Reporting on California’s dizzying mental health system for kids

One consistent memory I have from reporting on California’s mental health system for low-income children is of regularly putting my head in my hands and asking myself, “Why is this so hard?”

Every detail of the state’s Specialty Mental Health Services system — the biggest government program for providing mental health services to kids in the state — seemed to be mired in excruciating levels of complexity. With each step of reporting I felt like I was trying to solve a Rubik’s Cube of tortuous funding formulas, opaque data, bureaucratic jargon and circuitous backstories.

Ultimately, the underlying story was anything but complex. Essentially, poor kids who need mental health care aren’t getting it, and whether or not children get mental health care depends a great deal on where they live. 

Reaching that conclusion, however, required steely persistence, willingness to dive into mind-numbing minutia, accepting that some paths of inquiry would lead to dead ends or unearth an impenetrable well of questions, and seeking help from the few people who’ve taken the time to understand this program and its history. 

After discussions with my editor at the California Health Report, Hannah Guzik, I chose Specialty Mental Health Services (SMHS) as a topic for the fellowship project because we’d heard reports of problems with the children’s mental health system, and because we knew the state had data available to analyze. The California Health Report focuses on health and health policy issues that affect disadvantaged populations in the state. We also look for stories that go unreported in other media outlets. Exploring disparities in low-income kids’ access to mental health care met these criteria, and fit with what our audience expects. 

Here are some of the most important lessons I learned from the project: 

• California’s mental health care system is messy: There is no one program or funding source for mental health care provided under Medi-Cal, the state’s health insurance program for low-income residents. For children, mental health services are delivered through a patchwork of managed care plans, county behavioral health departments, and schools. Each county is in charge of its own Specialty Mental Health Services program (which generally aims to serve kids with more serious mental health needs), and these programs are uniquely shaped by local infrastructure, funding availability, administrative knowhow, leadership and political priorities.

This is not something you can understand by reading a webpage or doing a couple of interviews. Even some mental health experts I spoke to didn’t seem to fully comprehend the system, and it wasn't uncommon for researchers to not know what Specialty Mental Health Services were. To understand the SMHS program and how it fits into the overall Medi-Cal mental health puzzle, I had to talk to many people, read multiple reports, and ask regular follow-up questions. I also honed in on just two counties (Orange and San Francisco) and their programs’ financing in my second story because it was the most manageable way to identify and compare how local circumstances influence whether or not children get care. 

• Getting data takes time, persistence, and creativity: When I first sent in my data request to the Department of Health Care Services, I was told the “programming, extraction and compilation” of the documents I wanted would cost me $9,592. After some back-and-forth emails with the public information officer, I was able to narrow down my request so that DHCS only had to send me documents they already had, not create brand new spreadsheets. That brought the cost down to $0. From there I went through several weeks of alternately waiting for documents and requesting new ones, since what I initially received didn’t fully cover the information I was looking for. 

Unfortunately, I did have to let go of one element of data that I wanted — information on the number of SMHS mental health providers by county. Apparently, DHCS doesn’t keep easily accessible records of this. I ended up looking elsewhere for comparable data: the American Academy of Child and Adolescent Psychiatry’s count of practicing child psychiatrists by county, and County Health Rankings and Roadmaps data on the number of mental health providers per county. While this didn't give me the exact number of Medi-Cal specialty mental health service providers, it did give me a useful comparative tool to see whether the provider landscape in each county had any consistent impact on children's likelihood of getting care (it didn’t).

• Funding for mental health care is a minefield: Did I mention this story was complicated to report? One big reason for that is the state has an incredibly headache-producing way of organizing and distributing mental health care funds. There’s 1991 realignment and 2011 realignment, and these are channeled through multiple different account (“behavioral health subaccount,” “behavioral health services growth” account, “mental health subaccount,” and more), and each county receives a different amount (how that’s calculated is another minefield).

Realignment funds (and matching federal money) are the main way SMHS are financed. However, there are also Mental Health Services Act dollars, county general funds, and other local sources that can be used to pay for children’s mental health care. Even if you can figure out how much funding counties received for mental health, that doesn’t tell you what proportion of it they spent specifically on children and youth or on the Specialty Mental Health Services program.

Surprisingly, while counties have to provide detailed reports to the state on how they spend MHSA money and the amount they have left over, they don't do this for realignment funding. 

To make sense of this system I sought help from several mental health advocates who have done their own analyses of some of this information. I also contacted the State Controller's Office directly for information and guidance. However, I definitely have unanswered questions about how this money is managed.

A few tips for journalists brave enough to tackle the state’s mental health system:

• Start early: Getting the data you want can take time and you may need to ask for alternate or additional data once your first query is answered. The earlier you get started the more time you’ll have to do analysis and reporting.

• Find a go-to person or people who can help you understand the system and will be patient with you: For me, Alex Briscoe, former director of the Alameda County Health Care Services Agency, and Patrick Garner, founder of the group Young Minds Advocacy, really helped me get a grasp of what SMHS is about.

• Don’t let complexity discourage you: I'm convinced one of the reasons few journalists have written about SMHS is because it’s so hard to understand. Yet the program is very important: it serves tens of thousands of children across the state. By diving into the complicated details and untangling the jargon you can unearth problems that were hiding in plain sight and make sense of critical issues for your readers.

• Do more reporting on this: I did a lot of work for this project, but I think there's still a lot more to learn and understand about SMHS and Medi-Cal mental health services generally in California, especially how money for the program is being spent (or not spent). I encourage other journalists and news organizations to look into this topic too.

Read Claudia Boyd-Barrett's fellowship stories here.