legislative

California’s complex plan to save mental health funding by slashing it

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To balance the state’s budget, Governor Jerry Brown has proposed raiding a state fund set aside to transform public mental health care. In return, he’s promising long-term fixes to the structural underfunding of public mental health. Is it a fair trade?

          
          
          

Side View Sacramento CapitolCalifornia Governor Jerry Brown has inhereted a budget deficit estimated at $25 billion, which everyone agrees will require significant changes in state services. One fix the Governor has proposed is raiding Mental Health Services Act (MHSA, originally known as Proposition 63) funds, an idea voters rejected as a budget fix in 2009.

This time around, Brown is proposing a novel compromise: let the state raid the MHSA fund on a one-time basis, and in return mental health services will get a longer-term, structural fix to chronic underfunding. It’s an intriguing proposal.

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Thanks to a the MHSA, a voter-approved tax on millionaires*, California currently has about $2 billion set aside specifically for the improvement of its public mental health system. This money is meant to be used to provide new and expanded services, train public mental health workers in current research-supported approaches, and generally transform the system to one that is modern, client-centered, and accountable. (By law, the money specifically cannot be used to pay for existing services, which are chronically underfunded.) Many marriage and family therapists are employed in public mental health in California, often in clinics funded by Medi-Cal.

Of course, in a budget crisis, it is easy to see how elected officials could view $2 billion sitting in the bank as a budget-solution-in-waiting. Governor Schwarzenegger proposed raiding this fund in 2009, asking voters to shift $460 million from MHSA funds into the state’s General Fund. The proposal was defeated by a landslide.

In contrast to the failed 2009 proposal, Governor Brown proposes a scheme that — at least in theory — could help the state budget in the short term and preserve mental health funding in the long term. It includes several moving parts:

  • Shifting $861 million from the MHSA reserve account to the General Fund. The shift would pay for current mental health services for the 2011-2012 fiscal year. Net impact: Bad. But could be worse. Obviously, this is a setback for planned MHSA-funded new and expanded programs, but the money would still be used to pay for mental health services, and would be a one-time shift.
  • Shifting responsibility for three mental health programs from the state to counties. The programs include Early and Periodic Screening, Diagnosis and Treatment (EPSDT); Medi-Cal mental health managed care; and special education mental health services (known to professionals as AB3632). Net impact: Unclear. “Local control” is sometimes better in concept than in reality; state administration ensures careful auditing to ensure money is being spent wisely, and consistency in program standards. County control of these services may lead to some cost savings, but those are often overstated.
  • Changing how the state funds mental health. Starting in the 2012-13 fiscal year, mental health services would be given an additional dedicated portion of state sales tax and vehicle license revenues. These are projected to grow at approximately a 6% annual rate. Net impact: Good. Currently, mental health programs are funded through a mechanism that grows at about 2% a year, according to the California Council of Community Mental Health Agencies — lower than normal inflation, and certainly not enough to account for any growth in patient population. This is a prime example of structural underfunding, which leads to ever-increasing caseloads and access-to-care problems.

All of this adds up to a proposal that has public mental health leaders more cautious than optimistic. The California Mental Health Directors Association asks a long list of good questions about the proposal, most of which are presently unanswered.

But the fact that a proposed $861 million raiding of public mental health funds is not being met with noisy protests from the agencies that rely on those funds is telling. It suggests that the proposal may have merit.

In the state’s current budget environment, we know lots of cuts will need to be made. Some of those cuts are likely to impact public mental health workers, including marriage and family therapists. Weathering the storm with a minimal amount of damage to public mental health, and even a potential long-term improvement to how it is funded, could be a very good outcome. Maybe.

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* Background on MHSA: As Governor Brown notes in his budget proposal,

To provide additional resources for county mental health services, voters passed the Mental Health Services Act (Proposition 63) in 2004. The intent of Proposition 63 was to reduce the long‑term adverse impact of untreated mental illness by developing services or expanding existing services at the local level. To fund these resources, Proposition 63 imposed a one‑percent surcharge on personal income over $1 million.

That tax brought in $2 billion more than expected in its first four years. (The budget proposal fails to mention that since then, the MHSA has brought in less than expected due to the worsening economy.) Counties have engaged in a long-term planning process for how they would use MHSA money to transform their mental health systems; by law, MHSA money was not to be used as simply a replacement funding stream for existing services. So while the MHSA currently has about $2 billion in reserves, counties have been planning for — indeed, counting on — that money to be available.

Wyoming bill would require counseling before marriage or divorce

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With some exceptions, three hours of premarital or pre-divorce counseling would be required. For divorcing couples, it’s good policy, even though it is unlikely to reduce divorce rates. It is much harder to justify the premarital requirement, on either a clinical or policy level.

