son, who had multiple disabilities. The staff members at the nonprofit are family members of children with disabilities and understand those challenges. 

Data from PEP shows that the organization serves an average of about 1,000 families each month from across the state.

In the last year, Taycher said the organization saw a 30 percent increase in referrals, stemming from rising need and awareness of Nevada PEP’s services and mental and behavioral health.

“If the increase continues at this rate, our staff just won't be able to be as responsive,” Taycher said. “It will take longer for us to be able to engage with the family and provide them support. We don't ever say no to a family.”

Schools as a solution

Across the country, schools are being eyed as a major part of the solution to bolstering community-based services. As of 2022, about 96 percent of schools across the country offered at least one type of mental health service.

The model has multiple tiers, including teaching students across the board about their emotions, providing counseling to students who need it, referring students with more intensive needs to community providers and keeping track of students’ behavioral health progress. It has been around for more than 20 years and has been shown to reduce absenteeism and eliminate barriers for low-income households and children of color.

Woodard said COVID-19 funding in Nevada helped support and fortify school-based behavioral health services. 

With COVID-19 funding expiring, most states have put forward large funding plans to ensure behavioral health services are funded alongside education. Nevada’s switch to a pupil-centered funding model, however, means that dollars previously earmarked for school-based mental health providers go into the general education formula. Under the formula, Woodard explained, money can’t go to school-based behavioral health services until education funding requirements are met, which can lead to challenges with ensuring services are paid for.

Some states, Woodard said, have developed a Children’s Behavioral Health Trust that can be tapped as needed. Weeks said the state is working to ensure schools can start billing Medicaid for nursing services, screening, assessments and other necessary care.

Danielson and Kim's work is an example of a school-based behavioral health care service. Students can talk to them in a familiar setting at school, and the UNR students can provide support, which helps even in their limited capacity.

“It kind of feels like a lot is falling through the cracks,” Danielson said. “But I feel like, [there is] optimism and hope for what we as interns are trying to do, trying to implement small, little glimmers and nuggets for the next generation.”