There鈥檚 an open secret among those who care for people with serious mental illnesses.
Judy Bracken first heard it a few years ago from a hospital social worker: If Bracken wanted her adult son, who has schizoaffective disorder, to receive long-term mental health treatment, she should get him off her private insurance, UnitedHealthcare, and onto the public system for low-income people in Contra Costa County.
Lucinda Chiszar figured it out when she tried to take her then 10-year-old son, who was insured by Aetna, to the only nonprofit agency in Merced County that offered the intensive wrap-around services the county鈥檚 behavioral health services said he needed.
鈥淥h, you鈥檙e not on Medi-Cal?鈥� someone at the agency asked. 鈥淲e can鈥檛 help you.鈥�
Other families say they hear it whispered by well-meaning caseworkers, or even directly from the health plans themselves.
In dozens of interviews, families, attorneys, judges, therapists and public officials agree: People with serious mental illnesses often do better dropping private insurance and qualifying for taxpayer-funded treatment.
It seems counterintuitive.
鈥淚f someone was to develop lung cancer, it鈥檚 hard to imagine that one of the other insurers would say, 鈥榊ou鈥檙e going to need to get on Medi-Cal to get that paid for,鈥欌�� said Dr. Tom Insel, former director of the National Institute of Mental Health, who has advised Gov. Gavin Newsom.
Such stories provide further fodder for the debate about how to best enforce the state and federal that guarantee patients equivalent coverage for physical and mental health treatment.
They also reveal the limits of those laws. In many cases, commercial insurers aren鈥檛 legally required to offer the intensive mental health services available through Medi-Cal. This open secret exposes troubling questions: What should private insurance cover? What should the state 鈥� and thereby taxpayers 鈥� pay for? Who鈥檚 responsible for ensuring people with serious mental illnesses get the treatment they need?
Counties that administer Medi-Cal are tired of it. 鈥淲e鈥檝e let the private commercial plans off the hook pretty significantly,鈥� said Michelle Cabrera, executive director of the County Behavioral Health Directors Association of California. 鈥淚t鈥檚 time for a come-to-Jesus conversation.鈥�
As the coronavirus pandemic and economic downturn puts increasing pressure on people鈥檚 mental health, she said counties have seen more privately insured individuals seeking crisis services.
The insurance industry denies there鈥檚 a problem.
Mary Ellen Grant, spokesperson for the California Association of Health Plans, said she surveyed the commercial plans represented by her organization and none were familiar with the phenomenon.
鈥淲e鈥檙e not aware of any existing evidence that long-term mental health care needs are better served by county mental health agencies, nor in which counties this alleged trend is happening,鈥� she said.
鈥淲e鈥檝e let the private commercial plans off the hook pretty significantly. It鈥檚 time for a come-to-Jesus conversation.鈥�MICHELLE CABRERA, COUNTY BEHAVIORAL HEALTH DIRECTORS ASSOCIATION OF CALIFORNIA
Commercial mental health plans have been providing comprehensive coverage for severe mental illness for decades, Grant said, and some plans have begun to provide wrap-around services, in-home crisis intervention and intensive therapeutic behavioral programs.
鈥淭here鈥檚 a lot of great work that they鈥檙e doing,鈥� she said. 鈥淎nd I don鈥檛 think it鈥檚 helpful to say county mental health plans are providing better services than commercial health plans, because commercial health plans are doing their best.鈥�
And, yet, many insist that鈥檚 exactly what鈥檚 happening. Los Angeles attorney and psychotherapist Meiram Bendat says he鈥檚 seen, through cases he鈥檚 taken on, that insurers not only know about the issue 鈥� which he likens to 鈥減atient dumping鈥� 鈥� but sometimes actively encourage it. He calls the practice prevalent, 鈥渟imply inexcusable鈥� and, in his view, against the law.
鈥淚t is not something that regulators in California are actively looking into,鈥� he said. 鈥淎s a result, they are not protecting the interests of the taxpayers and are allowing the insurance companies to enrich themselves by pawning off their most severely compromised and sickest members to the public welfare system.鈥�
Some mental health services that counties provide, including wrap-around programs and case management, aren鈥檛 legally required to be offered by commercial health plans.
