Lawmakers Focus on Mental Health — Especially in Medi-Cal

California State Capitol

Mental health is getting renewed attention in California. Governor Gavin Newsom is passionate about the importance of mental health care. He created the post of California Surgeon General and appointed pediatrician Nadine Burke Harris, MD, who is a pioneer in linking exposure to childhood trauma with physical health problems later in life. Legislators have introduced dozens of behavioral health bills aimed at improving mental health care for Californians. And, in a CHCF/Kaiser Family Foundation poll released in January, Californians said the top health priority they wanted the governor and legislature to work on in 2019 was “making sure people with mental health problems can get treatment.”

Mental health disorders are among the most common health conditions faced by Californians: Nearly one in six California adults experiences a mental illness of some kind. One in 13 children have an emotional disturbance that limits participation in daily activities. Meanwhile, Medi-Cal is the major source of coverage for 13 million Californians, including low-income children and their parents, pregnant women, seniors, and nonelderly adults, including people with disabilities. The program also plays a key role in covering mental health care.

Against this backdrop, the respective health committees in the State Assembly and Senate have held informational hearings about the Medi-Cal mental health delivery system. (The Legislative Analyst’s Office prepared a background report [PDF] on funding of Medi-Cal mental health services, which is an excellent primer on the topic.)

Catherine Teare, CHCF’s associate director for high-value care, was asked to testify at the February 26 joint hearing to provide an overview of mental health in California. Her comments focused on four areas detailed below, and her complete presentation (PDF)  is available for download. The source material was primarily the CHCF publication Mental Health in California: For Too Many, Care Not There, one of CHCF’s 2018 Almanac products. That publication updated a 2013 report on mental health in California, and she spotlighted several trends.

Mental Illness Is Common

As noted above, nearly one in six California adults experienced a mental illness in 2014 (the most recent year for which we have data). That means they had a mental, behavioral, or emotional disorder. This category includes people whose mental illness causes any degree of functional impairment. In that year, about one in 24 California adults experienced a serious mental illness, which is defined as a diagnosable mental, behavioral, or emotional disorder resulting in functional impairment that interferes with or limits major life activities.   

Among kids age 17 or younger, one in 13 had a serious emotional disturbance, which is a mental, behavioral, or emotional disorder that substantially limits functioning in family, school, or community activities.

These numbers are essentially unchanged from those contained in CHCF’s previous Almanac report on this subject.

As the chart below shows, serious emotional disturbance in children and serious mental illness in adults is more common among people at the lowest income levels. Because eligibility for Medi-Cal is often determined by income, those most at risk for mental illness are also the most likely to be covered by Medi-Cal.

Graphic showing incidence of mental illness, adults and children, California, 2014

 

Chart showing children with serious emotional disturbance and adults with serious mental illness, by income

Mental illnesses can cost people their lives. Most people who die by suicide have a mental or emotional disorder. People with addiction or other substance use disorders are six times more likely to die by suicide than those without them.

California’s suicide rate is lower than the national rate and has been stable since 2011–2014 at approximately 10 to 11 per 100,000 people.

The chart below shows that rates of suicide differ dramatically by gender and race. The rate for men is three times higher than for women.

Bar chart showing suicide rate, by gender and Race/Ethnicity, all ages, California, 2011 to 2013Access to Care

For California, there are significant and concerning gaps in access to mental health care, and the situation has changed little in the last 10 years.

As the following chart shows, only about one-third of California adults with a mental illness received treatment or counseling during the prior year — lower than the national rate of 43%, which is about the same rate as reported in 2013.

In the CHCF/Kaiser Family Foundation statewide poll, three in four respondents said treatment is effective in helping people with mental illness lead healthy and productive lives.

For adults with major depression, which is associated with higher risks of suicide and cardiovascular death, access is better than for people with other mental illnesses. Nearly two-thirds of California adults who report a major depressive episode receive treatment.

But for adolescents with depression, the data were starkly different and perhaps the most concerning of Teare’s presentation. In only six years ending in 2014, the share of teens who reported experiencing a major depressive episode rose from 8.2% to 12.3% — a 50% increase. It means one in eight California adolescents reported a major depressive episode. Worse, unlike adults, two-thirds of adolescents with major depression do not receive treatment, as shown in the chart below.

This is not reflective of normal adjustments of adolescence, but of teens with major depression.

Pie chart showing treatment for mental illness, adults, California, 2011 to 2015

Pie chart showing treatement for major depressive episode in adolescents, California 2011 to 2015

Importance of Medi-Cal

Adults with serious mental illness and children with serious emotional disturbance who are covered by Medi-Cal receive mental health care through their own county’s specialty mental health services program. Under the Affordable Care Act’s Medi-Cal expansion, the number of adults served by these county programs has soared. Because they are now covered by Medi-Cal, they also have access to all Medi-Cal benefits, which is important because people with behavioral health disorders die at a far younger age than those without.

  • People with serious mental illness die 25 years earlier
  • People with a substance use disorder die 22.5 years earlier

We may reflexively think that they die from “unnatural causes” like suicide, overdose, or accidents. But people are much more likely to die earlier of the same causes as everyone else: heart disease, stroke, diabetes, and respiratory problems.

These disparities in health outcomes for people with mental health and substance use disorder are reflected on the cost side, too.

The next chart shows that total costs of care for Medi-Cal beneficiaries with diabetes and a co-occurring serious mental illness were more than double the amount for people with diabetes alone, and more than 2.5 times higher for patients also diagnosed with a substance use disorder. What’s significant is that the increased costs are mostly for physical health services, not additional treatments for mental illness or substance use disorder.

Chart showing Medi-Cal spending on Diabetes, by service category, with and without SMI or AD, 2011

The data Teare presented to lawmakers that focused on prevalence, costs, and utilization don’t do a good job of telling people’s stories. Every day in California, people with mental illness go to work, care for their families, and participate in their communities. Mental health providers across the state are working to provide care for people in need. Yet, too many in our state are suffering and missing out on treatment. The data create an inescapable conclusion: Our health care systems don’t make it easy for those who need care to actually get it.