California needs more proactive leadership on youth mental health

Virtually all youth in California have a legal entitlement to adequate mental health care. The right to mental health care stems from many federal and California-specific sources — including Medicaid, or Medi-Cal as it’s called in California (health insurance for low-income individuals), the Individuals with Disabilities Education Act (special education-related services), the 14th Amendment (care for youth in custody), “minor consent” (confidential mental health services for minors), and Emergency Medical Treatment And Labor Act (emergency room services), to name some of the most common mandates.

Having ready access to effective mental health services is important because one-in-four or five youth may struggle with mental health challenges. Providing effective mental health services and supports can help improve personal relationships and family dynamics, allow children to live safely at home, avoid delinquency and high-risk behaviors, gain job skills, and achieve academic success.

Unfortunately, even though virtually all children are covered by one program or several, most children do not get quality care — or any care at all. That’s because when it comes to delivering mental health services and supports, California’s child-serving programs and agencies are poorly coordinated and better attuned to the needs of the bureaucracy than those of children and families. Services are typically doled out in a “fail-first” approach that offers minimal assistance until youth fail out of low-level services and escalate to high levels of acuity and need. In addition, many children are denied or put off for bureaucratic and budget reasons, and many more are never adequately assessed or referred to healthcare providers that could improve their lives.

Barriers to care are not only counterproductive, harming the very people the system is designed to serve, but often contravene law and regulations. The result has been a series of class action lawsuits to enforce California’s children, youth, and families’ right to care. The leading cases — T.L. v. Belshé, CV-S-93-1782 LKK PAN (E.D. Cal. 1995)(settlement)(demand for Medi-Cal covered Early, Periodic, Screening, Diagnosis and Treatment (EPSDT) mental health services), Christopher T. v. San Francisco Unified School Dist., 553 F. Supp. 1107 (N.D. Cal. 1982)(demand for special education related mental health services), Emily Q. v. Bonta, 208 F. Supp. 2d 1078 (C.D. Cal. 2001)(demand for mental health services to allow institutionalized youth to live safely at home), and Katie A. v. Bonta, 433 F. Supp. 2d 1065 (C.D. Cal. 2006)(demand for Medi-Cal home and community-based mental health services) — have resulted in hundreds of millions spent on additional treatment and tens of thousands of children and youth gaining access to mental healthcare.

These lawsuits have made a huge positive difference for California’s youth; but there are drawbacks to this approach. Using the courts to drive mental health policy and programs can contribute to the disorganized state of programs and services because courts focus on individual rights, not broad systems of care. Plus, with each new lawsuit, managers turn their attention from the last remedy, or the larger “system,” to focus on the immediate challenge. Also, these cases tend to drag on for years; and while the state defends, children wait. Additionally, the adversarial nature of the judicial process can undermine the potential for collaborative problem-solving by the parties and other key stakeholders who will be essential to successful implementation of a settlement agreement or court-ordered remedy.

Notwithstanding these drawbacks, the pressure for a new lawsuit is growing. Why? Because psychiatric hospitalizations of young people have been rapidly climbing, access to Medi-Cal mental health services is declining, compliance with entitlements to home and community-based services and special-education related mental health care is falling short, the distribution of care is wildly inequitable, and the availability of crisis care is woefully inadequate.

It’s unlikely that Gov. Jerry Brown will change his spots and provide leadership to address these challenges before leaving office. Under his watch, first as attorney general, and then as governor, the state fought efforts to provide wraparound and intensive home and community-based services to thousands of children on Medi-Cal, barring access to care for more than a decade. The state lost this case, but to this day has failed to fully implement the settlement agreement in Katie A. The governor also championed realignment which handed over hundreds of millions of annual state revenues intended for mental health care to the counties with virtually no oversight or accountability. The result has been a steady downward trend in access to mental health care for Medi-Cal eligible youth.

Now is the moment to change direction, and, for those who would be governor, commit to delivering on the legal and moral promises of adequate and effective mental health care for all of California’s young people. A few straightforward steps would make all the difference:

1. Commit to cover all young people to age 21 with individualized mental health services and supports — that would change basic treatment incentives from avoiding costs through delay and denial, to reducing costs with early and effective care when needs and costs are low;

2. Eliminate “fail first” in favor of “right now” — delivering the right care, in the right intensity, for the right amount of time, from the start;

3. Launch a broad-based commission to identify (a) barriers to care; (b) opportunities to collaborate by and among child-serving agencies; and (c) system reforms needed to improve mental health treatment quality, effectiveness, and outcomes; and

4. Reform mental health financing by committing to make public dollars “follow the child” to more effectively meet the needs of children and families, rather than programs and bureaucracies.

These reforms would vastly improve outcomes for youth and their families and reduce the costs of care. Moreover, it would be far better for our elected leaders to deliver on promises made to California’s children and families with unmet mental health needs, than to defend against more statewide lawsuits. Lawsuits should not be the first recourse to sound mental health policy and effective programs; but when government won’t deliver, California’s public interest lawyers will continue to step up to enforce the rights of youth and families.

Patrick Gardner serves as founder, president, and board member at Young Minds Advocacy in San Francisco. Nisha Ajmani serves as staff attorney and policy advocate at Young Minds Advocacy in San Francisco.

Young Minds Advocacy is a nonprofit organization founded to address the unmet mental health needs of young people and their families. Using a blend of policy research and advocacy, impact litigation, and strategic communications, the organization works to change attitudes towards mental illness and break down barriers to quality mental healthcare for young people and their families.