Now in our sixth year of operation, the Steinberg Institute is capitalizing on the political momentum created by a new governor who has prioritized mental health policy by pursuing an ambitious and bold legislative agenda. We seek again to have an outsized impact on California’s policy agenda with bills that would end the discrimination and roadblocks too frequently faced by people seeking care, put an end to turf wars that keep qualified professionals from helping patients in need of treatment, enable additional housing types to provide badly needed supportive housing, find out how many people with mental illness are living in board-and-care homes, and update the LPS Act for the first time in over 50 years. Please feel free to contact us if you have any questions. We welcome your input and would deeply appreciate your support.
Today, about 6.5 million people receive a variety of primary care, podiatry, optometry, dental care and mental health service at 1,300 community health centers around the state. Most of them are enrolled in the Medi-Cal program or are uninsured. According to the Department of Psychiatry and Behavioral Sciences at UC Davis, as many as 40% of patients seen in a primary care setting on any given day also have an active psychiatric condition.
In recent years, health care systems have focused on integrating behavioral and medical care and have found that being able to transition a patient from primary care to an on-site mental health specialist on the same day is highly effective in helping patient get the care they need and ensuring that they follow through with treatment regimens. But current rules prevent providers from being reimbursed for more than one visit in a single day, keeping patients from getting mental health and medical care on the same day. SB 66 would allow health centers to bill Medi-Cal for two visits if they receive mental health and medical care on the same day.
Research has shown that “peer support specialists” – people who have had personal experience dealing with and recovering from a mental illness or substance use disorder – are very effective in working with other people experiencing the same thing. Studies suggest peers help reduce costly hospitalizations and hospital days, depression and the myriad of other symptoms affecting clients. They also improve clients’ ability to function, promoting their follow through with all steps on the path to recovery, as well as their resiliency. Peers often serve as the first point of contact for people living with mental illness and can forge connections, inspire trust, and importantly, diminish stigma.
The federal government has set up policies that make services provided by peer support specialists eligible for partial reimbursement through the Medicaid program if the peer specialists have been certified by a competent state body. The U.S. Department of Veterans Affairs and 48 states have a certification process in place or in development for mental health peer support specialists, yet California has no such program. SB 803 would direct the Department of Health Care Services to create a statewide peer support specialist certification program, inclusive of core competencies, curriculum, training, supervision standards and certification protocol. And, importantly, SB 803 would direct the Department to recognize certified peer support specialists as providers eligible to treat patients through the Medi-Cal program. This measure is potentially life saving, cost-saving, and a big potential help for the state’s serious mental health workforce shortage.
From 2007 to 2016, youth suicide has risen steadily and is now the second leading cause of death among young people aged 15 to 24. In California, almost 20% of all high school students and almost half of LGBTQ students report that they seriously considered attempting suicide in the previous year. Suicide rates among teenage girls have hit a 40-year high.
Studies show that prevention and early intervention efforts can reduce suicide. Santa Clara County has had a concerted suicide prevention effort since 2010, and in 2016 and 2017 suicides there decreased by 11% and 14%. But since 2009, only seven of California’s fifty-eight counties have adopted suicide prevention strategic plans. SB 66 will help prevent teen suicide by requiring all California counties to bring together diverse stakeholders to create and implement strategic suicide prevention plans, with the emphasis on young people. If this Act is found to increase costs to counties, the state will reimburse local agencies and school districts.
Eleven prescription medications have been approved by the FDA for treatment of opioid, alcohol and tobacco use disorders. These medications, in combination with counseling and behavioral therapy, have been found to be effective in helping people overcome and recover from these disorders. Yet rules imposed by health insurers can act as barriers that interfere with the ability of patients to get access to this kind of medication-assisted treatment (MAT). A 2017 survey by the California Society of Addiction Medicine found that 56% of treatment professionals experienced difficulties getting access to treatment for their patients due to insurance barriers.
SB 854 would bar private insurers from imposing rules that require patients to get prior authorization to use FDA-approved prescriptions or accompanying therapy, require patients go through “step therapy” before they can get approval for medications, or exclude from coverage any FDA-approved medications used to treat substance use disorders.
