In a paper released today, the California Children’s Trust and the First 5 Center for Children’s Policy propose a paradigm shift in how California conceptualizes, delivers and funds a system of care for MediCal eligible infants, toddlers and their families.
Whole-Family Wellness for Early Childhood: A New Model for MediCal Delivery and Financing is co-authored by Ken Epstein and Alicia F. Lieberman of the University of California, San Francisco — two of our state’s leading lights on mental health, youth development and dyadic therapy — along with myself and Nila Rosen of the California’s Children Trust.
The California Children’s Trust is a coalition-supported initiative to re-imagine how California deﬁnes, funds, administers and delivers children’s social, emotional, developmental and mental health supports and services. We serve a coalition of more than 400 community-based organizations, providers, administrators and advocates partnering to confront systemic failures, institutional racism and social inequities in California’s behavioral health and child-serving systems.
The crisis we formed to confront is real. Self-reported mental health needs for children have increased 61 percent since 2005. Hospitalizations for suicidal thoughts and attempts have gone up 104 percent over the past decade and intentional self-injury rates have doubled. Nationally, suicide is now one of the leading causes of death for children, outpacing cancer and car accidents.
On average, there is a 10-year delay between the onset of children’s mental health symptoms and any kind of intervention. Across all insurance types, more than 65 percent of children with a major depressive episode don’t receive any help at all. The reality is that we are failing to meet the needs of our children and their families.
The need for family- and community-centered care is particularly critical in pregnancy and the first five years of life, when the architecture of the brain is established and neural connections grow at the fastest rate in a person’s lifetime. During this period, the brain shapes key abilities for long-term wellness, such as forming trusting relationships, being open to learning, and regulating emotions. Healthy, loving caregivers promote healthy development in young children; thus, the whole-family context is vital.
Currently, California’s Medicaid system, known as MediCal, focuses on delivering individual services for children outside the context of their families and communities. For example, healthcare providers and systems must determine a young child’s “psychopathology” before they offer mental health care or are reimbursed for it. Yet many clinicians do not receive training in early childhood mental health, and the diagnostic criteria are based on adult symptoms, calling accurate diagnosis into question. At the same time, young children in genuine distress due to family conflict, community violence, economic hardship and parental mental illness may not fall under a diagnosis, but still need support.
Traditional medical model interventions often pathologize children and their families. Perhaps most critically for young children, our current reimbursement models do not allow for the kind of care and support we know works: dyadic models including child-parent psychotherapy and family support. The relational foundation of these approaches are not reflected in how we define or reimburse mental health services for young children and their families.
The data is telling. Children 0 to 5 have the lowest access rates of California’s 5 million children in the state’s Medicaid mental health program, known as MediCal. Access rates are under 3 percent. And after a 33 percent increase over the past five years, more than half of California’s children are now covered by the same federal entitlement that successfully immunizes more than 80 percent of low-income children.
We are proud to collaborate with the First 5 Center for Children’s Policy in this work. We have no illusions that payment reform will allow us to treat away structural racism and the stabilization of poverty. Like most complex social problems, the origins of the youth mental health crisis are deeply embedded in the fabric of our social contract.
The reality of structural racism, the pathologizing of the poor and an underfunded safety net designed to benefit the people who work in it — not the people it serves — are all realities that will require more than a brief. These historical realities have been exacerbated by new forms of public speech and communication — namely a digital society that has subjected children and families to the perpetual compare-and-contrast imagery of a society that equates wealth with value, and fame with merit.
For 25 years I have worked directly with marginalized communities. In my hometown of Philadelphia I helped start one of Pennsylvania’s first charter schools, which re-enrolled 18- to 24-year-olds in school while rehabbing abandoned houses for homeless families. I worked as a therapist in the Oakland public schools, started federally qualified health centers in schools there, worked for a Level 1 pediatric trauma center, and have designed and led programs for children in foster care and juvenile justice. I also led one of California’s largest public health systems. I have seen a lot of human suffering.
And I believe California is poised for change at scale. We welcome your review of this brief and our other materials detailing how California can fund and scale a new approach to supporting the social and emotional health of children and families.
Alex Briscoe is the principal for the Children’s Trust. Previously, he served as director of the Alameda County Health Care Services Agency, where he oversaw an agency with an annual budget of $700 million dollars and 6,200 employees. He has served on the Alameda County First Five Commission, The Alameda Alliance and The Kaiser Commission on Medicaid and The Uninsured, as well as a number of other public and private boards and commissions.
Don’t miss the Breaking Barriers Symposium, a working conference that focuses on providing practical ideas to help break the barriers to care for California’s youth and their families. The fourth annual Breaking Barriers Symposium will be held November 20-21, 2019, in Sacramento. You can register here.