The man standing inside Norma Pedroza’s apartment wasn’t supposed to be there.
It was a typical weekday afternoon in October, 2016, and Pedroza had just arrived at her apartment in Costa Mesa, Orange County, with her two sons, Gerardo and Cesar. The man – caught off guard as he tried to burgle their house – was as shocked to see them as they were him. He charged at the family with a knife, stabbing 11-year-old Cesar six times and puncturing the boy’s left lung. He fled outside, where he was apprehended by a police officer who had just arrived on the scene.
What followed for Cesar was 10 days in the hospital and months of recovery, not only from physical but also emotional wounds. Normally a happy, outgoing boy, Cesar became withdrawn and panic-stricken, his mother said.
“There were times we couldn’t get him out from under the bed, he didn’t want to go outside,” Pedroza recalled. “Other times he just wanted to be in the street because he felt safer there than in the house.”
Cesar is enrolled in Medi-Cal, the state’s health insurance plan for low-income residents, which covers more than half of all children in California. When kids like Cesar suffer serious mental health difficulties they’re entitled to treatment through a statewide, county-run program called Specialty Mental Health Services (SMHS). In Cesar’s case, the program in Orange County paid for him to attend a specialized clinic at Children’s Hospital of Orange County or kids with co-occurring physical and mental health concerns, hospital officials said. For more than a year, Cesar met regularly with a therapist there, who helped him overcome the trauma that followed the attack.
Cesar ultimately found relief from his mental distress, yet data suggest many other young people in the county aren’t so lucky. Statistics from the Department of Health Care Services show kids and teens in Orange County use specialty mental health services at a lower rate than children in most other counties in the state.
Fewer than 2 percent of Medi-Cal-enrolled youth under age 21 in Orange County consistently received a specialty mental health service in fiscal year 2015 to 2016, the most recent year for which such data is available. Only six other counties – Merced, Placer, Yolo, Madera, Marin and Riverside – served fewer youths through SMHS.
At the other end of the spectrum are counties like San Francisco. Almost 5 percent of San Francisco’s Medi-Cal enrolled kids came into regular contact with the SMHS system between 2015 and 2016, data show. In fact, San Francisco was among the 14 counties with access rates at least double those of Orange County.
While the percentage differences appear small, they represent potentially tens of thousands of kids in lower-performing counties who are missing out on mental health care. For example, if Orange County had the same proportion of kids getting SMHS as San Francisco, 13,000 more children and teens would have received mental health treatment.
“Access varies quite dramatically depending on where you are,” said Kim Lewis, managing attorney with the National Health Law Program, which works on health care litigation.”There isn’t a lot being done to ensure accountability in each county.”
In Some Counties, “Almost no Services.”
The variability isn’t just a problem for kids who need treatment, it’s also legally dubious, experts said. Under state and federal law, children enrolled in Medi-Cal should be able to access the same mental health services regardless of where they live, said Alex Briscoe, former director of the Alameda County Health Care Services Agency and an advocate for program change.
“There are some counties where there’s almost no services available to kids. That’s not fair, or right or frankly allowed,” said Briscoe. “You have to have a single standard of care across the entire state.”
Varying standards aren’t the only problem. Even in counties with better access rates, the proportion of children getting care isn’t keeping pace with growing Medi-Cal enrollment. Between 2010 and 2016, the percentage of children receiving SMHS dropped steadily in more than half of California’s counties, state data show. Only four counties – Calaveras, Fresno, Imperial, and Mono –increased access rates over that period.
In San Francisco County, the access rate declined from 5.7 percent to 4.9 percent between 2010 and 2016, data show. Orange County dropped from a high of 2.8 percent of Medi-Cal enrolled children using SMSH in the 2011 to 2012 fiscal year, to 1.9 percent of kids in the 2015 to 2016 fiscal year.
Why some counties perform so much better than others, and why access rates have declined in many regions, is subject to debate. Administrators and experts point to a variety of possible contributing factors, including tighter budgets in poorer counties, unequal funding allocations from the state, differences in administrative capacity and political leadership, shortages of mental health professionals and lack of effective state oversight.
