Counties still not prepared to offer expanded mental health care

Photo: Julien Haler/Flickr

More than one million people in California suffer from mental illness – the largest number of any state. When the final phase of the new federal health care law starts in January of next year, more California residents than ever before will be able to seek help for problems ranging from depression, anxiety, and addiction to schizophrenia and bipolar disorder.

But mental health providers in the state’s Central Valley are unprepared for an influx of thousands of patients. State and county officials remain in the planning phases, even though new patients will be able to access these services in less than nine months.

Manuel Jimenez, director of Merced County’s Mental Health and Alcohol and Drug Services, said that they haven’t begun expanding programs just yet.

Counties are awaiting more information from the state about how to handle the new caseload and have yet to enact any changes. Jimenez meets regularly with other county officials, in addition to safety-net clinics, like Golden Valley Health Centers and Livingston Medical Group, to discuss what to expect in January.

He believes that health-care reform will make roughly 30,000 more people eligible for Medi-Cal in his county. “Maybe ten percent will qualify for mental health or drug and alcohol services. That’s conservatively speaking,” Jimenez said.

Demand is difficult to predict, in part because of the pervasive and widespread stigma attached to mental illness, according to the National Alliance on Mental Illness (NAMI). One in five Americans lives with some form of mental illness, and nearly two-thirds of all people afflicted do not seek treatment, out of fear of societal discrimination, rejection or lack of knowledge.

This problem is compounded by spotty and unequal health insurance coverage for mental illness. Congress passed the Mental Health Parity and Addiction Act in 2008 to try to eliminate these discriminatory practices and force insurers to cover mental illness as they would other illnesses.

Lawmakers say that the new health care law, the Affordable Care Act (ACA) will further improve mental health and addiction coverage for 62 million Americans.

Mental health services constitute one of the “Ten Essential Benefits” of the new law, which mean they must be covered by most health insurance plans in the future. This applies to plans offered on state-sponsored insurance exchanges – websites like Covered California where people can shop for the best private insurance available to suit their needs.

The new health care law also expands the Medi-Cal program, which assists low-income residents, seniors and other vulnerable members of the community. A joint UCLA and UC Berkeley study released in January predicts that about 1.4 million more California residents will be eligible for Medi-Cal benefits under the new law.

Though exact numbers are of people who will seek care are difficult to predict, about 120,000 people in Stanislaus, San Joaquin and Merced counties will be eligible for some sort of government-subsidized health insurance come January, according to a Families USA report released last month. All of them would have access to mental health services if they needed it.

In the meantime, Merced county health officials are discussing education and outreach to the thousands of new potential patients – how to let them know they are qualified and can apply for services. Beyond this, they’re waiting to find out what the new health care law is going to entail. “It’s going to be a gradual build up,” Jimenez said. “I think the state is a little unsure about how we’re going to roll it out.”

Pete Duenas, the manager of neighboring Stanislaus County’s Behavioral Health and Recovery Services, also said that he was waiting for state guidance. He suggested that he would have a better idea of how programs offering mental health care would develop in six or seven months, around the time when reforms will be in full force.

Just this Tuesday, the governor announced that the state will oversee the expansion of Medi-Cal. Before that, legislators and the governor were considering whether or not counties should oversee the expansion.*

Mental health services, however, will still be administered through counties. A combination of budget cuts and a brutal economic recession has left the mental health system in parts of the Central Valley overloaded and overwhelmed in recent years. An award winning investigation last year by the Modesto Bee and the California HealthCare Foundation Center for Health Reporting presented a bleak picture of the situation in Stanislaus County – deep budget cuts had left many with nowhere to turn for help. It also revealed that incarceration rates in the county for the mentally ill had gone up by almost fifty percent since 2007.

Joyce Plis of the National Alliance on Mental Illness in Stanislaus County believes that the new law may lead to an onslaught on the existing mental illness services in the area, and that local clinics and providers are already overburdened. There’s a shortage of psychiatrists, she added. “We’ve had cut after cut after cut and now we can’t cut anymore.”

Plis’ son was diagnosed with schizophrenia in the 1980s, on his twentieth birthday, so she has seen her fair share of the ins and outs of the mental health system over the past few decades. She was pleased that the health care reform bill allowed children up to 26 years old to be covered by their parent’s insurance, but disillusioned with the existing mental health care system as a whole. “It’s bare-boned,” she said.

Alex Abarca, the director of behavioral health services with the Golden Valley Health Centers, agreed that there was a huge need in the area for more mental health services, going back to when the most severe budget cuts began in 2005.

While the counties are mandated to serve the seriously mentally ill, a category that includes people who are diagnosed as severely depressed, or have bipolar or schizophrenic disorder, this is really a small percentage of the population, Abarca said. Safety-net clinics like Golden Valley end up serving large segments of the population who don’t fit into those categories, but who still need help. Many of their patients are low-income, and about 60 percent speak primarily Spanish.

“Let’s say you’re a common person who has some anxiety, or depression, that’s not that severe but could be if left untreated,” Abarca said. “Those people…wouldn’t get those services, they don’t meet the criteria.”

The Golden Valley Health center network, which has clinics throughout the Central Valley, employs 15 therapists who see about 12,000 clients a year, Abarca estimated. Golden Valley already treats some uninsured patients, so the new law will be beneficial in that they will now be getting compensation for those services.

But the reality is that nobody knows what to expect at this point, Abarca said. “What we do know is that 20 to 30 percent of our patients that weren’t insured are going to now meet the criteria. That’s 20 to 30 percent more patients coming through the door.”

Ideally, they plan to grow, perhaps open another clinic, or hire another doctor or two. “Everyone is making plans,” he said. “If they can prepare, they’re going to try.”

* An earlier version of this story incorrectly stated that a county-based expansion of Medi-Cal was still under consideration.

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