But Mary Watanabe, deputy director of health policy for the state Department of Managed Health Care, said state law usually requires commercial plans to cover medically necessary early psychosis intervention and residential treatment. She emphasized that patients who think they are being denied necessary treatment should file a grievance with their health plans and contact the department鈥檚 help center to request an .
鈥淚t鈥檚 really Medicaid and Medicare that back up the commercial sector and allow them to have the profit margin that they have.鈥�DR. JOE PARKS, MEDICAL DIRECTOR OF THE NATIONAL COUNCIL FOR BEHAVIORAL HEALTH
No one keeps data on how often people feel forced to abandon private plans because the public system for poorer patients provides better options. But Dr. Joe Parks, medical director of the National Council for Behavioral Health, calls it 鈥渁 national issue.鈥�
Dr. Parks says private insurance historically hasn鈥檛 been set up to offer case management, help with transportation and other services to help people navigate to needed treatment.
鈥淚f you get old and sick or disabled and sick, then you leave commercial insurance,鈥� he said. 鈥淚t鈥檚 really Medicaid and Medicare that back up the commercial sector and allow them to have the profit margin that they have.鈥�
Many people with serious mental illness don鈥檛 intentionally decide to drop off of commercial insurance. Rather, the illness itself 鈥� especially if it鈥檚 inadequately treated 鈥� can lead them to lose their jobs, which then lands them on Medi-Cal.
But for some families and individuals, deciding to leave commercial insurance can be agonizing.
To meet Medi-Cal鈥檚 strict income eligibility requirements, families with children younger than 18 sometimes consider leaving their jobs or even relinquishing custody, advocates say.
Parents with children 18 or older often can just drop them from their private plan to make them Medi-Cal eligible. But that may entail giving up relationships with providers they鈥檝e known for years, and forgoing easier access to specialists who treat other complex medical conditions.
And then there鈥檚 the question of shame.
Teresa Pasquini, a Contra Costa County mother whose adult son has schizoaffective disorder, moved him off of Kaiser Permanente in 2010 after years of fighting to keep him on it. By then, Pasquini said, her son had attempted suicide multiple times. On many occasions, she鈥檇 hidden in the back bedroom, calling 911 in a whisper, waiting for authorities to handcuff her son to keep him, and his family, safe. Doctors said her son needed to be in a locked residential facility 鈥� but his private insurance didn鈥檛 cover a long-term stay, so the county had to pick up the cost, she said.
鈥淚t鈥檚 traumatic to reread the desperate emails I was sending to Kaiser, the county, the conservator, literally begging, 鈥榃hat can we do? We don鈥檛 want to drop his private insurance, we don鈥檛 want to dump his care on the state and county,鈥欌�� she said. 鈥淚 gave up my career. We were paying outrageous amounts of money. We were trying everything. So we felt we had no choice.鈥�
Suzanne Tavano, Contra Costa鈥檚 behavioral health director, said families have been making such decisions for decades.
鈥淲e鈥檙e used to it,鈥� she said. 鈥淲e expect it.鈥�
People regularly call her agency and ask if they should drop private insurance to get into county programs. 鈥淓ven with very good insurance, that continuum of care isn鈥檛 there for the most part,鈥� she said.
Privately insured people have been treated in the county鈥檚 first-episode psychosis program, though Tavano is reluctant to broadcast that, given limited space. Others with private insurance come into the county鈥檚 costly crisis stabilization unit, she said, or get help via the county鈥檚 mobile crisis response team.
鈥淲e鈥檙e not going to turn people away,鈥� she said.
But spending more on insured people leaves less to spend on people who are on Medi-Cal or uninsured and very low-income, she said.
Other counties facing similar demand restrict their offerings.
Solano County initially accepted people with private insurance into their early psychosis program 鈥� until the program was 鈥渋nundated,鈥� and didn鈥檛 have adequate room to serve people with Medi-Cal. The county then restricted it, said Sandra Sinz, the county鈥檚 behavioral health director, even though 鈥渨e know if you don鈥檛 offer it, people aren鈥檛 going to get help.鈥�
In 2014, plaintiffs in a class action lawsuit against Kaiser Permanente alleged they were told to take their sons off of Kaiser to get them into locked residential facilities. That suit settled in 2018. .