Three Wealthy Counties, but Only One Offers Sufficient Care
Explanations for why some counties serve more children than others through the SMHS program often center around economics. While every county gets funding from the state and federal government to cover these services, wealthier counties have more money of their own they can pitch in to supplement services, said Lynn Thull, a consultant with the California Alliance of Child and Family Services. Moreover, poorer counties usually have more low-income residents needing health and social services, so their financial resources are more stretched, she said.
Yet access rates don’t neatly correlate with county wealth. Marin County, for example, has the highest median household income in the state and one of the lowest access rates for specialty mental health services. Imperial County is near the bottom when it comes to household income, but its most recently reported SMHS access rate was five percent.
Orange and San Francisco are similarly wealthy counties with large populations, with vastly different access rates for children’s SMHS. The counties also differ dramatically in how much they spend on these services proportional to their youth Medi-Cal populations, according to financial information provided by each county.
In fiscal year 2016 to 2017, Orange County had about seven times more youth under age 21 enrolled in Medi-Cal. Yet it spent $90 million on SMHS for youth, only 13 percent more than San Francisco County, data show.
State Funding Formulas Short Some Counties
A critical source of revenue for SMHS comes from the state, which essentially turned responsibility for administering mental health care over to counties beginning in 1991 through a process called realignment. Every year, the state allocates what’s known as realignment funding to each county to pay for mental health services. Each county receives a different allocation of realignment dollars and the amount counties receive varies from year to year. There are two streams of realignment funding, one established in 1991 and the other in 2011. However, experts who study the topic said counties typically don’t use the 1991 funding for kids’ specialty mental health services.
Neither the Department of Health Care Services nor the State Controller’s Office could provide clear, concise information about how much realignment funding each county receives or how much they spend on specialty mental health services. There is no one report that provides the total realignment funding received by each county for this purpose per fiscal year. Instead, these amounts are spread out across multiple documents and funding streams, making the total difficult to calculate. There’s also no breakdown or formula specifying how much of the mental health funding is allocated to children.
A California Health Report analysis of the data suggests that Orange County receives much less mental health realignment funding than San Francisco in proportion to its Medi-Cal population. Orange County’s total allocation of 2011 realignment funds for behavioral health in fiscal year 2016 to 2017 was almost $50 million, only about a quarter more than the $39 million allocation to San Francisco. If these funds were divided equally among the kids enrolled in Medi-Cal in each county that year, youth in Orange County would have received $129 each, while those in San Francisco would have gotten $675 each.
One problem with realignment funding is that allocations are calculated in large part based on how much counties spent on mental health in the past, several experts said. For example, the state used 2013 to 2014 claims data to help calculate funding allocations for the 2016 to 2017 fiscal year. That means counties that have historically done a better job of providing SMHS to kids will receive more funding, while lower-performing counties get less money to work with and improve their services, explained Briscoe, the former Alameda County health director.
Briscoe added that administrative knowhow and creativity can also influence how much funding counties have to work with. Alameda County, for example, used money from local sales taxes, tobacco taxes and fines to generate additional revenue for mental health services and obtain federal matching funds, he said.
Gaining a full understanding of how realignment funds are dispersed and used by each county to pay for Specialty Mental Health Services, and how these relate to penetration rates will require better reporting of information by the state, said Jodie Langs, Policy Director for WestCoast Children’s Clinic, who has been researching the issue.
“A system that is transparent and accountable to children and families requires easily accessible information from the Department of Health Care Servicesabout county allocations and spending on children’s specialty mental health services,” she wrote in an email. “There’s no straightforward way to get this data.”