State and federal laws passed over the past 20 years have sought to provide “parity” and ensure that health insurers cover mental health and substance use treatment on the same basis that they cover medical treatment. Yet weaknesses in the laws have allowed insurers to avoid paying for these kinds of treatment or to enact roadblocks that make it difficult for patients to access needed therapy.
SB 855 defines services for mental health and substance use disorders as “medically necessary treatment” that must be covered when recommended by doctors and other treatment professionals, consistent with generally accepted standards. It prohibits insurers from covering only short-term or acute treatment since recovery from mental health and substance use disorders often requires longer-term treatment. If needed services aren’t available from an insurance plan’s network providers, SB 855 requires insurers to reimburse out-of-network coverage at in-network rates.
California has a large and growing shortage of doctors. Fewer than half of the state’s 139,000 licensed physicians are currently working and providing care and of those, only a third – about 20,000 — are primary care physicians. Nurse practitioners (NPs) – advanced practice registered nurses who have earned a master’s degree or PhD. – offer a great resource to help fill this need. Yet California today is one of 28 states – and the only western state — that restrict their ability to practice without physician oversight.
AB 890 would change state law to grant NPs full authority to practice medicine, prescribe, and otherwise treat patients. The US Dept. of Veterans Affairs has permitted the 6,000 NPs working in the VA system to do this since 2016 and the California Health Workforce Commission has urged that California do the same. According to the Commission, doing so would encourage nurses to obtain additional training and increase the number of NPs, expand the capacity of primary care practices and in the process, reduce the need for repeat visits to emergency departments and reduce health care costs by $58 million per year.
Adult residential facilities – better known as board-and-care homes — provide housing and care services for people suffering from severe mental illness (SMI) or cognitive impairment. Many have been recently discharged from hospitals or prisons or are in a conservatorship. They provide a critical form of housing and support for people who are vulnerable and unable to care for themselves and are at high risk of becoming homeless or returning to hospitals or incarceration. Yet this vital housing resource is disappearing due to low reimbursement rates coupled with increased costs of labor and property. Los Angeles County recently reported a loss of 200 beds in just one year.
AB 1766 would require the State Dept. of Social Services to collect data on the number of people with severe mental illness who live in adult residential facilities and to issue quarterly public reports on the number of facilities and beds that have been lost in the previous quarter. It would also require the Dept. to ensure that counties are notified of planned closings of residential facilities.
The Lanterman-Petris-Short Act was passed in 1967 at a time when people deemed mentally ill had few rights and were often brutally treated and confined against their will in mental hospitals and asylums. It requires that people must consent to psychiatric treatment — unless they are a threat to themselves or others or are gravely disabled, a standard that has proven hard to clearly define. Half a century later, that law is still on the books, unchanged. While it provides important protections, it also has allowed severely distressed people to go untreated even when they can’t care for themselves.
Today, there is a growing consensus that the law is out of date, is not applied uniformly across the state, and is keeping severely disturbed people from getting the help they need. The State Auditor is now conducting an audit of how the act is implemented in three California counties. Based on the results of that audit, and recommendations provided by the Auditor, specific language for revising the LPS Act will be inserted into this bill.
The No Place Like home law, which passed the legislature in 2016, and was amended by Proposition 2, approved by voters in 2018, provided $2 billion in bond proceeds for permanent supportive housing for people with mental illness who are homeless or at risk of becoming chronically homeless. The funds are administered by the Dept. of Housing and Community Development, which has established a competitive grant application process for counties across the state.
AB 2589 would amend the law to expand the definition of permanent supportive housing to include licensed adult residential facilities and residential care facilities for the elderly, commonly known as board-and-care homes. These kinds of facilities are rapidly vanishing because operators do not earn enough money to continue operating them. Making these facilities eligible to be funded by the NPLH program will protect this vital affordable housing resource.
This sense-of-the-legislature resolution would urge state officials and departments to vigorously enforce existing federal and state parity legislation and ensure that insurers don’t improperly reduce or limit care to people needing treatment for mental health or substance use disorders.
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