On West Line Street, in the heart of Bishop, sits a business that has, over the last year, quietly begun to transform this area’s access to mental health services. For years, this corner of the rural Eastern Sierra has struggled to meet the community’s mental and behavioral health needs. Those who sought care have often faced long wait lists, unaffordable services and the pressure of living in such a small town, where anonymity can feel impossible. Providers, meanwhile, have burned out as they tried to fight overwhelmed systems and needs that disproportionately fall on people of color.

Eastern Sierra Counseling founder Daniel Ranson has seen the need for affordable, accessible mental health care increase since he opened his business in Bishop in 2016. The licensed clinical social worker has worked in Inyo and Mono Counties for more than 25 years, and all along, he’d been told that certain services were out of reach for the community because of its small, dispersed populations.

“It’s in my face every day,” Ranson said. “One of the hardest things here is knowing that people are still falling in the cracks.”

There is a serious shortage of child mental health care providers in rural areas, according to the Centers for Disease Control and Prevention, leaving many people unable to access the care they need. California’s 121,000 psychologists, clinical social workers, and marriage and family therapists are unevenly distributed across the state, with a higher rate of providers per capita in the Bay Area and in the counties around Los Angeles, the Public Policy Institute of California noted in a 2023 report. The majority of counties in the rural north, Central Valley and the Eastern Sierra have fewer than 243 providers per 100,000 people.

The shortage is even more severe when counting psychiatrists, especially those who specialize in working with children: A 2022 brief from the Rural Health Research Center at the University of Washington noted that the number of psychiatrists per 100,000 people in rural counties was about a quarter of that of urban counties, and numerous studies show that the problem has only been exacerbated by the Covid-19 pandemic, which put greater strain on both patients and providers.

With a desire to address this strain on local resources, last year, Ranson brought on his wife, Sarah Vigilante, to help him manage Eastern Sierra Counseling, and they soon expanded their services to Mammoth Lakes and Ridgecrest, in Kern County. In the first few months, they had added several providers, including four psychiatrists and a psychiatric nurse practitioner. The team discovered that, while psychiatrists might not find a full-time workload in the Eastern Sierra, many providers would be willing to work in the area part-time.

Thinking creatively has been key: “We’ve flown out one of our providers all the way from the East Coast just to provide services in person here,” Ranson said. By getting away from the “corporate setting” of working 30 to 40 hours a week, Ranson said they’ve created a model that works for the area, and his team of therapists is thrilled to finally be able to collaborate with psychiatry when needed.

Outside of private practices like Eastern Sierra Counseling, the struggle for mental health and psychiatric care in Inyo Care continues. Northern Inyo Hospital in Bishop works with two psychiatric providers. Neither lives in the area, however, so they mostly see patients remotely.

One of the psychiatrists, Dr. Murat Akalin, said that while being able to meet with patients online has improved access overall, for some communities, there are other barriers to consider. For example, when working with the Toiyabe Indian Health Project in Bishop, Dr. Akalin noticed that many of his patients didn’t have reliable access to a laptop, cell phone or internet.

About 80 percent of Eastern Sierra Counseling’s clients prefer in-person care, Ranson said. “I think that’s a benefit of our hybrid system, is that you can come and meet your provider, especially for psychiatry, face to face, and then you can continue by video, and you’re a little more comfortable,” he said.  

Many providers in the Eastern Sierra also emphasized that access is only half the battle — affordability is also crucial. For Ranson and Vigilante, providing affordable services at their private practice has meant battling with insurance companies. “The way we think that we can make that affordable is by being in network with all the local insurances. And that has been an extremely big hill to climb,” Vigilante said.

For Eastern Sierra Counseling, this has meant convincing the major health insurance companies — who often subcontract their mental health coverage out to third parties — to include them in their networks. And that has usually meant proving that the companies are out of compliance with regulations called “network adequacy codes” that require insurance companies to meet a minimum level of coverage by area. They’ve been incredibly successful so far, and they now accept Anthem, Aetna, Healthnet Medi-Cal, Anthem Medi-Cal, Blue Shield and Magellan insurance companies; their goal is to be able to support all Eastern Sierra residents, regardless of their insurance provider. For uninsured potential patients, Vigilante said they would refer them to services that accept cash, though she emphasized that all Californians have access to an insurance plan through the state’s exchange marketplace.

Requiring insurance to cover mental health care is strongly supported by young people nationally. In a survey of first-time voters conducted by the Deliberative Democracy Lab at Stanford University, there was bipartisan support for the idea that private companies should be incentivized to invest in mental health initiatives through tax breaks or other benefits.

While Eastern Sierra Counseling accepts both Medi-Cal and private insurance plans, Inyo County’s behavioral health department, like many across the state, only treats patients with Medi-Cal, and they focus primarily on patients with moderate to severe mental illness. They, too, need more resources in order to meet the complex needs of the community. In an annual update from June, Inyo County leaders emphasized how the colonial legacy of the Eastern Sierra has left long-lasting impacts on its Indigenous communities, on top of compounding economic conditions like the high cost of living and limited work availability.

And yet, the report also highlights some of Inyo County’s strengths. The small-town environment often means multi-generational connections and the care of one’s community. Residents here are often deeply connected to the land and environment, and appreciate one another’s cultural differences, according to the report.