How Silos Broke a Promising Child Mental Health Settlement

In 2011, Rick Saletta was asked by the federal courts to work out a settlement in Katie A. v Bonta, a long-running lawsuit over California’s mental health services for children known to its child welfare system. Lawyers represented a handful of children and youth, alleging massive gaps in mental health care services available to children in the child welfare system.

These children were either in foster care or at risk of placement into foster care due to a maltreatment report. Katie A., the lead plaintiff, had never received therapeutic treatment in her home. By age 14, she had experienced 37 separate placements in Los Angeles County’s foster care system, including 19 trips to psychiatric facilities.

Of particular focus in the case was California’s obligation to provide certain guaranteed services to children who are eligible for the state’s Medi-Cal program. Under all state Medicaid programs, the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit assures that children are screened and treated for conditions including mental health issues.

Saletta, a veteran child welfare practitioner from Placer County had recently had success settling another mental health lawsuit in the state, Emily Q., and the court hoped he and his team could find a way to agreement again. He did manage to achieve a settlement in the case, which ended in 2014. But a turbulent political climate, and resistance from some critical government agencies, limited what could have been a landmark reform effort.

Saletta sat down with The Chronicle of Social Change five years after the end of Katie A. to discuss the case, the settlement, and his thoughts on its successes and shortcomings.

Why do you think the state, and Los Angeles in particular, had come to lean so heavily on psychiatric units to care for children and youth with mental health issues?  

Rick Saletta, former special master in charge of the Katie A. v Bonta settlement.

A couple of reasons — obviously, in the period of time we’re talking about [the early 2000s], we had a large number of children and youth in foster care, over a 100,000 in care in the state. At any given time, approximately 10,000 of these children and youth were in group homes.

Children and youth would bounce between multiple foster care placements, end up in group homes and in out-of-county child welfare receiving homes, which would have children and youth from ages 5 to 18. Those placements became almost mini psych-units where counties would reluctantly place children and youth instead of psych hospitals. Some of these youth would be committed to juvenile halls. Psychiatric hospitals were a big part of this revolving door for children and youth, and it did not meet their needs.

Limited funding was available for intensive mental health, targeted for in-home or community-based mental health service that could prevent these children and youth from being removed from their families and/or fail foster care, group home care and end up in a psychiatric hospital, county receiving home or juvenile hall. At that time, some would say it was easier to place children and youth in a psychiatric hospital, receiving home or a juvenile hall than match existing services with their needs.

What did you know about the Katie A. lawsuit before you were asked to be the special master?

I was the chief of a children’s system of care, overseeing, mental health, child welfare, probation and elements of special education. Initially, and I’m probably not alone with this understanding, it was unclear what agencies were really responsible for taking on Katie A.

Is it mental health? Was child welfare responsible? Probation? There seemed to be lot of different positions taken by the state, its representatives, and the plaintiffs and their representatives.

So you are brought in as special master on the statewide case in 2009; Los Angeles had already reached a settlement in its separate Katie A. lawsuit. What was your mandate and what did the court ask of you?

There had been approximately six years of litigation in federal court, with no satisfactory resolution and no agreement reached between the parties. The court felt it had employed, to the fullest extent possible, its means to negotiate the matter before it, to a successful closure. Before proceeding any further, the court elected to appoint a special master.

I was directed by the court, to work with the state Department of Social Services and the Department of Mental Health, and other parties to narrow the differences between the parties on what services that had been identified by the plaintiffs were payable under specialty mental health plans, [or] Medi-Cal Early and Periodic Screening, Diagnostic, and Treatment and seek an agreement, if possible, with all parties that satisfied the court.

Generally speaking, the services under dispute were a range of intensive and comprehensive community-based services, emphasizing therapeutic interventions in the home and/or home-like environments (foster homes) and in the community, which would be eligible for reimbursement under EPSDT.

What sort of staff did they give you?

My team consisted of two special master assistants, along with myself. The team had extensive subject matter expertise and were trained in the Interest Based Decision-Making model of negotiation. It’s a mode of negotiation that aligns parties’ interests with options for solutions and seeks consensus decision making.

Who worked on the settlement agreement and implementation plan?

The Katie A. Negotiation Work Group: attorneys from the State Departments of Justice, Departments’ of Health Care Services (DHCS), Mental Health (CDMH) and Social Services (CDSS). Plaintiffs’ lead attorneys, the deputy directors and/or chiefs from the DHCS, CDMH and CDSS. A representative from the California Welfare Directors. A county child welfare director, and a county deputy director from mental health. A parent and a private provider were also full members of the Work Group.

Leadership from the County Mental Health Directors’ Association did not participate in the negotiation of the agreement. I met directly with leadership on more than one occasion in an effort to encourage their direct engagement with the Negotiation Work Group as they had done Emily Q.

