The Need for a California Behavioral Health Care Standard
In early 2018, Behavioral Health Action members committed to a momentous task: to develop a better way to provide behavioral health care in California. We began to convene a series of meetings to develop recommendations on an ideal continuum of care, crisis services, and ways to address finance and delivery system issues. When the full Behavioral Health Action coalition met to review this work from 2018 and set priorities for 2019, coalition members heard a presentation on a paper published in 1981 that inspired us: “A Model for California Community Mental Health Programs.”
That project had been initiated by now retired Assemblymember Thomas H. Bates, who chaired the California Assembly Permanent Subcommittee on Mental Health and Development Disabilities. Following a 1979 subcommittee hearing on the future of mental health in California, Bates and subcommittee members unanimously voted to ask a coalition of mental health providers and consumers to develop a consensus on appropriate mental health care in California. During the two years that followed, a workgroup determined the basic needs for care, which were developed into standards, resulting in a “Model for California Community Mental Health Programs.”
After hearing the presentation on the paper, Behavioral Health Action members saw our overdue need to articulate a modern, ideal continuum of care that includes both mental health and substance use disorder services. In this document, we detail a standard of care for behavioral health that should be available to promote the health and well-being of all Californians.
To develop this proposed model, Behavioral Health Action held numerous workgroup meetings and closely reviewed the benefits currently provided through health plans and public programs. We identified numerous areas where coverage varies widely — depending on where an individual resides and the source of their health coverage, rather than on what people need. While many perceive that behavioral health services are primarily the responsibility of state and local government providers, the reality from both from a legal and practical perspective is that the responsibility for Californians’ health and well-being is shared by private insurers, health plans, and government.
One in every four Americans experiences a behavioral health challenge in any given year, and half of us will care for someone living with a mental health issue during our lives. However, far too many Californians still struggle to access a full array of behavioral health care and supports. According to a 2017 report by the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA):[i]
- 18% of all adults in California had some level of diagnosable mental illness in the past year and 3.9% had a serious mental illness that caused functional impairment. However, only 11.7% received any mental health services.
- 13.3% of young Californians ages 12 to 17 had a major depressive episode in the past year and 4.6% had a substance use disorder in the past year.
- 13.2% of young adults ages 18 to 25 had a substance use disorder in the past year. While 8% of people ages 12 or older needed substance use treatment in the past year, only 10.8% who needed treatment received it.
Despite major improvements in health care coverage over the past decade, substantial discrepancies persist in available behavioral health care among commercial health plans and public programs. Under the Affordable Care Act, Medicaid coverage, individual market plans, and plans offered by small employers are required to offer 10 categories of essential health benefits. These benefits include preventive care, mental health care, emergency and urgent care, rehabilitation therapy, home health or nursing home care after a hospital stay, prescription drugs, and substance abuse treatment. However, people insured by large employers are not guaranteed these essential health benefits.
Even when commercial plans cover mental health and substance use disorder treatment, they fail to meet many basic quality standards. The California Office of the Patient Advocate’s 2020-21 Report Card gave “excellent” five-star ratings to only two of the top 10 health plans for their quality of their behavioral and mental health care.[ii] Only three of the 16 plans in the report card met or exceeded the national average percentage of adolescent and adult patients who started treatment services within 14 days of an alcohol or other drug dependence diagnosis. Only two of 16 plans met or exceeded the national average percentage of patients who were seen within seven days after being discharged from psychiatric hospitalization.
For individuals covered by Medi-Cal, federal block grants and state tax revenues fund counties to deliver public behavioral health services to specific target populations. Medi-Cal enrollees whose mental health needs do not severely impair their functioning can access certain outpatient mental health treatment from their Medi-Cal managed care plans. If they need “specialty care,” Medi-Cal enrollees access it through counties. With at least two separate health systems to navigate — each which offers different types of care — consumers, families, and health and social service partners can be easily confused, frustrated, and discouraged. And while a wide variety of mental health and substance use disorder treatment services are “covered” in the Medi-Cal program, each service type is not required to be made available on a statewide basis. As a result, some of the most effective outpatient services that reduce hospitalization and incarceration rates are not delivered everywhere in the state.
The importance of addressing disparate, fragmented care for people with behavioral health needs is substantial. As stated in the California Health Care Foundation’s Behavioral Health Integration in Medi-Cal: A Blueprint for California, “People with behavioral health conditions —mental illness and/or substance use disorder — often experience poor health overall. They are less likely to receive preventive care, have higher rates of major chronic illnesses, and often experience a lower quality of care for their physical health needs. Those with a diagnosis of serious mental illness or substance use disorder die on average over 20 years earlier than those without such a diagnosis, often from preventable physical illnesses.”
California must turn longstanding practices and investments on their head. California needs to create a statewide minimum standard for behavioral health care, one that emphasizes prevention and early intervention. These investments will reduce our state’s rates of hospitalization, law enforcement involvement, emergency department visits, out-of-home care, involuntary detention, and conservatorship for people with behavioral health needs.
[i] Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2016, https://www.samhsa.gov/data/sites/default/files/NSDUH-DetTabs-2016/NSDUH-DetTabs-2016.pdf and 2017, https://www.samhsa.gov/data/sites/default/files/cbhsq-reports/NSDUHDetailedTabs2017/NSDUHDetailedTabs2017.pdf
[ii] California Office of the Patient Advocate, HMO and PPO Quality Ratings Summary 2020-21 Edition, https://reportcard.opa.ca.gov/rc/ HMO_PPOCombined.aspx