Boutonniere-whitesuitA bill introduced in this year’s session of the Wyoming state legislature, HB0065, would require couples to attend three hours of premarital counseling before obtaining a marriage license, and three hours of marriage counseling before obtaining a divorce.

While there is little data to suggest that any three-hour process for couples already planning to split up will make much of a dent in the state’s divorce rate, requiring divorce counseling is a good idea for other reasons. Divorce education reduces conflict in the divorce process, particularly where custody is concerned (see this summary of several studies on divorce education for parents), and saves the divorcing couple as well as the public a significant amount of money in the process. Three hours is not an unduly burdensome amount, and the a judge can waive the requirement if the court finds there is “clear and convincing evidence that marital counseling will not lead to a reconciliation of the parties” — an important consideration for victims of relationship violence. Several states have adopted such programs, often similar to one called “Children in the Middle,” with good results.

The premarital counseling requirement is harder to support, either on a policy or scientific level — and this is coming from a guy who specializes in couples work (San Diego marriage counseling) and loves premarital counseling.

There is ample evidence that these relationship education programs improve communication, but it is unclear whether premarital education actually improves relationship satisfaction or stability, and there is virtually no evidence to suggest they actually have a long-term impact on divorce. (That’s primarily due to a lack of data, not studies showing failure.) A recent, thorough review in the journal Family Relations described current research on the very basic question of whether these programs work as “not as settled as program developers and practitioners might assume or like it to be.” There are at least three large-scale, federally-funded demonstration projects of premarital education (Appendix 2) underway now that should provide clearer answers.

In the meantime, these programs continue to grow because they are, in the words of one report, “popular and valued.” And there is some evidence to suggest they have a greater impact on low-income families, who do suffer from higher long-term divorce rates.

But here’s the catch. In the studies that have been done, as well as the large studies underway now, few have suggested that just three hours of education would be enough to even expect an impact. The federally-funded studies use programs of at least 24 hours of education. Most programs utilize at least 12 hours. Anything under eight hours was considered in the Family Relations review to be a “low-dosage” program.

This is why it’s so hard to get behind the premarital requirement in the proposed Wyoming law. I could see requiring 12 hours, and I can certainly understand requiring none. But three hours? It adds a hurdle to marriage, without sufficient reason to believe it will have a lasting positive impact. And while I believe quite strongly that premarital education can be effective, I cannot support requiring an amount of it that is too low to have any likely effect. Wyoming and other states should either require enough premarital education to make a lasting difference, or none at all.

Update: The bill died in its first committee in February 2011.

Can MFT interns pay for supervision?

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Aaron Feldman is frustrated. He’s spent several months telling the BBS, AAMFT-CA, CAMFT, and anyone else who will listen that he can’t run a therapy business legally and be successful in the state of California. No one has told him he’s wrong.

The problem, which Aaron is trying to conquer while others mostly ignore, is California’s Labor Law. Depending on whom you ask, it might prohibit marriage and family therapist interns from paying their employers for supervision; if it actually does (CAMFT argues otherwise), then a significant number of clinics around the state would be in violation.

But the supervision issue could be only the beginning. Mental health clinics are no different from any other business in the eyes of state labor law. But when was the last time a clinic required its therapists to take at least a 10-minute break every two hours, or mandated a lunch break for shifts lasting beyond six hours? Each of those is a labor law requirement.

At the October 2009 meeting of the Board of Behavioral Sciences (BBS), the licensing board’s counsel was clear: Those who employ MFT interns are subject to labor laws just like any other employer, and “there is no scenario under which it would be appropriate for a supervisee to pay an employer for supervision.” The BBS has since elaborated on that position here. CAMFT has since put forth its contrasting interpretation of the law, arguing that it is perfectly legal for an intern to pay their employer for supervision, as long as the terms of the arrangement are agreed to by both parties, in writing, in advance.

It is the Labor Board‘s opinion — or perhaps ultimately a judge’s — that matters. And so far, the Labor Board has chosen to stay away from the issue, politely rebuffing requests to attend BBS meetings or issue any written statement on the question. For the Labor Board to address this issue directly, it appears, they will have to face a complaint from a disgruntled supervisee.

And that has been Aaron’s frustration. He doesn’t want to run his clinic in constant fear of becoming the test case. CAMFT has hinted that they might try to clear up the issue through legislation, but the odds of getting a bill passed if it looks in any way like a weakening of, or exemption from, state labor laws is slim.

