California’s privately owned health plans have made a decades-long practice of providing inadequate mental health services to their patients, a habit for which they’ve repeatedly been called on the carpet by lawmakers and, in one case, fined a record amount in an effort to force improvement.
But nowhere does the situation look worse than when it’s applied to the state’s kids. And by all appearances, only decisive action by an engaged state Legislature will change that picture.
Again this summer, there’s a bill in the works that strives to counter the worst of the health industry’s practices regarding mental and behavioral issues among young Californians. Carried by state Sen. Scott Wiener (D-San Francisco), SB 294 triggers an automatic review any time a health plan denies mental health services to anyone 26 or younger.
Why does it matter? Because once reviewed, a stunningly high percentage of such denials are overturned, meaning the plans are ultimately forced to provide kids with the mental health services they need — but only because the review occurred.
“Our youth are facing a mental health crisis,” said Wiener, whose bill is a rewrite of his own legislation that stalled last summer. “We need to remove barriers to access to those who are wrongfully denied mental health care.”
It’s not breaking news that California’s youth are facing a surge in mental and behavioral health issues. Between 2016 and 2020, anxiety or depression diagnoses for children ages 3 to 17 in the state rose by 70%, the second highest jump in the nation, according to the Annie E. Casey Foundation. And while we wait for updated statistics, experts agree that the pandemic exacerbated the problem.
In the midst of that increased need for mental health services for kids, there’s no question that health plans are denying such services in the state. The numbers are irrefutable.
Among the cases submitted to the state-run Independent Medical Review (IMR) program for a ruling in 2022, the most recent year available, eight in 10 that involved the denial of mental health services to those age 20 or younger were overturned, according to the state Department of Managed Health Care (DMHC). In 2021, it was 75%; in 2020, 82% of the denials were overturned.
That is powerful and ongoing testament to the notion that health plans are denying treatment that is clearly needed. But there are two huge issues. One is that, because the private plans aren’t required to divulge the information, no one knows exactly how many children are being denied treatment.
The other is that although the percentage of IMR overturns is massive, they account only for the cases of families who even know an appeal process exists — much less how to navigate it.
This isn’t just a matter of procedure; it represents wildly unequal access to care. According to Wiener’s office, call center records maintained by the DMHC show that between 2020 and 2022, 94% of IMR appeals were filed in English, only 4% in Spanish.
Immigrant working families and English second language families are far less likely to appeal denials of care, Wiener said. Researchers at the Kaiser Family Foundation, meanwhile, reported in 2021 that people who used the public marketplace to buy their insurance appealed fewer than two-tenths of 1% of their denied in-network claims.
Wiener’s latest legislative effort is sponsored by the advocacy group Children Now and Santa Clara County, which noted that half the people receiving mental health treatment in the county are 26 or younger. “This is a health care issue, plain and simple. It’s long past time to get serious about it,” County Supervisor Joe Simitian said in a statement.
SB 294 now sits with the powerful Assembly Appropriations Committee, where last year’s effort stalled after it was deemed too expensive. But the fact that the bill even exists is a measure of the desperation with which its sponsors feel compelled to force health plans to do what state law already tells them to.
Lishaun Francis, senior director of behavioral health for Children Now, worked with Wiener on the bill to address concerns about its cost.
In the 2023 version, every denial of care would have triggered an automatic appeal to the IMR. Even though the health plans would be made to bear that expense, state officials told Capital & Main that the resulting flood of cases would still cost California tens of millions of dollars per year because of the staff that would need to be added to process the claims.
Under the new version of the bill, only the most urgent cases go immediately to the IMR. (An “urgent” mental health need is defined by state law that already exists.) All other denials of mental health care would still be automatically appealed, without families needing to grind through mass paperwork as they’re required to now. But those initial appeals would go to the health plans themselves for review. If treatment was again denied, the families could then advance to IMR.
A state spokesperson said that despite that revision, “The Department of Managed Health Care would still need significant resources to implement SB 294.” He provided no estimate of the cost.
“But when commercial plans deny care, it’s actually a cost to the public system,” Francis countered. “Either parents will pay out of pocket, or a school will be required to provide the care, or county mental health will pick it up. Those are all public costs.”
It also may be nothing compared with the long-term cost of denying mental health care to young people in California who need it. The denial of care crisis has been generated by private health plans. Once again, it falls to the state to fix a problem it didn’t create.
