This article originally appeared in the July-August 1999 Children's Advocate newsmagazine, published by Action Alliance for Children.

Medi-Cal: An open door to mental health care for kids?

By Jean Tepperman

Three-year-old Eric is biting uncontrollably at preschool. The teachers are almost at the point of asking him to leave. Without child care, Eric's mom may lose her job. Where can she turn for help?

If the family's income is below the poverty line, Eric is entitled to mental health care through Medi-Cal. Eric's mom can call an 800 number and connect to a system of services run by her county Department of Mental Health.

The promise: an open door to help

For all kids on Medi-Cal, the county mental health system is supposed to provide:

• Help with a wide range of problems:
  "Severely emotionally disturbed" children enter the county's "system of care," in which therapists from the county mental health department work with teachers, social services, health care providers, and community organizations to coordinate care for the child.
  Less severe problems used to be handled differently—until two years ago, the parents of children with mild or moderate emotional problems had to try to find a provider who would take Medi-Cal—often difficult because of low fees, delays in payment, and red tape. The provider billed the state directly.
  Now the county is responsible for providing help for "almost any kid who has a distressing problem," says Laura Fowler, director of Children's Services at the Solano County Mental Health Department—as long as the child has an officially recognized diagnosis.

• A wide range of services:
  Besides traditional psychiatric office visits, Eric might see a counselor or social worker, participate in group therapy, or receive therapy at home or at child care. A mental health consultant might work with mom and teachers on managing Eric's behavior.

The law: any help a kid needs

Medi-Cal provides only limited mental health services to adults but is required to give kids whatever help they need. A 1988 federal law created the policy of Early and Periodic Screening, Diagnosis, and Treatment (EPSDT), which requires states to do health and mental health checkups for all children on Medicaid (Medi-Cal in California), and then to give them any kind of treatment that would improve their condition. The state pays half the cost, the federal government the other half.

"The law says kids should get what they need," says Jim Preis, an attorney with Mental Health Advocacy, Inc. He was one of the lawyers who sued California in 1994, charging that it was violating the EPSDT policy by failing to provide enough care—especially mental health care.

In the settlement of that suit, California promised to open the door to comprehensive mental health care for kids. According to a financial deal worked out after the suit, counties have to spend up to a certain limit, then they can send the state a bill for the rest. In the five years since, California's spending on Medi-Cal mental health care for children has more than tripled.

The down side: "huge unmet need"

As a result of both the lawsuit and the new county-run mental health systems, "access has increased significantly," says Preis, "but there's still huge unmet need."

Experts estimate that about 10 percent of all kids are in need of treatment for emotional problems. Between 3 percent and 4 percent are "severely emotionally disturbed." But only about 2.5 percent of kids on Medi-Cal are receiving mental health treatment. Why the gap?

• Limited outreach: The new county system has "made a big difference," says Patty Hart of Parents Helping Parents in Alameda County, but "a lot of people still don't get the help they need because they don't know it's available."

• Shortage of providers:
  "The younger the age, the smaller the number of people who have training in dealing with that age," says Bill Carter, director of Children's Services for the California Institute for Mental Health.
  In rural areas it is sometimes impossible to find providers who treat children.
  Providers who are comfortable with various cultures are hard to find, says Gale Bataille, Solano County mental health director. L.A.'s director of children's mental health, John Hatekayama, says there's a severe shortage of providers who speak Spanish and Southeast Asian languages.
  Low pay has kept many providers away. Medi-Cal has historically paid therapists $29 an hour—far less than than the $100 or more psychiatrists often command. Some counties are now raising the rates to attract more providers.

• Counties' financial caution:
  Many counties have been very cautious about expanding children's mental health services despite the state's promise to pick up the tab. Some counties feared that "if they spent too much they would end up having to pay it back," says Carol Hood, deputy director of the state Department of Mental Health. Some counties couldn't put up the money and wait for state reimbursement. So this year the state is giving counties most of the money up front.

• Procedures and requirements:
  Many counties require providers to get approval for treatment from the county Department of Mental Health, which may approve only six or eight sessions at a time. Does the child need more? That can be a very subjective judgment. "I still get calls from parents who feel their child's therapy was terminated too soon, or who say their child needs therapy and they just get medication," says Hart.

Limits of care: the "medical model"

Medi-Cal health care is provided on a "medical model": "treatment" is provided only for a patient with an officially recognized diagnosis. This limits mental health care in several ways.

• Work with parents and teachers to help the child can be billed to Medi-Cal, says Gale Bataille, director of mental health for Solano County, but it's a matter of interpretation how far this flexibility goes.

• Help for a parent's problem, such as depression or alcoholism, isn't included in Medi-Cal for the child, even though improving the parent's condition could be the most important mental health factor for the child, says Bataille. And resources for parents' mental health care are limited.

• Preventative measures are rarely covered because all services have to be provided for a specific patient who already has an official diagnosis. "This is a big problem," says Sai-Ling Chan-Sew, director of children's mental health for San Francisco. "There's no funding source for consulting with teachers about kids presenting problems -- for making a behavior management plan so you don't have to open a case for the kid."

Navigating the System

For Medi-Cal:

• Your county's 800 number for mental health care is listed under "mental health" under the name of your county in the government section of your phone book

• Many counties now employ "parent partners," parents of children who have received mental health care and now advise and support other parents. Contact them through the county 800 number or call the California Institute for Mental Health at (916) 556-3480, which has a list of counties' "parent partners."

• All counties are required to have "patients' rights advocates" as part of their mental health system.

For any mental health care problems:

• United Advocates for Children of California is a statewide organization of family members of children in mental health care, with regional coordinators who provide information and support. Contact Carolyn Cooper at (510) 547-8754

• National Alliance for the Mentally Ill -- California also provides referrals to local resources and advocates. Contact the state office at (916) 567-0163.
• Mental health associations operate in many counties to provide referrals, support groups, and other resources. Look in the white pages or yellow pages of your phone book under "mental health." Or call the statewide Mental Health Association at (916) 557-1167

• California Mental Health Advocates for Children and Youth provides public education and policy advocacy on children's mental health issues. Call Steve Elson at (805) 445-7801.

For legal advocacy:

• Protection and Advocacy, (800) 776-5746.

• Mental Health Advocacy Services, (213) 484-1628