City Agencies Pool Money in San Francisco
What’s clear in San Francisco is that the county has prioritized meeting the mental health care needs of kids for decades. Ken Epstein, who leads children’s mental health initiatives for the county’s Community Behavioral Health Services department, said San Francisco long ago adopted a “system of care” model in which various government entities that serve children – from child welfare to juvenile justice to mental health – collaborate to identify kids with mental health needs. They also pool funding for children’s mental health treatment, a practice that resulted in an extra $8 million for SMHS in the 2016 to 2017 fiscal year, about 10 percent of the county’s total spending on the program. The Substance Abuse and Mental Health Services Administration has championed the “system of care” model as a way to improve mental health treatment for kids. But California, and many counties in the state do not collaborate in this way, Epstein explained.
“Our systems are actually built to not work together,” he said. “Each day it takes intentional acts on all of our parts to break through those contradictions to actually build a system of care.”
More recently, the San Francisco Unified School District began collaborating with the county to identify kids with mental health needs. The district has set up “Wellness Centers” in all 17 of its high schools, where teens can get help with mental health issues. Some of the funding for the clinics comes from the county, said Kevin Gogin, director of the school health program. San Francisco County also has a 24-hour “crisis team” that includes mental health-care experts who can respond to reports of children experiencing severe mental distress and connect them to services, Epstein said. This team has been around for about three decades, he said. Additionally, the county helps fund a “crisis stabilization unit” for children in mental health crises, allowing them to get care and avoid hospitalization. The longevity of San Francisco’s efforts to improve mental health care for kids has contributed to the county’s strong penetration rates, Epstein said. However, other factors such as creative county leadership, economic advantages and a compact geography have also helped, he added.
“Many counties are building these things now or augmenting them. We’re not the only county that has done it,” Epstein said of the mental health initiatives. “But I think…because of our available resources, and because there have been creative people, and because we adopted system of care principles and got grants early on, as early adopters we built these systems that are and have been in place for a while.”
The situation isn’t perfect, even in San Francisco, Epstein acknowledged. Professionals who work with children such as teachers, pediatricians, probation officers and even librarians need better training on how to spot potential mental health issues, he said. There’s also a need for more resources to help parents, he said. Additionally, counties are hamstrung by systemic problems such as increasing documentation requirements, difficult audits, confusing legislation and aging infrastructure, Epstein added.
Orange County Steps Up Efforts
Dawn Smith, division manager of Children and Youth Behavioral Health at the Orange County Health Care Agency, said the county is well aware of its low SMHS access rates and wants to increase them. However, Smith said the county doesn’t know why the rates are low.
“Anybody who comes to us requesting services is able to access it without a waiting list,” she said. “We’re not in a situation where people come in the door and we have to turn them away.”
Recently, Orange County has increased the amount of money it spends on prevention and early intervention mental health services, Smith said. Funding for these programs typically comes from Mental Health Services Act dollars, and children served are not generally counted in calculating the SMHS access rates, she said. Programs include a “school readiness” initiative, in which health workers go to schools and community centers to do developmental and behavioral assessments of children ages 8 and under.
Meanwhile, Children’s Hospital of Orange County has taken a lead role in expanding mental health care options for local children. In April, the hospital opened the county’s first psychiatric inpatient unit for children and teens. Before this unit opened, kids suffering severe mental health crises were hospitalized outside of the county, said Heather Huszti, chief psychologist at the hospital.
About two years ago, Children’s Hospital of Orange County also opened the mental health clinic for children with both a medical and psychiatric diagnosis, which served Cesar. The clinic has seen a huge demand for services, Huszti said, and the number of clinicians has almost doubled since it opened.
Additionally, the hospital has spearheaded the creation of a county-wide taskforce focused on improving pediatric care, which includes representatives from local health care agencies, clinics and hospitals, the county behavioral health department and the school district, she said.
“I’m hoping all of those things together will help up [access] rates,” Huszti said.
For Cesar, getting access to treatment at Children’s Hospital of Orange Countydual-diagnosis mental health clinic has helped him process the trauma of the robbery and knife attack. Today, Cesar is 13 years old and no longer living in fear, said his mom.
“I’m so grateful,” said Pedroza. “He was like a stranger, and now he’s the boy he used to be. There is calm after the storm.”