A year has passed since a massive statewide effort called CalAIM started to unfold. Among several significant changes, CalAIM promised: An overhaul of mental health care availability for youth insured by Medi-Cal, the public insurance program for low-income Californians.
Youth mental health advocates say they remain excited about CalAIM’s potential, using words like “game changer” and “transformational.”
But they also say the new framework was born at a delicate time. Three years into the pandemic, provider burnout and increased patient needs have combined to create a serious mental health staff shortage. Meanwhile, community organizations that provide many of the mental health services described in CalAIM say they feel left out of important conversations about upcoming payment reforms.
Governor Gavin Newsom budget proposal — which would delay certain investments in behavioral health to combat a projected deficit of $22 billion – also risks hampering CalAIM’s progress.
“Our members are really freaked out right now,” said Adrienne Shilton, director of public policy for the nonprofit California Alliance of Child and Family Services. In September 2022, his was among a dozen organizations that signed a letter to the State Department of Health Services to express concerns about the lack of transparency around the new fee structure. “Providers must have the ability to plan and prepare alongside their county partners,” he said.
Shilton’s organization also co-wrote a letter wednesday to lawmakers, denouncing the proposed budget delays.
Shilton told CalMatters earlier that other issues CalAIM is supposed to solve, including alleviating onerous documentation requirements, have yet to change the reality on the ground for many vendors.
CalAIM is about more than mental health. The initiative, short for California Advancing and Innovating Medi-Cal, is a five-year plan that began rolling out a year ago. It aims to provide children and adults insured by Medi-Cal with better access to a range of health and mental health services. It also strives to use a “whole person care” approach to addressing social issues that impact health, including housing and food insecurity.
It is also overhauling the payment system to more seamlessly integrate county mental health plans and the managed care organizations that pay for those services..
The relevance and urgency of addressing children’s mental health is particularly clear: Racism. School closures. Online bullying. Climate disaster. A pandemic filled with grief, loss and fear.
All of these factors have compounded a youth mental health crisis that has raged for more than a decade. Incidence of self-harm among young people, which dramatically increased even before the pandemic, increased again during the last years.
According to experts, CalAIM has yet to significantly change the reality on the ground for many of these young people, but a number of significant policy changes are officially underway:
- About 40% of children and youth in the state are insured by Medi-Cal. They no longer need a formal diagnosis to access specialized mental health services.
- The state has simplified behavioral health documentation requirements.
- A “no wrong door policy” should make it easier for children and adults to receive behavioral health care no matter where they enter the system, replacing what can feel like a bureaucratic maze that varies by county.
- An “enhanced care management” provision provides services and case management to members of priority populations, including those who are homeless, suffer from early psychosis, or are involved in child protection systems or of criminal justice.
Other efforts, including changing the way mental health services are paid, are also underway this year..
Newsom’s administration, which early on made behavioral health a signature issue, is simultaneously unveiling several other ambitious initiatives, all of which require additional staff and funds: a statewide program to implement place new justice systems to meet the needs of people with serious mental illness, known as CARE Court; expanding crisis response services with state funding for a 988 hotline; and a major initiative to improve mental health care for children and young people, parts of which will be affected by the proposed budget delays.
Despite belt-tightening in other areas of the budget proposed by the governor in January, CalAIM continues to be funded. Newsom’s proposal would spend more than $10 billion on implementing CalAIM, including $6.1 billion over five years to improve local treatment services and pay for short stays in treatment facilities for people with serious mental and behavioral illnesses.
“We are engaged. We’re not touching that,” he told a news conference earlier this month.
The budget proposal, however, delays more than $1.1 billion in other behavioral health investments over the next two years, including funds to increase treatment capacity for adults and children in crisis and funds for workforce development. These investments were intended in part to further CalAIM’s goals, according to state documents.
“We are concerned about the delays,” Shilton said. “It’s funding outside of CalAIM but…the system is so stressed. This additional state investment was really beneficial.
The governor’s office did not respond to questions about the proposed funding delays. He will revise his budget proposal in May, based on actual state revenues, and reach a final funding deal with lawmakers in June.
While CalAIM is an important step toward meeting the mental health needs of vulnerable young people, experts say staffing shortages, in particular, are complicating the situation. As a result, some say it is not yet clear how and when official policy changes will result in better mental health treatment for individuals. The proposed budget would delay nearly $400 million for health worker training, including some social work and behavioral health pipeline programs.
“Where are the people who will provide these services? said Shilton.
Michelle Cabrera, executive director of the County Behavioral Health Directors Association, calls CalAIM “an ultra-ambitious reform agenda that builds on a system that has truly weathered the storm.”
Counties are urged to implement “ambitious and sweeping new reforms on top of the worst workforce crisis we have ever seen,” she said.
In an emailed response to CalMatters, the Department of Health Services said the Newsom administration is committed to “working closely” with counties, health plans and others to plan, implement and monitor. the various “unprecedented and cross-cutting initiatives”.
Yet community organizations that contract with counties and managed care organizations to provide mental health services say they are concerned about the payment they will receive for their services and how that might affect their ability to recruit and retain the necessary staff.
Jodi Kurata, executive director of the Association of Community Human Service Agencies, which represents nonprofits in Los Angeles, said the groups she works with are too overwhelmed with labor shortages to concentrate on the ongoing administrative transformation.
“The system right now is so exhausted,” she said.
She said she worries that inadequate rates could lead to a further exodus of nonprofit mental health care providers from the Medi-Cal system, a concern that others have echoed.
The state says a draft of revised payment rates has been shared with counties. The Department of Health Services said it was committed to publishing a fee schedule in the first months of this year.
Cabrera of the County Behavioral Health Directors Association said CalAIM’s new payment structure marks a significant shift as the state will now allow counties to pay providers without caps and remove many cumbersome documentation requirements. . She said counties are only now seeing the new rates and the administration’s “aggressive” timing will likely lead to a “bumpy ride this year” before ultimately resulting in positive change.
When care depends on your county
Other long-standing funding issues remain unaddressed. Last fall, Young Minds Advocacy, a children’s mental health advocacy organization, published a report showing that long-standing variability in how the state funds specialized county mental health services has translated into disparities in the types of critical care offered to young people enrolled in Medi-Cal.
For decades, said Patrick Gardner, an attorney who founded the advocacy organization, the state has underfunded some counties “and their performance has suffered as a result, sometimes quite dramatically.”
In his report, Gardner found that counties with significantly below-average public funding generally provided less intensive services for young people than counties with significantly above-average public funding. According to its report, in 2019-20, the poorly funded counties of San Joaquin and Madera provided only 16% and 17% of estimated care needs, while the better funded counties of Santa Clara and Butte provided 86%.
Although CalAIM is moving “in the right direction,” Gardner said, it fails to address this fundamental problem. (Cabrera argues that the analysis fails to capture services provided by counties without charging Medi-Cal.)
Despite these concerns, many mental health advocates say they are already seeing significant changes in the way care is delivered under CalAIM.
“We are already seeing changes,” said Leticia Galyean, CEO and President of Seneca Family of Agencies. She said her organization – which serves youth and families in 14 counties – particularly sees “immediate benefit” in terms of faster access to specialist mental health care for young people in foster care, young people homeless and those involved in the juvenile justice system.
Brian Blalock, a senior attorney at the Youth Law Center who advocates for youth in the child protection and juvenile justice systems, called CalAIM “the most important thing California has done in a long time.”
“There’s just a tremendous opportunity there,” he said.
Now, he added, “we as a state can go both ways – either we deliver on that promise or we let it go.”