Mental health care for low-income adults in California is haphazard. There is no state mandate for mental health treatment, and individual counties set their own standards.

That’s changing, however, with a state and federal program that brings health services similar to Medi-Cal to low-income adults ahead of the 2014 national health care reform. The low-income healthcare plan uses federal funds to match money spent by counties on uninsured residents, allowing the counties to expand coverage.

Nearly 2 million adults in California report that they need mental health treatment, according to a November 2011 study from the UCLA Center for Health Policy Research. Over half of these adults reported receiving no treatment for their condition. Among uninsured adults who said they needed mental health treatment, 87 percent reported that those needs were unmet, researchers found.

“The need, we know, for many is enormous,” said Rusty Selix, executive director of the Mental Health Association in California, an advocacy group for mental health.

The guidelines for the expanded coverage under the low-income healthcare plan include a minimum standard for mental health care. Minimum benefits include up to 10 days per year of acute inpatient treatment, psychiatric medications, and up to 12 outpatient treatments annually. People who earn slightly more than the federal poverty line qualify for the benefits.

Mental health care officials in California say the insurance expansion program is an opportunity to reach out to low-income people suffering from mental illness or substance abuse.

“A lot are homeless with severe mental illness,” Selix said. “They are really eligible for Medi-Cal, but the counties have limited funds. The hope is that more of them get enrolled.”

Participating counties must offer the minimum mental health benefits, but may offer additional benefits and also may give people with slightly higher incomes the chance to enroll.

Manuel Jimenez, Merced County mental health director, said his county is already providing that minimum level of care, but is not getting reimbursed for it.

“Mental health affects everyone, and a lot of folks don’t have insurance,” Jimenez said. “There’s definitely a big need for a safety net for folks.”

Jimenez said 800 people are being treated by his department through the medically indigent program, a number that has risen in recent years with the recession.

The state Department of Health Care Services is conducting a needs assessment study to determine who uses benefits currently and the needs in different population groups.

The study results, due in March of next year, will be used to design a plan to deal with issues like health disparities, access barriers, and gaps in basic services in different counties, according to Anthony Cava, a spokesman for the department.

The UCLA study showed ethnic disparities in rates of mental health problems and lack of access to treatment. Seventeen percent of American Indians and Alaska Natives had mental health needs, the highest of all racial and ethnic groups, followed by Native Hawaiian, Pacific Islander and multi-racial groups, 13 percent of whom reported mental health needs.

Getting low-income people with mental health problems into the programs may be a challenge, Selix said.

“The biggest problem is that these programs rely on people to know that they are sick and seek treatment,” he said. “That’s not true for the mentally ill. People around them may know something is wrong. How do we put in place things to make sure those people get identified?”

Louise Rogers, deputy chief of San Mateo County’s health system, said there are ways to avoid the stigma of mental health treatment and get people the care they need, such as including mental health screenings as a part of primary care.

“The stigma of mental health and drug and alcohol abuse is very great,” she said. “We address it by getting people in primary care settings.”

People with behavioral health problems like mental illness and drug and alcohol abuse tend to develop chronic medical problems, and die earlier than the population without those problems, Rogers said.

Drug and alcohol abuse are not mandated in the low-income programs, but counties have the option of offering it, Rogers said. Eight counties in the state are offering substance abuse care with the low-income program, she said.

The problems can be inter-related. People with mental illness may try to self medicate with drugs or alcohol, and drug abuse can lead to mental illness.

The incidence of mental illness is slightly higher among low-income people, Rogers said, but the rate of severe mental illness like schizophrenia is constant throughout the population.

Many factors can contribute to mental illness, including homelessness, said Patricia Ryan, executive director of the County Mental Health Directors Association.

“If they are homeless, if they didn’t start out mentally ill, the level of depression is pretty high,” she said. Mental illness also contributes to homelessness, she added. “it contributed to them losing their job, losing their home, losing their family. It spirals.”

Another challenge leading up to the 2014 federal health care reform is recruiting enough mental health and substance abuse care providers to meet the demand.

“There are some gaps that are particularly challenging,” Rogers said. “In rural areas, just access to psychiatry at all is a challenge.”

Bi-lingual providers are in short supply in both rural and urban areas, Rogers said, and attracting and retaining people in the drug and alcohol abuse treatment field is particularly difficult, she said.

“The compensation is so low. Services are usually provided by community-based groups, non-profits, and their funding has been reduced,” Rogers said.

Despite the problems, mental health care officials are happy to have the low income insurance plan, and say it will help the state get a head start on the 2014 mandates.

Rogers estimated that 3,300 people in San Mateo County will be eligible for the low income mental health and substance abuse care. About 1,000 of them are already enrolled, she said. “We are feeling very encouraged by the preliminary results,” Rogers said.

“We see this as a great opportunity to provide integrated health care to people, including mental health and substance abuse,” Ryan said. “It’s been underfunded for many years.”

Tim Moran is a correspondent for the California Health Report at www.calhealthreport.org