There are about 6 million children enrolled in California’s Medicaid program. And although every single one of them is eligible for mental health screening and services, only four of every 100 received even one mental health visit last year.
A coalition of youth advocates, health experts and philanthropists are pushing an ambitious goal: To completely revolutionize the largest children’s mental health system in America.
The aim is to use a confluence of changes and opportunities around the year 2020 to move California away from a diagnosis-driven model of mental health, and toward a system focused on early intervention and social justice.
“We see an immediate convergence of opportunities to improve the systems that support the health and well-being of California’s children,” said Reed Connell, one of the organizers of the venture, which is being called “The California Children’s Trust: An Initiative to Achieve Health Equity and Healthy Development.”
“Ultimately, we recognize that our success will depend on our ability to inspire, partner with and mobilize an extraordinary diversity of stakeholders,” said Connell, who is managing partner of Social Change Partners.
The initiative, which has already drawn $500,000 in backing and is targeting a $6 million outlay over the next three years, will recruit partners and develop proposals in advance of the November election of a new California governor.
“We have an obligation to try to do better,” said Amy Price, program executive for the Zellerbach Family Foundation, an early funder. “It’s going to require some fundamental shifts.”
California is often looked at from afar as a laboratory for progressive reform on human services. But internally, there is widespread agreement that the state struggles mightily in the area of behavioral health.
“No one in California … I’ve never directly talked to anyone who said, ‘Oh yeah, we’re killing it on mental health,’” said Alex Briscoe, former director of the Alameda County Health Care Services Agency and one of the chief architects of the campaign. “There is universal acceptance that it’s broken.”
The penetration rate on Medicaid mental health treatment for children is perhaps the strongest indicator of problems in the state. Just 4.1 percent of Medicaid youth received a single intervention in 2017, down from 4.5 percent in 2014. And since few mental health issues are addressed in one appointment, the 3 percent penetration rate for five-plus visits is more reflective of the state’s poor performance.
“This is for a service that under federal law is uncapped and guaranteed to all Medicaid-eligible children,” Briscoe said. “It’s the same law that covers child immunizations, which is at 97 percent usage.”
The mental health guarantee comes through the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) section of Medicaid, which guarantees health screenings and follow-up services for all Medicaid-covered children, including children in foster care. This includes mental health services, according to the federal Medicaid and CHIP Payment and Access Commission.
Briscoe said part of the problem with California’s system is that the state has pushed operation of EPSDT services to the counties. When the state moved toward governmental “realignment” in 2011, EPSDT was one of five Medicaid-related programs that was put under the control of counties, with fixed allocations of funds tied to a guaranteed flow of funds for eligible services.
“While California publicly rails against block grants of Medicaid, it has used that same system to devolve to counties,” Briscoe said. “And it did what block grants do under the thin veneer of flexibility: It lowered the percentage of people getting access to care.”
Meanwhile, crisis service utilization is up 20 percent since 2014, Briscoe said.
The Children’s Trust initiative’s objective is to capitalize on what Briscoe sees as a “unique opportunity in 2020” to carry out a substantial redesign. Among the confluence of events leading to that date:
- Strong tax revenue continuing to come into state coffers from a flourishing economy.
- A new governor’s administration that is not tied to the status quo of the state’s mental health plan.
- The expiration of what Briscoe said is an antiquated Medicaid waiver that serves as the underpinning of the realignment that pushed implementation of mental health to the county level. This could be replaced with a federal waiver that targeted children’s mental health as a priority; California obtained a similar issue waiver to focus Medicaid resources on the homeless.
Those are the potential levers for a redesign. So what would the redesign look like?
The Children’s Trust is pitching a reform agenda that would dramatically widen the net on state-funded mental health services by threading mental health access into all child-serving systems.
It begins with improving access to mental health care. “Lots more kids seen, and seen earlier,” Briscoe said.
He noted that primary-care utilization “drops off a cliff” at age 10 because youth at that age don’t need a lot of physical health care, he said. “But 75 percent of mental illness manifests between 12 and 24. Right when we need there to be one, there’s no touch point. That’s where schools and child-serving systems can come in.”
Health equity is also a key plank on the campaign’s agenda. “Some children experience structured racism and poverty,” Briscoe said. “It impacts young people’s development, and we can use mental health to help achieve equity.”
The Washington, D.C.-based New Venture Fund is serving as the incubator for the campaign. Other early participants include Genentech, a California-based biotech company, and Toby Ewing, who runs the state’s Mental Health Services Act Oversight and Accountability Commission.
Briscoe said there is no plan to make this a permanent fixture.
“This will not become an organization,” he said. “It’s a campaign aimed at the 2020 opportunity.”
Correction: This article incorrectly states that states are not obligated to include mental health evaluations as part of that original EPSDT screening. It has been updated to reflect that mental health is a required component.
Note: Zellerbach Family Foundation has made charitable contributions to Fostering Media Connections, the parent organization of The Imprint.