With Mental Health, “Out of County” Should Not Mean “Out of Luck”

When Myron took in Rob and Ken, two young boys from the foster care system, he received every assurance that their medical needs would be covered through Medi-Cal, including mental health services, should those be needed.

The fact that the boys were moving from a temporary foster home in one county into Myron’s foster-to-adopt home in a neighboring county wasn’t supposed to present any particular problems. Myron had learned that “out-of-county placements” were actually very common in California.

After the expected honeymoon period, as Rob and Ken became more comfortable in their new family, they began pushing the limits and acting out, as everyone had predicted. Their behavior was not particularly troublesome for Myron, who understood that they were beginning to feel safe enough to test whether he really meant it when he said that one day, with the help of the judge, they would be a “forever family.”

What did worry Myron was Rob’s tendency to feel victimized in almost every difficult situation. “We were playing a game of ‘Sorry’ the other evening and Rob lost,” he said. “He was insistent that Ken won only because I helped him get the best cards. I didn’t help either one of them.”

He continued: “I let the kids take turns picking a movie and dinner each Friday night. Ken often goes out of his way to pick Rob’s favorite, pizza, instead of his own favorite, burritos. Even so, Rob will complain that Ken picked the wrong kind of pizza. I feel so bad for Ken, but I feel bad for Rob, too. He just feels as if the world is against him.”

Myron felt that eight-year-old Rob had suffered more from his mother’s neglect and emotional abuse than Ken, who was two years younger, both because he had endured it longer and because as the older sibling he’d seemed to be more of a target. In truth, Ken usually did get better treatment from both adults and kids because he was open, sunny, and playful –  in contrast to his older brother’s brooding, blaming, and complaining attitude.

Myron felt that the promise of a “forever family” and what he could offer as a parent was not enough for Rob. He strongly believed that Rob needed psychotherapy because his low self-esteem and continual feeling of victimization was interfering with his relationships, as well as leaving him deeply sad much of the time.

Myron also felt that he himself needed professional guidance to be a more effective parent for Rob. As he’d been assured that support would be available through Medi-Cal, he optimistically set out to find a therapist who could help both of them.

He contacted his caseworker at the foster family agency (FFA) that had placed the boys with him. She explained that the county with legal responsibility for Rob and Ken maintained a list of approved mental health providers in Myron’s county, and that only the professionals on that list were authorized to receive Medi-Cal payments  for Rob.

There were three people on the list. Myron called their offices. One no longer accepted Medi-Cal. One had retired a year earlier. The other had no openings and didn’t expect to be accepting new patients for another six or more months.

Myron went back to the FFA caseworker to explain the problem. She suggested that if he could transport Rob back to his “home county” that supervised his case, he might have more choices. She gave him the name of a clinic that she frequently referred to because they provided particularly good services for children in foster care.

Taking Rob to therapy at a clinic 45 minutes from their home every week did not make sense to Myron. It would mean having the boys in the car after school, in rush-hour traffic, then 45 minutes or so for Ken to wait while Rob was with his therapist, and either a stop for fast food or a long, hungry drive home.

Nevertheless, feeling that he had few options, Myron called the clinic and explained the situation. The intake worker was kind as he explained that, although Rob was a dependent of their county and his Medi-Cal coverage was in place, the clinic was only authorized to see current residents of the county. Though very sympathetic to Myron and Rob’s plight, the intake worker referred Myron back to the county in which they lived.

At some point in the process, Myron decided that waiting for Medi-Cal was not worth it.

“I’m adopting him,” Myron told me. “As his legal father, I will be fully responsible for his care and have  committed to getting him the help that he needs. So I may as well start that now. I’ll pay for a good therapist that I don’t have to pick from a list. It will be a stretch financially, but I’ll do it because I love him.”

Myron had both the commitment and the means to get Rob the help he thought he needed. But in truth, the responsibility was not his to bear. In California, the county of jurisdiction is legally responsible for ensuring that children receive the health and mental health care that they need.

But all too often, administrative and legal complications result in children not receiving any care at all. Myron’s commitment to ensuring that Rob got the help he needed should be celebrated, but the county that placed Rob shouldn’t be let off the hook. When our system results in a situation in which it’s unreasonable or impossible to actually access care, there’s something wrong.

This is a well-documented and persistent problem, one that advocates are currently seeking to address in the legislature. Thousands of families across the state don’t have the option to just pay out of pocket. Moreover, the law is crystal clear: As a foster child, Rob should get the care he needs, free of charge to his family.

As I watch advocates fighting to right this situation, I think of Rob and Myron and the thousands of other families for whom our current system’s next step after asking them to provide a home to children who have been abused and neglected, is to make it harder for them. It’s got to change.

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Toni Heineman
About Toni Heineman 15 Articles
I am licensed as a Clinical Social Worker and Clinical Psychologist and serve on the Clinical Faculty in the Department of Psychiatry at UCSF. I am the founder and Executive Director of A Home Within, and the author of numerous articles on identifying and meeting the emotional needs of children, youth, and young adults in foster care.