After the settlement was reached in July of 2011, leadership from County Mental Health Directors’ Association joined the effort in 2012. By then, the association was known as the County Behavioral Health Directors Association (CBHDA). Their absence in the long run was problematic and, I believe, impacted the pace and scope of Katie A. implementation.

Why wouldn’t they come to the table? The outcome would obviously have a huge impact on its members.

Yes, you’re absolutely correct. I think it’s fair to say that they felt they’d be exposed to liability if they participated in developing the agreement.

So as far as the settlement, did you have success?

We reached an agreement rather quickly, approximately 18 months. The court approved the settlement agreement in late 2011. Developing the implementation plan was very problematic as the CBHDA representatives, as I mentioned, were not part of the development of the settlement agreement. Their lack of ownership/participation in the settlement agreement also proved problematic for other members of the Negotiation Work Group. Progress was slow, it took a year, and was uneven; but progress was made.

As the settlement period ended in December 2014, several of the plaintiffs praised you and your staff but that implementation had been pretty uneven: some counties did well, others didn’t care, and the state played out the clock. Do you agree with some or all of that assessment?

As I indicated earlier, CBHDA and their representatives came on late to the process and were not fully engaged in developing the settlement agreement, which complicated the development of the implementation plan.

The settlement agreement was developed prior to Realignment 2011. At that time, Medi-Cal share of cost for counties was 5 to 10 percent … There was confusion whether or not EPSDT would be addressed under realignment. Questions were raised during the state budget process. Should EPSDT stay at the state? Should it be realigned to the counties? And what were the funding ratios for the EPSDT entitlement?

This uncertainty and the short time frame for developing the implementation plan and meeting the 36-month exit target put undue pressure on all parties and negatively impacted the counties’ ability to bring up the level of statewide implementation of Katie A. services that was desired.

Realignment was a pretty big factor here, right? The whole way child welfare and mental health get funded in California changes.

Counties, in the early stages of Katie A., would be subject to 5 to 10 percent share of cost for Medi-Cal/EPSDT depending how you calculated cost. So there was some bewilderment about why CBHDA wouldn’t participate in the settlement negotiations. That 5 to 10 percent share of cost could have been easily overcome with local partnerships with child welfare, probation or other mental health funding.

Public Safety Realignment 2011 came forward as a model led by then Governor [Jerry] Brown and elevated the counties’ issues, because under proposed legislation they would be responsible for 50 percent of the EPSDT match. The state did realign funding based on best estimates on EPSDT expenditures to date, with the message that counties would have enough money to implement Katie A.

Counties now had 50 percent of Katie A. costs, and felt like they didn’t get enough from the state in realignment to do their existing work, let alone Katie A. I believe, as a result, they were initially hesitant to expand at the pace one would have expected.

Does the state share some responsibility though?

I don’t want to minimize the state’s role. Although realignment limited their authority, there were options to pursue that could have aided in a more robust implementation of Katie A. services.

The authority for the state is two pronged; there’s statutory authority and the governor’s or department’s administrative authority. Realignment reduced and/or limited the statutory authority and gave considerable flexibility to the counties.

The message was: Counties know best what their needs are and how to meet them, give the money and get out of their way.

Governor [Brown] wanted to ensure “public safety realignment” was getting off to a good start. The administration, as well as the legislature, didn’t want to jeopardize the early stages of realignment implementation and therefore limited using its authority under federal and state statue to “meddle” in the counties’ business of implementing Katie A.

The real question now is what is Governor Newsom’s … message to counties going to be?

Where do you think Katie A. ended up falling short?

In particular, the two cornerstones of the agreement and plan: First, The Katie A. settlement agreement and implementation plan called for a shared management/governance structure between the directors of the California Departments of Health Care Services and Social Services. Second, the agreement and implementation plan called for a data, quality assurance and outcome structure.

The state did agree in good faith to implement these structures after the court’s exit. This was to be led by the department directors. There was also an agreement to hire a “transformation manager,” I believe that did occur. There were some focused efforts by all the system partners, but the team that formed was too large, had too many government/state representatives, and it’s very difficult for large state systems to actually and authentically release their power, to fully engage youth, parents and others in a legitimate shared manner. The effectiveness of this effort is questionable as there has been little transparency or monitoring after the court’s exit.

Shared governance and shared outcomes across systems are still needed at the state and county levels across all child and youth serving systems. That’s what Breaking Barriers is really all about, holding each other accountable, and maximizing resources across systems for improved outcome for all children and families.

Rick Saletta serves on the advisory council for 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 19-20, 2019, in Sacramento. You can register here.


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John Kelly
About John Kelly 1131 Articles
John Kelly is editor-in-chief of The Chronicle of Social Change.