Youth Insured By Medicaid With Restrictive Eating Disorders—Underrecognized and Underresourced

Abstract

a fictional yet realistic exemplar, is a 16-yearold Latinx girl hospitalized for bradycardia and hypotension attributable to malnutrition. Family-based treatment (FBT) for anorexia nervosa (AN) was recommended but not provided by her county, given an absence of trained clinicians. Instead, she received supportive individual therapy. Paloma required repeated hospitalizations over 18 months, each time requiring longer stays because of greater medical acuity. Her parents felt less and less empowered to manage her symptoms on discharge. After 6 hospitalizations, the county behavioral health plan agreed to contract with residential and partial-hospitalization programs. On discharge to outpatient care, she precipitously lost weight and was readmitted to the hospital. Paloma represents one of countless patients receiving Medicaid who are denied access to evidence-based care, with devastating consequences.The number of individuals requiring eating disorder treatment has increased dramatically since the onset of COVID-19, 1 with a increase of nearly 80% in calls to the National Eating Disorders Association helpline. 2 Eating disorders are severe but treatable psychiatric disorders that are underidentified and undertreated in youths from low-income families, with tragic consequences. Elevated suicide risk and serious medical consequences lead to 77 000 hospitalizations and emergency department visits and 10 000 deaths yearly, with annual costs of $65 billion in health care expenditures, informal care, and lost productivity and efficiency. 3 This Viewpoint focuses on AN and atypical AN (AAN) as eating disorders with more severe medical complications.Anorexia nervosa and AAN typically develop in adolescence or young adulthood and affect 4% of the US population. 4 Lay media and entertainment perpetuate the misperception that AN and AAN are conditions of White cisgender adolescent girls that somehow do not affect individuals from racially, ethnically, and socioeconomically diverse groups, despite the fact that AN does not differ by race or ethnicity 5 and extreme dieting prevalence does not differ by socioeconomic status. 6 Nevertheless, screening for eating disorders in public mental health care systems is poor, with some systems deliberately minimizing or excluding screening questions from standardized assessments to absolve them of the legal obligation to provide treatment for a disorder in which their clinicians typically lack expertise. Screening is also low in primary care, schools, and other non-mental health sectors. Even when identified, eating disorders are undertreated. Although medical and behavioral health interventions for eating disorders in inpatient and outpatient settings are covered by Medicaid, terms of

Adaptation of family‐based treatment within an inpatient medical stabilization program for children with eating disorders

“…Many patients receiving care through CHOC at Mission's program are Medicaid‐insured which means higher levels of care such as residential, partial hospitalization, and intensive outpatient treatment are not accessible. Further, it is rare for community therapists working with Medicaid‐insured children to have eating disorder expertise (e.g., Accurso et al, 2021). Patients with private insurance may also struggle to find outpatient FBT providers; they may be able to access higher levels of care, but there is limited confidence in the long‐term success of such programs (Derenne, 2019).…”

“…Further, it is rare for community therapists working with Medicaidinsured children to have eating disorder expertise (e.g., Accurso et al, 2021). Patients with private insurance may also struggle to find outpatient FBT providers; they may be able to access higher levels of care, but there is limited confidence in the long-term success of such programs (Derenne, 2019).…”

Disparities in access to eating disorders treatment for publicly-insured youth and youth of color: a retrospective cohort study

“…While information on services available to youth with public insurance is limited, evidence suggests that public insurance may be a barrier to accessing specialized eating disorder treatment [ 11 , 12 ]. In fact, youth with public insurance who have restrictive eating disorders have been described as grossly underserved due to under-resourced health care systems that are unable to meet patient needs [ 13 ].…”

Development of evidence-informed bridge programming to support an increased need for eating disorder services during the COVID-19 pandemic

“…An earlypandemic survey of over 1000 individuals in the United States and the Netherlands revealed that only about half of those surveyed were receiving ED treatment [3]. These gaps in care are exacerbated for marginalized groups, who face additional systemic inequities and barriers to ED treatment [9,10].…”