Young Minds Advocacy President Partrick Gardner takes on the challenge of dramatically expanding children’s mental health services.
Last year, Patrick Gardner, the lead attorney in a landmark settlement substantially expanding mental health services for California’s most vulnerable children, decided he needed a platform to ensure that those services were actually delivered.
So he launched Young Minds Advocacy, a non-profit organization that will monitor and spur the implementation of mandates set forth in the Katie A. v Bonta settlement, and use other levers to expand mental health services for children in or at risk of entering the child welfare system in California and other states.
In 2011, nine years after being filed, a federal district court judge approved the settlement of Katie A v. Bonta. This set into motion a process to compel the Department of Health Care Services (DHCS) and the California Department of Social Services (CDSS) to coordinate the mental health services they provide for children who are either in foster care or who are alleged victims of maltreatment.
Leviathans never make for graceful dance partners, and while progress has been made toward the 2014 goal of integrating services, a semi-annual report slated for release in February found 812 children in 16 reporting counties were receiving “Katie A. services.” While the report, which was first cited in a recent edition of Insights put out by The California Child Welfare Co-Investment Partnership, estimates nearly 5,000 children and youth will be receiving services by April 2014, there is still a long way to go before reaching the 20,000 young people that Young Minds contends should be receiving services.
In addition to Katie A, California’s 2011 Realignment of health and human services programs further complicates the issue. Under Realignment, the state transferred significant responsibilities for the management of mental health programs to the counties, including the programs that provide mental health services for foster children. These concurrent policy shifts have caused confusion over counties’ responsibility to better provide mental health services to children, youth and families.
On a recent Friday, Patrick Gardner and I sat down to discuss his new advocacy shop’s short term strategy and to talk through some of the pressure points that advocates, journalists and other stakeholders should pay attention to as California wrestles with the mental health needs of tens of thousands of vulnerable children. Below, you will find a synthesis of our conversation, broken up between Gardner’s statements and the transitions I have written to set them up.
Daniel Heimpel: The first issue is how Realignment is effecting the provision of federal Early and Periodic, Screening, Diagnosis and Treatment Program (EPSDT). EPSDT is a federal entitlement carved out of Medicaid, a federal-state partnership called Medi-Cal in California. Under federal law, EPSDT services including mental health screening, testing, and counseling are available to all Medi-Cal eligible children, including foster youth.
Patrick Gardner: The first place that we are focused on, and we think is vitally important is to ensure that the children’s mental health EPSDT program remains a place where counties can expand, improve, really do a better job of delivering services. And there is some concern that the realignment mechanism is going to make that difficult to accomplish. And there are some steps along the way that have to be resolved, the most immediate one being that the distribution of money statewide. There’s supposed to be a formula that determines what counties get in terms of their funding for the EPSDT program. And that was supposed to happen some time ago. It hasn’t happened yet.
DH: Under Realignment counties are given a certain allocation of funds up front to provide services they would otherwise bill for. That total pot for all services statewide represents a percentage of the state’s sales tax revenue and Vehicle License Fees. Currently, the total allotted to EPSDT is about $700 million statewide, according to Gardner. As the economy continues to grow, total available revenues should grow as well.
PG: That’s the critical key is it’s no longer driven directly by what you bill, but rather it’s driven by the dollars coming in based upon actual tax revenues. And the expectation is that over the next two or three years, that there’s going to be a substantial increase, like to the tune of hundreds of millions of dollars.
DH: Those new dollars will come from a projected increase in sales tax revenue as well as an increase in the proportion going to EPSDT, according to Gardner. The big question is how will this money be divided up among California’s 58 counties.
PG: The bottom line is, mental health gets an adequate sum to start with, and that adequate sum grows significantly over a two-year period. And how that money gets allocated among the counties is a decision that has not been made.
And that’s the key question. It’s: how do you split up this money among the counties, so as to encourage investment in mental health services, as opposed to discourage it because under the new regime, you can spend the money on a variety of things.
Under the old system, you could only get reimbursed for dollars that you actually spent on children’s mental health. And so, the incentives are very different now for the counties. So, our concern is – and the thing that we want to make sure happens immediately is – that the allocation formula is set up such that the counties that spend money on children’s mental health get their needs met first. And only after that happens, do you then allow people to spend money on other things.
DH: Increasing the county-by-county allocations would result in a higher rate of youth who access mental health. This is important because the percentage of youth receiving services varies widely across the state.
PG: The differences can be substantial. And that is suggestive of some really important disparities in terms of access to care in different parts of the state. And one of the things that we want to be sure that the state does is that they set up their allocation formula such that it encourages the low-performing counties to do better.
We don’t want to continue to perpetuate these differences by saying, “Well, we’ll just give you what you got last year.” And if you do that, then of course, what happens is the low-performing counties will continue to be low-performing counties. And if resources are growing to the tune of tens or hundreds of millions of dollars, that would seem to be the golden opportunity to do a better job in the low-performing counties, but not if you just do business as usual.
DH: Until the state sets the per-county allocations, those counties that do provide expanded EPSDT services and overspend their allocation from the state do so at their own peril, despite the fact that EPSDT services are an entitlement under federal law. Gardner points to Alameda County, which has expanded its mental health services for young people without the state creating an allocation that reflects the needs of the county. The problem is the state hasn’t made the county whole.
PG: We’re at the cusp of ‘It’s time to put up or shut up’ for the state because they [the state] have excess dollars – growth dollars – something I believe in the neighborhood of about $14 million. It would seem that now is the time where they have to begin to address the needs that Alameda County has. I think Contra Costa also overspent their allocation, but they haven’t been as vocal about getting paid back.
DH: Beyond setting up the allocation formula for EPSDT, Gardner is concerned about the quality of care being provided to children and youth and how that quality is assessed.
PG: Another huge question in the state of California is: do we do the job of understanding what we’re buying and what we get for what we buy? In other words: do we know anything about quality of services that are going out there? Do we know anything about who gets the services, what services do they get? Do we have a basic management capability to answer those sort of fundamental questions?
We should know if we’re spending $4.5 billion dollars on publicly-paid-for mental health services in the state of California. We ought to know what we get, and that’s for both adults and kids. The kids’ program is in the neighborhood of $2 billion. We ought to know what we’re getting for that.
DH: And if they can get it right on that account, all this work promises big changes for kids who touch the child welfare system and often have mental health needs that can be exacerbated by inadequate care.
PG: When you look at failure in the child welfare system, you can usually point to unmet mental health needs as a primary reason.
So yeah, so it’s a big deal. And the way that we at Young Minds look at this issue is, we don’t look at mental health in a vacuum. We look at it as it impinges upon children in these various systems. And what you typically discover is that most of these kids with serious mental health challenges actually are revolving through these systems.
Daniel Heimpel is the founder of Fostering Media Connections and the publisher of The Imprint.