Where California Stands in Mental Health Needs and Services

Two new assessments released Wednesday gave an overview of mental health in California – from suicide rates to access to care to the supply of mental health professionals.

While there are bright spots, they provide a pretty sobering view. The first, Mental Health Care in California: Painting A Picture, details that nearly 1 in 6 adults in the state has "a mental health need" and 1 in 20 has a serious mental illness. The rate in children is even higher: 1 in 13.

And too many people are not getting treatment. According to the analysis, half of adults and two-thirds of adolescents with a mental heath illness do not receive treatment. A big contributing factor is likely the state of the mental health workforce in California which is quantified in both the first report and the second. Both analyses are from the California HealthCare Foundation. They describe a varied and fragmented delivery and financing system in the state.

Steve Schilling knows the issue all too well. He's CEO of Clinica Sierra Vista which has multiple health centers in southern San Joaquin Valley. He said "scarcity" would be a better word than "variation" when it came to describing mental health services. In the CHCF analysis, the San Joaquin Valley fell well below a state average for all  mental health professions. The Inland Empire also fared poorly. "I really think we have a non-system of behavioral health in California," he said.

California has a layer-upon-layer system of mental health funding that can vary dramatically according to what county you live in, or where you seek care. This year's state budget brought a ray of good news with a boost of $140 million in funds. But county funding has long been determined by an arcane formula. CHCF's researchers noted that "(w)hile no current analysis comparing county's total per capital mental health program revenues and expenditures is publicly available, it is widely assumed that the amounts vary greatly between counties."

Then there's federal funds. Because Clinica Sierra Vista is a federally-qualified health center, or FQHC, it is constrained by federal rules as to who can provide services. This is an issue because California's mental health workforce has a different composition from that of the U.S. as a whole. In particular, California has more Marriage and Family Therapists, or MFTs, than the U.S. But, in general, MFTs are barred from billing Medi-Cal or Medicare, so, essentially, barred from serving those patients.

These reports come at a critical time -- as the state is preparing for the full implementation of the federal health law on Jan. 1 and the tens -- or hundreds -- of thousands of newly insured people seeking access to care.

"The challenge is going to be ... do we have the manpower and the capacity within the system to meet everyone's needs," said Dr. Neal Adams with the California Institute for Mental Health, one of the co-authors of the Painting a Picture study.

A big uncertainty, Adams noted, is a 2008 law requiring parity between mental health services and medical/surgical services. While the law specifically covered group health plans only, the Centers for Medicare and Medicaid Services (CMS) has yet to issue regulations to put the law into effect. The Affordable Care Act and the benefits package in Covered California, the health care marketplace being set up by the state to comply with the ACA, both mention parity. But, "absent guidelines," Adams says, "I'm worried there will be continued problems with access."

He pointed out that Proposition 63, passed by the voters in 2004, was intended to provide state funding to community-based mental health services. But while revenue from this so-called "millionaires' tax" -- since it created a 1 percent tax on personal income in excess of $1 million -- has flowed, alternative state funding to mental health services was cut in the wake of the economic downturn.

Still, the upcoming expansion of insurance under the ACA -- both through the new marketplace and the expansion of Medi-Cal will bring new dollars to health care overall. Adams is optimistic that "we're going to see more people come into the system with benefits and better ability to pay for services."

While Rusty Selix, executive director of California Council of Community Mental Health Agencies, argued that better outpatient mental health programs are sorely needed, the ACA's new funding should make a difference.

"Mental health has always been under-funded," he observed. Under Obamacare, "there will be funding."

Learn More:

Higher Mental Illness Rates Among Low-Income Californians (KQED Forum):