Without a clear set of guidelines, what is an employer or agency to do? The lowest-risk approach appears to be to abide by the BBS stated opinion: Assume MFT interns, when they are employed (as opposed to volunteering), are subject to all labor laws, and act accordingly. In practical terms, this would require an employer to go the extra mile to make sure that interns are taking adequate breaks. Do not have interns pay for supervision. Ensure that, however interns’ pay is computed, it amounts to at least minimum wage once all the intern’s time (including time spent on supervision, marketing, administrative tasks, etc.) is taken into account. (Of course, I’m not a lawyer, so please do not construe this as legal advice; any employer with questions about labor law or its application should consult an attorney.)

The problem for Aaron, and anyone else trying to run a therapy business honestly, is that even if he chooses to play by all of the labor law rules, plenty of other employers are not. If Aaron abides by the labor law, he will need to either pay his employees less, or charge his clients more, than similar clinics. The extra burden could be enough to make his clinic, as a business, unsustainable. Until at least one disgruntled intern makes a test case out of it, those who disregard the labor law appear to be at a competitive advantage.

From DC: Update on MFT inclusion in Medicare and school programs

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I’m at the AAMFT Leadership Conference in Washington, DC, where Division leaders from across the country have spent the last three days visiting our federal representatives. Priorities this year include Medicare inclusion and adding MFTs as named providers within the Elementary and Secondary Education Act (otherwise known as No Child Left Behind). Before I go to the details on the visits, some words of praise: this was the first time that AAMFT’s California Division and CAMFT, an independent organization of California MFTs, have combined efforts on their federal advocacy visits, and it went swimmingly. CAMFT’s lobbyist and leaders were kind, cooperative and helpful throughout, and I hope their experience of AAMFT was similar. Legislators and their staff people seemed impressed with the level of cooperation. As to the key issues, here is where we currently stand:

Medicare. As we were starting our second day of hill visits to California representatives on Thursday, we were greeted with bad news: the inclusion of MFTs as providers under Medicare, which had been part of the House health care reform package but not the Senate package, was pulled out of the reconciliation bill that will be voted on as early as next week. There is a slim chance that MFT inclusion in Medicare could still be accomplished this year through a different piece of legislation, but at this point that appears unlikely. On a more positive note, though, there remains significant bipartisan support in both chambers for adding MFTs in Medicare, as it would improve access to mental health care for seniors and those with disabilities. For a video of Senator John Barrasso (R – Wyoming) discussing the importance of this issue, click here.

School programs. MFTs can provide services to school populations under the Elementary and Secondary Education Act (ESEA), but because we are under the somewhat vague category of “other providers,” most programs do not seek to include MFTs when they apply for federal grant funding under ESEA. Adding MFTs as specifically named providers would improve the availability of behavioral health services for children. It also comes at no cost, which is helpful in seeking bipartisan support. Currently, these changes are in a House bill (HR1710) that has sponsors from both parties. I always enjoy the Leadership Conference for the trips to the Hill as well as the opportunities to connect with divisions from around the country. I’ll have another update from the conference in the next few days.

California LPCC law passes; should MFTs dually license?

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Late in the evening of October 11, Governor Schwarzenegger signed California Senate Bill 788, adding Licensed Professional Clinical Counselors (LPCCs) to the state’s masters-level mental health professions, alongside MFTs and LCSWs. Licensure by grandparenting will take place over a six-month period in 2011, with routine licensure starting January 1, 2012. Should MFTs dually license?

For most, there would be no benefit, and significant added expense. Since licensure is inherently a state-based activity, there is no reason to believe that licensing as an LPCC will make one’s license more portable; in fact, a license obtained through grandparenting may have greater trouble getting recognized in another state. Add to that the still-unclear question of whether California will recognize national exams in counseling (national exams in MFT and Clinical Social Work are not recognized in the state), and the likelihood of a portability benefit grows even slimmer. The added expense of two renewal fees could be little more than wasted money.

There is, however, a legitimate reason why some MFTs may want to dually license: They want to reflect what their professional orientation has been all along. California was the first state in the US to license MFTs, and the last in the country to license LPCCs. As a result, some who work under the MFT license do so because that was the masters-level entry point into a career in mental health, and not because they particularly identify with systemic concepts. For those therapists, the Clinical Counselor license is probably a better fit.

They will not, however, want to switch over entirely. Counselors will enter the mental health marketplace in California more than four decades after MFTs did, and will need to fight for themselves every battle MFTs waged and won for recognition in hiring and reimbursement. They’ll be able to make up ground, but it will be many years before counselors can claim the kind of recognition and stature in the state that MFTs claim today, thanks to decades of good work by CAMFT and AAMFT.