I once had a patient with severe bipolar disorder who moved to the US to get away from people in his native country who tormented him for being gay. He had been hospitalized with preventable pneumocystis pneumonia and was breathing on a ventilator. Although he was HIV positive, he had not been taking the retroviral medications that would have reduced his risk, and he wasn’t taking psychiatric drugs to manage his bipolar condition. I believe that if our health care system were able to share information and manage everyone’s psychiatric and medical needs collaboratively, my patient might not have had to endure a harrowing stay in the intensive care unit. He is fortunate to have survived the pneumonia, and thanks to San Francisco’s sophisticated system of community-based, integrated care for HIV patients, today he is successfully taking care of himself and getting the care he needs.
Patients like this illustrate why CHCF is intent on advancing the integration of behavioral and medical care as a significant way to improve access for low-income populations, ensure that care is cost-effective, and provide data to help decisionmakers develop and implement forward-thinking policies. At CHCF, we define behavioral health as the full range of mental and emotional well-being — how we cope with daily frustrations and challenges, the treatment of mental illnesses like depression and personality disorders, as well as substance use disorders and other addictive behaviors.
Recognition of the significant human and financial costs of behavioral health disorders, along with recent implementation of federal and state laws enhancing coverage of mental health services, have lifted behavioral health to the top of the nation’s health policy agenda. In 2013, mental disorders topped the list of most costly conditions, with spending estimated at $201 billion, according to a report in Health Affairs. This finding was featured in one of the 29 impressive articles published in the new behavioral health-themed issue of Health Affairs. CHCF proudly supported this issue of the journal, and I invite you to read key articles.
In California, more than eight million adults and children live with mental illnesses and addiction disorders. An estimated 16% of adults have mental illness, and 4.3% have serious mental illness (SMI). People with SMI die 25 years earlier than people with no mental disorder from the same medical causes that affect the general population — heart disease, diabetes, cancer, stroke, and pulmonary disease. Not surprisingly, people with SMI have very high medical costs.
Of the 5% of Medi-Cal enrollees who have the highest costs, 45% have a serious mental illness. That’s why behavioral health integration — in which people receive coordinated or colocated care for all their health needs — has such huge implications for Medi-Cal, California’s largest health insurance program. At the state level and locally, Medi-Cal is engaged in multiple initiatives to move toward behavioral health integration. CHCF is working to advance many of these efforts.
To be sure, guaranteeing that all Californians have timely access to culturally appropriate, evidence-based treatment for mental illness and substance use disorders that is linked to their physical health care represents a huge challenge — but we are not daunted. Behavioral health conditions are eminently treatable. I believe that with smart investments in high-impact strategies, CHCF can make meaningful contributions to encourage behavioral health integration. As Margarita Alegría and colleagues observe in their excellent article about reducing racial and ethnic disparities in behavioral health care, a systematic commitment to improvement could create real and lasting improvements in the health status of all Americans.
Sandra R. Hernández, MD, is president and CEO of the California Health Care Foundation. Prior to joining CHCF, Sandra was CEO of The San Francisco Foundation, which she led for 16 years. She previously served as director of public health for the City and County of San Francisco. She also cochaired San Francisco’s Universal Healthcare Council, which designed Healthy San Francisco. It was the first time a local government in the US attempted to provide health care for all of its constituents.
In February 2018, Sandra was appointed by Governor Jerry Brown to the Covered California board of directors. She also serves on the Betty Irene Moore School of Nursing Advisory Council at UC Davis and on the UC Regents Health Services Committee. Sandra is an assistant clinical professor at the UCSF School of Medicine. She practiced at San Francisco General Hospital in the HIV/AIDS Clinic from 1984 to 2016.
Sandra is a graduate of Yale University, the Tufts School of Medicine, and the certificate program for senior executives in state and local government at Harvard University’s John F. Kennedy School of Government.