Later that year, a Kaiser therapist in Solano County, who asked not to be named because she feared being targeted by management, received a message from the company that workers should not tell patients to drop Kaiser coverage and go onto Medi-Cal.
鈥淧eople with severe mental illness absolutely pay the price,鈥� she said. 鈥淭hey suffer. They absolutely get better care through county mental health.鈥�
She hasn鈥檛 voiced that to patients, though.
鈥淚t鈥檚 not something I鈥檝e said,鈥� she said. 鈥淚t鈥檚 something I think.鈥�
鈥淚 gave up my career. We were paying outrageous amounts of money. We were trying everything. So we felt we had no choice.鈥�TERESA PASQUINI, CONTRA COSTA COUNTY MOTHER
Stuart Buttlaire, regional director of inpatient psychiatry and continuing care for Kaiser Permanente in Northern California, emailed that Kaiser 鈥渙ffers a full range of long-term, residential or inpatient treatment for members in need of more emotional or psychiatric help than is available in outpatient sessions.鈥� These inpatient stays can range from days to a year or more, he said. He said Kaiser works closely with county mental health agencies through a 鈥減ublic-private partnership.鈥�
It 鈥渕ight have been the case some years ago鈥� that some families dropped commercial insurance to go onto Medi-Cal, Buttlaire said, but 鈥渇ederal parity laws are helping eliminate the need for this.鈥�
Even those concerned about the private-public service gap acknowledge Medi-Cal is no panacea. , and they, too, face challenges.
A spike in demand for mental health services in recent years has left Medi-Cal and private insurance struggling to get the workforce and infrastructure they need.
Dr. Paula Wadell, medical director of the UC Davis Early Diagnosis and Preventive Treatment Clinic in Sacramento, said Medi-Cal offers many services to her patients that those with private insurance can鈥檛 access.
鈥淭here鈥檚 kind of no way to win for families,鈥� she said.
Once children on private insurance turn 18, clinic staff explain to their families the broader services the clinic provides to individuals with Medi-Cal. Many then elect to move their children onto Medi-Cal.
But once they drop private insurance, Wadell said, 鈥渋t鈥檚 not all rainbows and sunshine.鈥�
For example, a 2014 law requires doctors to submit a treatment authorization request to the state before giving anti-psychotics to kids on Medi-Cal. That can lead to delays in getting urgent medication that don鈥檛 happen for privately insured kids, she said.
Young people with complex medical problems 鈥� seizure disorders, for example 鈥� can find it more difficult to secure a neurologist or geneticist through Medi-Cal, she added.
Katrina Gant, a San Bernardino County mother whose son was diagnosed with schizophrenia after high school, said she heard about a great residential program in the mountains nearby. It wouldn鈥檛 accept her private insurance 鈥� but it took Medi-Cal.
The catch: Medi-Cal patients had to wait nearly a year to get in. Instead, Gant鈥檚 parents sacrificed $8,000 a month for their grandson to attend.
鈥淚t was difficult, but to help my son they would do anything,鈥� Gant said. Although her son remains with Kaiser, she plans to switch him to Medi-Cal 鈥� despite the waitlists.
So what can be done?
San Francisco Democratic Sen. Scott Wiener鈥檚 would require insurers to cover all medically necessary treatments for mental health and substance use disorders.
Dr. Henry Harbin, former CEO of Magellan Health, a managed behavioral health care company, said that some private plans lack the billing codes that allow payment for more complex mental health treatments. He鈥檚 working on developing a standardized billing code that first-episode psychosis treatment programs can use to bill commercial insurance, and says a similar initiative would do the same for crisis services.
Several California agencies that serve children have begun piloting partnerships with commercial plans. Marika Collins of Casa Pacifica, which serves children and families on the Central Coast and in Southern California, said her organization is working with Anthem and Kaiser to provide the same intensive mental health services to children with private insurance they鈥檝e long provided to children on Medi-Cal.
鈥淚鈥檓 just thrilled to say that we鈥檝e done it,鈥� Collins said. 鈥淚鈥檓 less quick to bash the health plans than I was three years ago. Some of them really get it.鈥�
This story was made possible by a grant from the California Health Care Foundation.